PRESENTED BYA.ARAVIND KUMAR

Classification is defined as the act or method of

distribution into groups.

Our understanding of the etiology and pathogenesis of

periodontal diseases is continually changing with increasing

scientific knowledge.

Classification systems should be viewed as dynamic works-

in progress that need to be periodically modified based on

current thinking and new knowledge.

Classification systems are necessary in order to provide a frame

work in which to scientifically study the etiology, pathogenesis and

treatment of disease in an orderly fashion.

why Classification system necessary

Direct research aimed at learning more about the diseases

concerned.

Help determine the evidence base for better-targeted therapy.

Guide practitioners towards the best method for treating a

disease.

Enable the international community to communicate in a

common language.

Guide public health planning and targeting of therapy.

Help practitioners plan treatment protocols to maximize benefit

to all their patients

The ideal way to classify any disease is to use the name of the

etiological agent.

Periodontal diseases are polymicrobial& polyimmuno-

inflammatory in nature.

The first classification system for periodontal disease was

recorded in 1806 when Joseph Fox attempted to classify

“gum- disease”.

Alphonse Toirac in 1823 called it Pyorrhea Alveolaris.

The development and evolution of the periodontal classification

system was largely influenced by paradigms that reflect the

understanding of periodontal diseases at the given historical period

Clinical characteristic paradigm(1870-1920)

C.G Davis Classification

G.V Black Classification

Classical pathology paradigm ( 1920-1970)

Gottlieb Classification (1928)

Orban’s Classification (1942)

WHO Classification (1961)

Page and Schroeder (1982) ADA Classification (1982) AAP (1986) Topic’s classification (1986) Grant Stern and Listgarten (1988) Suzuki (1988) World workshop in clinical periodontology (1989) Ranney’s classification (1993) European workshop on periodontitis(1993) World workshop classification (1999) Van der velden classification (2000)

> Based on extent of the disease

> Based on severity of disease per tooth

> Based on age

> Based on clinical characteristics

CLINICAL CHARACTERISTICS PARADIGM

(1870-1920)

Very little was known about the etiology and pathogenesis of

periodontal diseases during this period and most of the diseases were

classified almost entirely based on their clinical characteristics and

also on unsubstantiated theories about their cause.

Many authors considered these diseases to be caused by local factors

(G.V.Black-1893)

Some believed that systemic disturbances played a dominant etiological

role.

(Dunbar LL-1894; Mills GA-1877)

John M.Riggs called periodontitis as Riggs`disease .

First: margins of the gums showed inflammatory

action & bleeding at slightest touch of the brush.

Second: inflammation extends over the thinner alveolar border causing

absorption of bone & gum tissue, forming small pockets filled with pus.

Third: thicker portions of the process are involved absorbing it most

rapidly.

Fourth: the disease has swept away all of the alveoli & much of the

gum.

A classical example was the paper published by C.G.Davis(1879)

who believed that there were 3 distinct forms of destructive

periodontal disease

1.Gingival recession with minimal or no inflammation

2.Periodontal destruction secondary to “Lime deposits”

3. “Riggs disease” the hallmark of which was ‘loss of alveolus without

the loss of gum’

Similarly G.V.Black-1886 classified periodontal disease into

5 categories

1.Constitutional gingivitis

2.A painful form of gingivitis

3.Simple gingivitis

4.Calcic inflammation of the peridental membrane

5.Phagedenic pericementitis

(phagedenic –spreading ulcer or necrosis)

By 1929 Becks.H estimated that there were over 350

theories of pyorrhea and much more confusing

terminologies such as ‘

Pyorrhea alveolaris

Calcic inflammation of the peridental membrane

Phagedenic pericementitis

Chronic suppurative periodontitis

CLASSICAL PATHOLOGY PARADIGM

(1920-1970)

According to this concept there were at least two forms of destructive periodontal disease –inflammatory and non-inflammatory (degenerative or dystrophic)

Gottlieb in particular postulated that certain forms of destructive periodontal disease were due to degenerative changes in the periodontium.

In 1923 he described the disease & called it “the diffuse atrophy of

the alveolar bone”.

Gottlieb classified periodontal disease into four types:

1. Schmutz – pyorrhoe

2. Alveolar atrophy or diffuse atrophy

3. Paradental-pyorrhea

4. Occlusal trauma

McCall & Box (1925) introduced the term ‘Periodontitis’ to those

inflammatory diseases in which all components of periodontium are

involved.

Wannenmacher (1938) – Paradontosis marginalis progressiva

Thoma & Goldman(1940) called the disease as Paradontosis.

Orban & Weinmann (1942) coined the term Periodontosis

Classification systems were dominated by the Orbans principles during this time.

1.Periodontal disease follow the same pattern as do diseases of

other organs

2. The basic pathologic tissue changes , however are the same

as those of other organs

3.Environmental factors however dictates the inclusion of a third

and different category of pathologic reaction in periodontology

i.e.,‘pathologic reactions’ produced by occlusal trauma.

This was the first classification scheme to be accepted by AAP.

He grouped them according to the “Pathologic” categories of

inflammation.

Inflammation

I. Gingivitis : Local

Systemic

II. Periodontitis: Simplex

Complex

Degeneration

I. Periodontosis : Systemic disturbances

Hereditary

Idiopathic

Atrophy

I. Periodontal atrophy: Local trauma

Senile

Disuse

Idiopathic

Hypertrophy : Gingival hypertrophy

- Chronic irritation

- Drug action

- Idiopathic Traumatism

In 1966 world workshop questions were raised about the existence of

‘Periodontosis’ as a distinct disease entity.

The term ‘Juvenile Periodontitis’ was introduced by Chaput &

colleagues in 1967 & by Butler (1969) .

In 1971 Baer defined it as “a disease of the periodontium occurring in

an otherwise healthy adolescent which is characterized by a rapid loss

of alveolar bone about more than one tooth of the permanent dentition.

the amount of destruction manifested is not commensurate with the

amounts of local irritants.”

W.D. Miller (1890), in particular, was an early proponent of the

infectious nature of periodontal diseases.

His work had very little impact on convincing his contemporaries that

periodontal diseases were infections . however, an early advocate of

the ‘Infection/Host Response Paradigm’.

The classical‘experimental gingivitis’ studies published by Harald

Löe and his colleagues from 1965 to 1968 that the Infection/Host

Response Paradigm began to move in the direction of becoming the

dominant paradigm.

The next major discovery in periodontal microbiology was the

preliminary demonstration in 1976–1977 of microbial specificity at sites

with periodontosis. ( Newman et al -1976,1977)

This finding, coupled with the demonstration in 1977–1979 that

neutrophils from patients with juvenile periodontitis (periodontosis) had

defective chemotactic and phagocytic activities, (Genco et al

1977 ;Lavine et al 1979) marked the beginning of the dominance of the

Infection/Host Response paradigm.

1977 – convincing arguments were provided that there was no

scientific basis for retaining the concept that there were non-

inflammatory or degenerative forms of periodontal disease

(Ranney-1977)

It was concluded that ‘Periodontosis’ was an infection &

‘Juvenile Periodontitis’ should become the preferred term.

THE 1977 WORLD WORKSHOP CLASSIFICATION

1.Juvenile periodontitis

2.Chronic Marginal Periodontitis

1977 1986 1989

Page & Schroeder (1982) suggested four different forms of

periodontitis.

1. Prepubertal periodontitis:

Localized

Generalized

2. Juvenile Periodontitis

3. Rapidly progressive periodontitis

4. Adult periodontitis

The need to revise classification system for periodontal diseases

was emphasized during the 1996 World Workshop in Periodontics. In 1997

the American academy of periodontology responded to this and formed a

committee to plan and organize an international workshop to revise the

classification system for periodontal diseases.

 

On October 30 – November 2, 1999, the International Workshop

for a classification of Periodontal Diseases and conditions was held and a

new classification was agreed upon.

CHANGES IN THE CLASSIFICATION IN PERIODONTAL DISEASES

Addition of a section on “ Gingival Diseases”

Replacement of “adult periodontitis” with “chronic periodontitis”

Replacement of “early onset periodontitis” with

“aggressive periodontitis”

Replacement of “necrotizing ulcerative periodontitis with

“Necrotizing periodontal diseases”

Elimination of a separate disease category for “refractory

periodontitis”

Addition of a category on “Periodontal abscess”

Addition of a category on “Periodontic endodontic lesions”

Addition of a category on “Development or acquired deformities

and conditions”

Classification of periodontal disease and condition

(1999 international workshop)

The new classification (1999) is as follows:

I : GINGIVAL DISEASES

A)  Dental plaque induced gingival disease.

(Can occur without attachment loss or on a periodontium with

attachment loss that is not progressing)

1.Gingivitis associated with dental plaque only:

a) Without other local contributing factors

b) With local contributing

 

2.Gingival diseases modified by systemic factors

a) Associated with the endocrine system

1. Puberty associated gingivitis

2. Menstrual cycle associated gigivitis

3. Pregnancy associated a) gingivitis b) pyogenic granuloma

4. Diabetes mellitus associated gingivitis

b) associated with blood dyscrasias

1. leukemia associated gingivitis

2. Other

3. Gingival diseases modified by medications

a) drug influenced gingival diseases

     1.  drug influenced gingival enlargements

2.  drug influenced gingivitis a)  oral contraceptive assoicated gingivitis b)  other

4.Gingival diseases modified by malnutrition

a)      ascorbic acid deficiency gingivitis

b)      other

B. Nonplaque induced Gingival lesions

1.Gingival disease of specific bacterial origin

a. Nesseria gonorrhea assoicated lesions

b. Treponema pallidum associated lesions

c. Streptococcal species assoicated lesions

d. Others

2.Gingival disease of viral origin

a) herpes virus infection

         : primary herpetic gingivostomatitis

        : recurrent oral herpes

    : varicella zoster infections

b)Others

3) Gingival disease of fungal origin

a. candida species infections

1.generalized gingival candididosis b. linear gingival erythema c. histoplasmosis d. other

4) Gingival lesions of genetic origin

a.hereditary gingival fibromatosis b.other

5. Gingival manifestations of systemic conditions a. mucocutaneous disorders 1. lichen planus 2. pemphigoid 3. pemphigus vulgaris 4. erythema multiforme 5. Lupus erythematosus 6. Drug-induced 7 .Other

b. Allergic reactions

1)     Dental restorative materials

a. Mercury

b. Nickel,

c.  Acrylic

d. Other

2)     Reactions attributable to

a. Toothpaste’s /dentifrice’s

b. Mouth rinses / mouth washes

c. Chewing gum additives

d. Foods and additives

3)     Other

6) Traumatic lesions (factitious, iatrogenic, accidental)

a. Chemical injury

b. Physical injury

c. Thermal injury

7) Foreign body reactions

8) Not otherwise specified (NOS)

II. Chronic Periodontitis

III. Aggressive Periodontitis

IV. Periodontitis as a manifestation of systemic diseases.

A) Associated with hematological. disorders.

1) Acquired neutropenia 2) Leukemias

3) Other

B) Associated with genetic disorders

1. Familial and cyclic Neutropenia

2. Down syndrome

3. Leukocyte adhesion deficiency syndromes

4. Papillon - Lefevre syndrome

5. Chediak – Higashi syndrome

6. Histiocytosis syndrome

7. Glycogen storage disease

8. Infantile genetic agranulocytosis

9. Cohen syndrome

10. Ehlers – Danlos syndrome (Types IV and VIII)

11. Hypophosphatasia

12. Other

C) Not otherwise specified (NOS)

V. Necrotising Periodontal Diseases

A) Necrotising ulcerative gingivitis (NUG) B) Necrotising ulcerative periodontitis (NUP)VI. Abscesses of the periodontium

A) Gingival abscess B) Periodontal abscess C) Periocoronal abscess

VII. Periodontitis assoicated with endodontic lesions

VIII. Developmental or Acquired Deformities & conditions

A) Localized tooth related factors that modify or predispose to plaque induced gingival disease / periodontitis 1. Tooth anatomic factors 2. Dental restorations / appliances 3. Root fractures 4. Cervical root resorption & cemental tears

B) Mucogingival deformities and conditions around teeth

1. gingival / soft tissue recession a. facial or lingual surfaces b. interproximal (papillary)

2. lack of keratinized gingiva

3. decreased vestibular depth

4. aberrant frenum / muscle position

5. gingival excess a. pseudopocket b. inconsistent gingival margin c. excessive gingival display d. gingival enlargement1 1 6.abnormal color

C) Mucogingival deformities and conditions on edentulous ridges

1. vertictal and / or horizontal ridge deficiency

2. lack of gingiva / keratinized tissue

3. gingiva / soft tissue enlargement

4. aberrant frenum / muscle position

5. decreased vestibular depth

6. abnormal color

D) Occlusal trauma

1. Primary occlusal trauma

2. Secondary occlusal trauma

1.The classification is very long and extensive.

2.The word “Other” is used too freely.

3.Under “drug influenced gingival diseases” it does not mention the

effects of alcohol, cocaine, heroine, crack and heart medications that

are well documented in the literature as causing increased plaque

formation and stimulating gingival over growth.

3.Removal of the term “Localized Juvenile periodontitis” is most

unfortunate because it is the most clearly defined of all periodontal

diseases.

4.There is no provision for the category of “Historical or “previous

disease” for a patient who has suffered periodontal disease in the

past and is no longer currently active.

5. The developmental & acquired conditions/deformities are not strictly

periodontal conditions.

5. NUG & NUP together called as necrotising periodontal diseases, they

should remain as separate terms.

6. The term ‘necrotizing stomatitis’ does not appear in the

necrotizing periodontal diseases list.

7. There is no discussion of TMJ problems.

8.There is no discussion on stress as aggravating factors in periodontal

disease.

9.There is no mention of biochemical mediators of GCF and their

effects on periodontal tissues.

10. The section on occlusal trauma does not in our opinion adequately

cover the magnitude of the pathology associated occlusion,

malocclusion and conutribute to TMJ malfuction.

11. There is still considerable overlap in disease categories

For administrative and third-party insurance reporting purposes, the

American Academy of Periodontology classifies gingivitis and periodontitis

into five broad case types (1997).

Plaque-associated gingivitis is designated as Case Type I.

Case Type II (early periodontitis) is characterized by progression of

inflammation into the deeper periodontal structures with slight bone and

attachment loss.

Case Type III (moderate periodontitis) is classified as a more advanced

state with increased destruction of the periodontal structures and

noticeable loss of bone support, possibly accompanied by increased tooth

mobility and furcation involvement on multirooted teeth.

Case Type IV (advanced periodontitis) is characterized by further

progression of periodontitis with major loss of alveolar bone support that

is usually accompanied by an increase in tooth mobility. Furcation

involvement is a common finding.

Case Type V (refractory periodontitis) includes those patients that

continue to demonstrate attachment loss after good conventional therapy.

Classification based on the extent of the disease

Van der Velden in 2000

Based on the severity of disease per tooth

Based on the age

Based on the clinical characteristics

First ,the extent of disease Severity Diagnosis made based on the clinical characteristics Based on age.

Ex:- localized severe juvenile periodontitis - semi-generalized minor juvenile periodontitis -generalized severe refractory post adolescent periodontitis

It is very likely that “Chronic periodontitis “ is a constellation of

diseases i.e. it is not a single entity, One of the main problems with

any attempt to classify this or any other forms of periodontitis is

that these infections are polymicrobial and polygenic ,in addition

the clinical expression of these diseases is altered by important

environmental and host-modifying conditions.

The facility to study gene expression & the genetic factors underlying

the differences in host response to periodontal pathogens between

patients may help inform the classification systems of 2010-2020.

Future systems are likely to be controversial, stimulate much debate

& require further modification.

Annals of periodontology vol.4 1999

Perio-2000 volume.39 2005

Perio-2000 volume.26 2001

A Chonological classification of periodontal disease: A

review

journal of internal academy of periodontology 2011 7/2 31-39