KEY WORDS
Periodontology, classification
The updated periodontal classification:
answers to 10 common questions
18
Learning objectives
• To understand the background and
reasons for updating the periodontal
classification system
• To clarify answers to commonly
asked questions
Reena Wadia
Prim Dent J. 2019;8(4):18-20
ABSTRACT
In 2017, the World Workshop Classification system for periodontal and peri-
implant diseases and conditions was developed. Thereafter, the British Society of
Periodontology convened an implementation group to develop guidance on how
the new classification system should be implemented in clinical practice in the UK.
This paper covers answers to commonly asked questions on this new guidance.
1
Why was the classification
system updated and why did the
British Society of Periodontology
then release an updated version
(implementation guide)?
The 2017 World Workshop
Classification system for periodontal
and peri-implant diseases and conditions
was updated in order to accommodate
advances in scientific knowledge,
including our understanding of
periodontal and peri-implant diseases
and conditions that has evolved since
the 1999 International Classification
of Periodontal Diseases.1 The European
Federation of Periodontology (EFP) and
American Academy of Periodontology
(AAP) management committees were
involved in updating the classification
system.2
The British Society of Periodontology
(BSP) convened an implementation
group to develop guidance on how
the new classification system should be
implemented in clinical practice. They felt
the complexity of the proposed system
rendered its adoption in UK general
practice unlikely. A particular focus was
to describe how the new classification
system integrates with established
diagnostic parameters
author
Reena Wadia BDS Hons (Lond)
MJDF RCS (Eng) MClinDent (Perio)
MPerio RCS (Edin) FHEA
Specialist periodontist at RW Perio
and King’s College Hospital
and pathways, such as the basic
periodontal examination (BPE). Following
wider consultation within the BSP, the
implementation group produced a paper
that was approved by the BSP Council
and published in the British Dental
Journal in January 2019.3 This is the
guidance that all UK dental professionals
should be following in practice.
2
Why have chronic and
aggressive periodontitis been
removed from the classification?
The distinction between chronic and
aggressive periodontitis has been
removed on the basis that there was
little evidence from biological studies
that chronic and aggressive periodontitis
were separate entities, rather than
variations along a spectrum of the same
disease process. The only exception was
for the classical localised aggressive
periodontitis, where a clearly defined
clinical phenotype exists, however,
there was unease about including this
as a distinct and separate entity within
the classification system. Therefore, the
2017 classification system recognises
only three types of periodontitis –
periodontitis, necrotising periodontitis
and periodontitis as a manifestation
of systemic disease.4
p r i m a r y d e n ta l j o u r n a l
3
How do you determine
the extent of the
periodontitis?
Bone loss assessed by radiographs
is a key component of the updated
classification system. The extent of
the radiographic bone loss is used to
describe if the condition is localised
(up to 30% of teeth with radiographic
bone loss), generalised (more than 30%
of teeth with radiographic bone loss)
or of a molar/incisor pattern (first
molars and incisors with evidence
of bone loss).
4
How do you assess
the stage and
grade?
The stage is related to the severity of the
periodontitis, which is also associated
with the complexity of overall patient
management.
To determine the stage, the BSP
implementation group proposed a
simplified staging grid based on
radiographic bone loss alone. This
is based on percentage bone loss in
relation to the root length, which is an
intuitive measure already used by many
practitioners. The bone loss is taken
as the worst value at any site in the
mouth, where it is clear that the bone
loss has arisen due to periodontitis.
For some patients, in particular for
those with early stage periodontitis, the
availability of radiographs may be limited
to bitewings in the posterior regions and
no radiographs may be available for the
anterior sextants. In such cases, and when
periapical or panoramic radiographs
are not indicated for clinical reasons,
the clinician should use bitewings or
clinical attachment loss (CAL) measured
from the cementoenamel junction to
estimate percentage of bone loss.
In rare situations where a patient is
clearly known to have lost teeth due
to advanced periodontal bone loss
likely to have been within the apical
third of the root, clinicians may, on
a case by case basis, immediately
assign a stage IV classification.
Vol. 8 No. 4 winter 2019/20
Ta b l e 1
Staging3
Stage I Stage II
(early/mild) (moderate)
Interproximal bone Coronal third
loss <15% or <2mm* of root
*Measurement in mm from CEJ if only bitewing radiograph available
(bone loss) or no radiographs clinically justified (CAL)
The grade reflects the patient’s
susceptibility to periodontitis and can
be used as a predictor of future disease
experience in the absence of treatment.
The BSP implementation group felt that
the ratio of percentage of bone loss/
age was the most pragmatic way of
determining this.
Grade A is assigned if the maximum
amount of radiographic bone loss in
percentage terms is less than half the
patient’s age in years (for example, less
than 25% in a 50-year-old). Grade C
is assigned if the maximum amount of
bone loss in percentage terms exceeds
the patient’s age in years (for example,
more than 20% in an 18-year-old or more
than 60% in a 59-year-old). Grade B
is assigned otherwise.
5
Why do you need to determine the
stage and grade if we treat pockets
and bleeding, not bone loss?
Stage and grade are a reflection of
historical disease experience, but this is
just as important to determine, especially
in patients who have received periodontal
therapy in the past. Even a successfully
treated periodontitis patient remains
a periodontitis patient for life because
the disease may progress at any time if
periodontal maintenance is sub-optimal
and risk factors are not controlled.
Therefore, assigning the severity and
rate of progression of periodontitis is
important.
The next important step is determining
the current disease status as this is what
will be treated. The patient may represent
Stage III Stage IV
(severe) (very severe)
Mid third Apical third
of root of root
a case of health in a successfully
treated patient (stable), or a case
with recurrent gingival inflammation
(bleeding on probing ≥10%) at sites
with periodontal probing depths ≤3mm
and no periodontal probing depths
>4mm (disease remission), or a case of
recurrent periodontitis, where there are
bleeding sites ≥4mm or any periodontal
probing depths ≥5mm (unstable). The
4mm threshold is critical as it determines
periodontal disease stability at non-
bleeding sites following successful
periodontal therapy.
6
What do you do
if you don’t have
radiographs?
Without radiographs you are unable
to determine the extent, stage or
grade of periodontitis. It is important
that the appropriate radiographs
are taken at the initial assessment
appointment.5 This may include
horizontal bitewings, vertical bitewings,
periapical radiographs and/or a dental
panoramic radiograph. Without this,
the treatment plan cannot be formulated
and only a provisional diagnosis can
be made.
If a patient has interproximal
attachment loss but BPE codes of only
0, 1 and 2, (for example, a previously
treated, stable periodontitis patient),
and radiographs are not available/
justifiable, staging and grading should
be performed on the basis of measuring
attachment loss in ‘mm’ from the CEJ
and estimation of concomitant bone
loss.
19
 The updated periodontal classification:
answers to 10 common questions

7 9
Which risk factors have
been included in the updated
classification system?
There are numerous risk factors
which play a role in the aetiology
and management of periodontitis.
Diabetes and smoking (including
previous smoking) were chosen to be
documented as part of the diagnostic
statement in the new classification
system. These have been included
due to their strong evidence base.
They can also be objectively measured
and modified.
10
How does the BPE fit
in with the updated
classification system?
The use and interpretation of the BPE
has not changed. However, the BPE is a
screening tool and determines the need
for further diagnostic measures before
establishing a definitive periodontal
diagnosis and appropriate treatment
planning.
As per current BSP guidance, a
maximum BPE code of 3 would trigger a
panoramic radiograph and/or selective
periapical radiographs, which will allow
Is there a simple way of
remembering the updated
classification for the
periodontitis component?
The BSP have produced a flowchart
to help with implementation in daily
practice. This can be downloaded from
their website.6 These six steps may also
be useful to remember and include as
a template in your clinical notes:
1 Determine type of periodontal
disease – is the bone loss due to
periodontitis?
2 Disease extent – localised (up to 30%
of teeth), generalised (more than 30%

8
How often do I need
to update the diagnostic
statement?
The diagnostic statement should be
reflected upon and revised if relevant at
every new assessment. Patients cannot
regress to a lower stage of periodontitis
due to treatment, but if they remain
untreated this may increase and need
to be updated if further radiographic
bone loss is detected at a future
assessment. Grading may also change
in the long-term. The current disease
status is important to determine at each
assessment as this is likely to change
with treatment.
determination of percentage bone loss
relative to the root length. A maximum
BPE code of 4 would trigger periapical
radiographs (or a panoramic radiograph)
and a detailed pocket chart. Following
a radiological analysis and report – and,
where appropriate, additional diagnostic
tests – a final diagnosis of the type of
periodontal disease is made.
It is important to recognise that the
BPE is of limited value in patients
who have already been diagnosed
with periodontitis. This is particularly
relevant in the context of the new 2017
classification system, as staging of
periodontitis is based on radiographic
bone loss and/or CAL, which is not
captured by the BPE.
of teeth) or molar/incisor pattern.
3 Stage – how severe is the bone loss?
Stage I (early/mild), Stage II (coronal
third of root), stage III (mid third of
root), stage IV (apical third of root).
4 Grade – how susceptible is my
patient? Is the maximum amount of
bone loss more than my patient’s
age (grade C), is the bone loss less
than half the patient’s age (grade A)?
Anything else is grade B.
5 Current disease status – Stable =
health/successfully treated patient,
disease remission = recurrent gingival
inflammation (BoP ≥10%) at sites
with PPD ≤3mm and no PPD >4mm,
unstable = recurrent periodontitis
with bleeding sites ≥4mm or any
PPD ≥5 mm.
6 Lifestyle risk factor profile –
smoking, diabetes.

This guidance remains a framework.

Further individual detail can be added
on a case by case basis and clinical
judgement will remain the cornerstone
of formulating an appropriate diagnosis
and treatment plan.

references
1 Armitage GC. Development
of a classification system for
periodontal diseases and
conditions. Ann Periodontol.
1999;4:1-6.
2 Caton JG et al. A new
classification scheme for
periodontal and peri‐implant
diseases and conditions –
Introduction and key changes
from the 1999 classification.
J Clin Periodontol. 2018;45
(Suppl 20):S1–S8.
3 Dietrich T et al. Periodontal
diagnosis in the context of the
2017 classification system
of periodontal diseases and
conditions – implementation
in clinical practice. Br Dent J
2019;226:16-26.
4 Papapanou PN et al. Periodontitis:
Consensus report of workgroup
2 of the 2017 World Workshop
on the Classification of Periodontal
and Peri‐ Implant Diseases and
Conditions. J Clin Periodontol.
2018;45(Suppl 20):S162–S170.
5 Good practitioners guide,
BSP [online]. https://www.
bsperio.org.uk/publications/
good_practitioners_guide_2016.
pdf?v=3. Accessed Dec 1 2019.
6 BSP Flowchart [online]. https://
www.bsperio.org.uk/publications/
downloads/111_153050_bsp-
flowchart-implementing-the-2017-
classification.pdf?fbclid=IwAR0
a-9vx_

20 p r i m a r y d e n ta l j o u r n a l
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