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Clinical New Disease Classification System The New Classification Scheme

for Periodontal Diseases and Conditions

Article  in  The Journal of the Ontario Dental Association · April 2019

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 Clinical
New Disease Classification System

The New Classification Scheme

Zeeshan Sheikh
Dip.Dh BDS MSc PhD

Nader Hamdan

for Periodontal Diseases

BDS MSc MDent (Perio)

Michael Glogauer
DDS Dip.Perio PhD

and Conditions

Recently, the American Academy of Periodontology Step 2: Establishing a stage focuses on considerations
(AAP) published the official proceedings from the 2017 of clinical attachment loss (CAL), radiographic bone
World Workshop on the Classification of Periodontal and loss (RBL), tooth loss due to periodontitis, and case
Peri-Implant Diseases and Conditions (1). The proceed- complexity. For mild to moderate periodontitis, CAL
ings provided and announced a new periodontal disease is the central focus, unlike the more advanced stages
classification system to replace what was previously in (Stages III and IV) where RBL and case complexity
the AAP Clinical practice guidelines. The guidelines have factors are taken into account.
not been updated from the previous disease classification Step 3: Establishing a grade focuses on assessing risk
since being established at the 1999 International Work- factors, systemic considerations, rate of disease pro-
shop for a Classification of Periodontal Diseases and gression, and outcomes of non-surgical periodontal
Conditions (2). therapy.
A classification scheme for periodontal and peri-
implant diseases and conditions is required for dental Staging of periodontitis
clinicians to appropriately diagnose and treat patients Four stages have been developed to differentiate be-
and to allow researchers to investigate the etiology, tween severity, complexity and extent, and distribution
pathogenesis, natural history, and treatment of peri- of periodontitis. The stages, consisting of Stage I-IV are
odontal diseases. In 1999, periodontal diseases were determined by several variables and range from the least
mainly classified as chronic, aggressive (localized and severe Stage I to most severe Stage IV, as presented in
generalized), necrotizing, and a manifestation of sys- Table 1.
temic disease (2). Since then, new technology, research Narrative descriptions of the stages are below:
and information has emerged, which has led to the new
revisions. Stage I (mild disease): CAL = 1-2 mm, probing depth
The AAP released two documents entitled, “Three ≤4 mm, radiographic evidence of horizontal bone loss
Steps to Staging and Grading a Patient” and “Staging and ≤15 per cent, and will require non-surgical treatment. No
Grading Periodontitis” (3). A quick outline of the three post-treatment tooth loss is expected, indicating the case
steps are: has a good prognosis going into maintenance care.
Step 1: Initial Case Overview to Assess Disease rec-
ommends conducting a screening consisting of full- Stage II (moderate disease): CAL = 3-4 mm, probing
mouth radiographs and probing depths and noting depth ≤5 mm, radiographic evidence of horizontal bone
missing teeth. Based on the findings from Step 1, a loss between 15 and 33 per cent and will require non-
determination of mild-moderate periodontitis, which surgical and surgical treatment. No post-treatment tooth
is considered Stage I or Stage II, can be made. Severe loss is expected, indicating the case has a good prognosis
or very severe periodontitis is considered to be Stage going into maintenance.
III or Stage IV.

30 OD • April 2019
 New Disease Classification System

Table 1.
Staging periodontitis

Periodontitis Stage I Stage II Stage III Stage IV

Severity Interdental 1-2mm 3-4mm ≥ 5mm ≥ 5mm

CAL (at site of
greatest loss)
RBL Coronal third Coronal third Extending to middle Extending to middle third of
(radiographic (<15%) (15%-33%) third of root and beyond root and beyond
bone loss)
Tooth loss (due to No tooth loss No tooth loss ≤ 4 teeth ≥ 5 teeth
periodontitis)
Complexity Local – Maximum – Maximum In addition to Stage II In addition to Stage III
probing probing complexity: complexity:
depth ≤ depth ≤ – Probing depths _ Need complex
4mm 5mm
≥ 6mm rehabilitation due to:
_ Mostly _ Mostly _ Vertical bone loss _ Masticatory
horizontal horizontal
≥ 3mm dysfunction
bone loss bone loss
_ Furcation involve- _ Secondary occlusal
ment Class II or III trauma (tooth
_ Moderate ridge mobility degree ≥2)
defects – Severe ridge defects
– Bite collapse, drifting,
flaring
_ <20 remaining teeth
(10 opposing pairs)
Extent and Add to stage as For each stage,
Distribution descriptor describe extent as: Localized (<30% of
teeth involved);
Generalized; or
Molar/incisor pattern

Source: American Academy of Periodontology. Available at:

https://www.perio.org/sites/default/files/files/Staging%20and%20Grading%20Periodontitis.pdf

Stage III (severe disease): CAL ≥ 5mm, probing depth To determine extent and distribution of periodontitis,
≥6 mm, radiographic evidence of horizontal and/or the per cent of “teeth” affected by periodontitis is as-
vertical bone loss beyond 33 per cent and may have sessed. This provides information about how many teeth
furcation involvement of Class II or III. This will require are affected by periodontitis, which is expressed as local-
surgical and possibly regenerative treatments. There is ized or generalized. It does not give information about
the potential for loss of up to four teeth. The complex- the per cent of teeth with slight, moderate, or severe
ity of implant and/or restorative treatment is increased. destruction. Distribution refers to affected teeth, such as
The patient may require multi-specialty treatment. The first molars and/or incisors (e.g., Stage III periodontitis
overall case has a fair prognosis going into maintenance. with a generalized molar distribution).

Stage IV (very severe disease): Includes all of Stage Grading of periodontitis

III features. Less than 20 teeth may be present and there The three levels of periodontitis grading consider the
is the potential for loss of five or more teeth. Advanced overall health status of the patient and risk factors,
surgical treatment and/or regenerative therapy may be such as smoking and metabolic control of diabetes, and
required, including augmentation treatment to facilitate indicates low risk of progression (Grade A), moderate
implant therapy. Very complex implant and/or restora- risk of progression (Grade B), and high risk of progres-
tive treatment may be needed. The patient will often sion (Grade C). Grading of periodontitis is also based on
require multi-specialty treatment. The overall case has a evaluating the rate of progression of disease and expected
questionable prognosis going into maintenance. response to treatment (Table 2).

April 2019 • OD 31
New Disease Classification System

Table 2.
Grading periodontitis

Progression Grade A: Grade B: Grade C:

Slow rate Moderate rate Rapid rate
Primary Direct evidence of Radiographic bone No loss over 5 years < 2mm over 5 years ≥ 2mm over 5 years
criteria progression loss or CAL
Whenever available,
direct evidence Indirect evidence % bone loss/age < 0.25 0.25 to 1.0 >1.0
should be used. of progression

Case phenotype Heavy biofilm deposits Destruction Destruction exceeds

with low levels of commensurate with expectations given
destruction biofilm deposits biofilm deposits;
specific clinical
patterns suggestive
of periods of rapid
progression and/or
early onset disease
Grade modifiers Risk factors Smoking Non-smoker < 10 cigarettes/day ≥ 10 cigarettes/day

Diabetes Normoglycemic/no HbA1c < 7.0 % in HbA1c ≥ 7.0 % in

diagnosis of diabetes patients with patients with
diabetes diabetes

Source: American Academy of Periodontology. Available at:

https://www.perio.org/sites/default/files/files/Staging%20and%20Grading%20Periodontitis.pdf

Narrative descriptions of the grades are below: are now mainly defined as one of three distinct forms,
which include periodontitis (formerly aggressive and
Grade A (slow progression): No bone loss or CAL chronic), necrotizing periodontitis, and periodontitis as
over five years, no smoking, no diabetes, heavy biofilm a manifestation of systemic conditions.
but no tissue destruction.
Periodontal and peri-implant diseases
Grade B (moderate progression): Less than 2 mm and conditions
bone loss or CAL over five years, half pack or less per day Periodontal diseases and conditions can be broken down
smoking, HbA1c less than 7 per cent, biofilm commen- into three main categories:
surate with destruction. 1. Periodontal health and gingival diseases
- periodontal and gingival health
Grade C (rapid progression): Greater than 2 mm of - gingivitis caused by biofilm (bacteria)
bone loss or CAL over five years, half pack or more per - gingivitis not caused by biofilm
day smoking, HbA1c 7 per cent or higher, tissue destruc- 2. Periodontitis
tion exceeds amount of biofilm. - necrotizing diseases
- periodontitis as a manifestation of systemic
Staging and grading provide a structure for treatment disease
planning and for monitoring a patient’s response to - periodontitis
therapy. They also allow the assessment of several di- 3. Other conditions affecting the
mensions beyond severity of past destruction, including periodontium
specific elements that contribute to complexity of man- - systemic diseases affecting the periodontium
aging the patient’s case and the risk for future disease - periodontal abscess or periodontal/endodontic
progression. Thus, the new classification system can be lesions
used to develop a well-rounded treatment strategy based - mucogingival deformities and conditions
on a patient’s specific needs, resulting in a personalized - traumatic occlusal forces
approach to patient care. Forms of periodontal disease - tooth- and prosthesis-related factors

32 OD • April 2019
 New Disease Classification System

Figure 1: Localized Stage III, Grade B Periodontitis

Clinical photographs and radiographic images (periapical and vertical bitewings) of a 55-year-old male patient. Patient reported smoking 20
cigarettes/day and is a controlled diabetic (most recent HbA1c <7%). The deepest CAL is >5mm and PPD >6mm, patient lost no teeth to peri-
odontal disease. There were class II and III furcation defects around some of the molars and secondary occlusal trauma (Grade II mobility). The
risk here is losing some of those affected teeth and not the whole dentition. Compared to previous records, the patient had a moderate rate of
progression. The extent of this disease has been assigned “localized” as <30% of teeth are affected.

Figure 2: Generalized Stage IV, Grade B Periodontitis

Clinical photographs and radiographic images (periapical and vertical bitewings) of a 78-year-old male patient. Patient reported smoking 7-10
cigarettes/day and is a controlled diabetic (most recent HbA1c <7%). The deepest CAL is >5mm, patient lost >5 teeth to periodontal disease.
Patient suffers from masticatory dysfunction, secondary occlusal trauma (tooth mobility degree ≥2), bite collapse/drifting/flaring. The extent of
this disease has been assigned “generalized” as >30% of teeth are affected.

Figure 3: Generalized Stage IV, Grade C Periodontitis.

Clinical photographs and radiographic images (periapical and bitewings) of a 34-year-old female patient. Patient is a non-smoker and
normoglycemic. The deepest interproximal CAL is >5mm, patient lost a few teeth to periodontal disease. There were class II and III furcation
defects around some of the molars. Patient also suffers from masticatory dysfunction, secondary occlusal trauma (tooth mobility degree ≥2),
bite collapse/drifting/flaring, and is at risk of losing her dentition. Despite absence of previous records for this case, based on the patient’s
age and amount of bone loss, this is considered a rapid rate of disease progression “C.” According to the previous periodontal disease
classification system (1999), this would have been “generalized aggressive periodontitis case.”
Aggressive periodontitis does not exist in the new classification system.
(Radiographs courtesy of Dr. Robert Schroth — Private Practice, Manitoba).

April 2019 • OD 33
New Disease Classification System

In addition, the workshop proceedings also included, 2. Armitage GC. Development of a classification
for the first time, a new classification for peri-implant system for periodontal diseases and conditions.
diseases and conditions. Implant dentistry has become Annals of Periodontology. 1999 Dec 1;4(1):1-6.
a main component of patient treatment planning and 3. Tonetti MS, Greenwell H, Kornman KS. Staging and
care since 1999. And just like tissues that support natural grading of periodontitis: Framework and proposal
teeth, the bone and soft tissues surrounding dental im- of a new classification and case definition. Journal of
plants are susceptible to inflammation-driven complica- Periodontology. 2018 Jun;89:S159-72.
tions in the absence of proper care and management (4). 4. Lindhe J, Meyle J, Group D of the European Work-
Peri-implant diseases and conditions can be broken shop on Periodontology. Peri-implant diseases: con-
down into four major categories: sensus report of the sixth European workshop on
1. Peri-implant health: Identified by the absence periodontology. Journal of Clinical Periodontology.
of visible inflammation and bleeding on probing. 2008 Sep;35:282-5.
2. Peri-implant mucositis: Characterized by 5. Heitz-Mayfield LJA, Salvi GE. Peri-implant mu-
bleeding on probing and visual signs of inflamma- cositis. Journal of Clinical Periodontology. 2018
tion without pathologic bone loss. It is a plaque- Jun;45:S237-45.
associated condition occurring in the soft-tissues 6. Renvert S, Persson GR, Pirih FQ, Camargo PM.
around dental implants. Peri-implant health, peri-implant mucositis, and
3. Peri-implantitis: Peri-implantitis is indicated by peri-implantitis: Case definitions and diagnostic
inflammation of mucosal tissue and subsequent considerations. Journal of Clinical Periodontology.
progressive loss of supporting bone (5). 2018 Jun;45:S278-85.
4. Peri-implant soft- and hard-tissue deficien-
cies: Hard- and soft-tissue implant site deficiencies Dr. Zeeshan Sheikh is trained as a dental clini-
(associated with healing after tooth loss, extrac- cian and a biomaterials scientist and has more
tion trauma, endodontic infections, injury, and than five years of clinical experience in private and
other causes) are also included within the implant hospital-based dentistry. He currently works at the
condition classification (6). University of Toronto and Mt. Sinai Hospital, and
In conclusion, this short article is not a comprehen- his expertise lies in developing novel biomaterial options for
sive reflection of the 2017 World Workshop on the bone grafting and alveolar ridge augmentation applications.
Classification of Periodontal and Peri-Implant Diseases
and Conditions. It is meant to inform busy colleagues Dr. Nader Hamdan is an assistant professor and
about the main features of this new classification, and director of the graduate periodontics program,
we encourage them to read the full articles published by Faculty of Dentistry at Dalhousie University.
the AAP. We recognize and highly appreciate the hard Besides his academic full-time position, Dr.
work of our expert colleagues who were involved in the Hamdan treats his own patients in multiple pri-
workshop, and we expect that the classification system vate practices limited to periodontics and dental implant
we still see some changes and additions as our knowledge surgery in Canada. Dr. Hamdan is a member of the Ameri-
and understanding of periodontal diseases and condi- can Academy of Periodontology, the Canadian Academy of
tions continues to grow. Nevertheless, the new classifi- Periodontology, the Atlantic Society of Periodontists, and the
cation system aligns with what we have learned about Steering Committee of the Network for Canadian Oral Health
periodontal disease progression in the last 20 years and Research (NCOHR).
it will lay the foundation for future research. Though its
widespread adoption is expected to take time, the classi- Dr. Michael Glogauer is a professor at the
fication system will be the primary paradigm for patient University of Toronto and interim head of den-
care around the world in the years to come. OD tal oncology at Princess Margaret Hospital. His
research and clinical interests focus on developing
REFERENCES novel bone-grafting approaches prior to implant
1. Berglundh T, Armitage G, Araujo MG, Avila-Ortiz G, placement and the role of the oral innate immune system in
Blanco J, Camargo PM, et al. Peri-implant diseases maintenance of health. He is currently focusing on using oral
and conditions: Consensus report of workgroup innate immune biomarkers to detect early stages of periodon-
4 of the 2017 World Workshop on the Classifica- tal diseases through his role as scientific director at Mt. Sinai
tion of Periodontal and Peri-Implant Diseases and Hospital’s Centre for Advanced Dental Research and Care. He
Conditions. Journal of Clinical Periodontology. 2018 is a periodontist at OMGPerio.ca.
Jun;45:S286-91.

34 OD • April 2019

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