Classification of Periodontal Diseases

INTRODUCTION Classification should be a systematic arrangement of groups that possess common attributes. This arrangement should provide insight into the relationship between groups and between members of the same group. Classification of disease is necessary to separate conditions into distinct categories so as to aid clinical and laboratory diagnosis and specific treatments. A system of classifying or grouping the pathologic processes affecting the periodontium serves to identify the etiology and to facilitate communication among clinicians, students and epidemiologists. Over the years a number of classification systems have been developed to organize and name various disease entities or conditions affecting the periodontium. PURPOSE OF CLASSIFICATION SYSTEM 1. Communicating clinical findings accurately to other dental health care providers and to dental insurance providers. 2. Presenting information to the patient about his or her disease. 3. Formulating individualized treatment plans. 4. Predicting treatment outcomes.

DOMINANT PARADIGM IN THE HISTORICAL DEVELOPMENT OF PERIODONTAL CLASSIFICATION SYSTEM Development and evolution of classification systems for periodontal disease have been largely influenced by paradigms that reflect the understanding of the nature of periodontal disease during a given historical period. Thoughts that guided the classification of periodontal diseases can be placed into three dominant paradigms primarily: I. Clinical characteristics paradigm (1870-1920): From the periods 1870 to 1920, very little was known about the etiology and pathogenesis of periodontal disease. Accordingly, the diseases were classified almost entirely on the basis of their clinical characteristics supplemented by unsubstantiated theories about their cause. II. Classical pathology paradigm (1920-1970): The classification systems of this period were dominated by the classical pathology paradigm which was based on the principles of general pathology and included disease categories labeled as dystrophic, atrophic or degenerative. In 1928, Gottlieb classified periodontal diseases as: 1. Inflammatory Schmutz pyorrhea (poor oral hygiene) 2. Degenerative or atrophic Diffuse alveolar atrophy Paradental pyorrhea

In 1940, Box classified periodontal diseases as: 1. Gingivitis Acute Chronic 2. Periodontitis Acute Chronic Periodontitis simplex Periodontitis complex III. Infection/Host response paradigm (1970-present): Classification systems for periodontal disease currently in use are firmly based on and dominated by Infection/Host response paradigm. In 1977, Schluger, Yuodelis and Page classified periodontal diseases as: 1. Gingivitis Plaque associated gingivitis ANUG Hormonal gingivitis Drug - induced gingivitis 2. Marginal periodontitis Adult type Juvenile type In 1982, Page and Schroeder classified periodontal diseases as: Periodontitis Prepubertal (Generalized/Localized) Juvenile Rapidly progressing periodontitis Adult type periodontitis. AAP 1989 CLASSIFICATION (WORLD WORKSHOP IN CLINICAL PERIODONTICS) AAP World workshop in clinical periodontics classified periodontal diseases as: 1. Adult periodontitis 2. Early periodontitis (may be prepubertal, juvenile, rapidly progressive) 3. Periodontitis associated with systemic disease 4. Necrotizing periodontitis 5. Refractory periodontitis This classification was a refinement of one that had been proposed by Page and Schroeder in 1982. Main featuresThis classification was based on the infection/ host response paradigm depended heavily on the age of the affected patients (Prepubertal and Juvenile periodontitis), rate of progression (Adult and Early periodontitis), host factors (Periodontitis associated with ystemic disease) and response to the conventional therapy (Refractory periodontitis). Drawbacks associated with 1989 AAP classification: i. It does not include gingivitis/gingival disease category. ii. Periodontitis categories had nonvalidated age dependent criteria. iii. There was extensive crossover in rates of progression of the different categories of periodontitis. Rapidly progressive periodontitis was a heterogeneous category.

iv. There was extensive overlap in the clinical characteristics of the different categories of periodontitis. v. Refractory periodontitis was a heterogeneous category. vi. Prepubertal periodontitis was a heterogeneous category. vii. Finally, different forms of periodontitis proposed in the classification shared many microbiologic and host response features, which suggested extensive overlap and heterogeneity among the categories. As a consequence of these drawbacks, the 1989 classification was criticized shortly after it was published and different system was proposed and new classification was developed in 1993, by European workshop on Periodontology as: 1. Adult periodontitis 2. Early onset periodontitis 3. Necrotizing periodontitis. This classification lacked adequate categorization of broad spectrum of periodontal disease. Moreover, gingival diseases were also not included.

AAP 1999 CLASSIFICATION (INTERNATIONALWORKSHOP FOR CLASSIFICATION OF PERIODONTAL DISEASES) CLASSIFICATION OF PERIODONTAL DISEASES AND CONDITIONS
1. Gingival diseases Plaque induced gingival diseases Non- plaque induced gingival diseases 2. Chronic periodontitis Localized Generalized 3. Aggressive periodontitis Localized Generalized 4. Periodontitis as a manifestation of systemic diseases 5. Necrotizing periodontal diseases Necrotizing ulcerative gingivitis (NUG) Necrotizing ulcerative periodontitis (NUP) 6. Abscesses of the periodontium Gingival abscess Periodontal abscess Pericoronal abscess 7. Periodontitis associated with endodontic lesions Endodontic periodontal lesion Periodontal endodontic lesion Combined lesion 8. Developmental or acquired deformities and conditions

 Localized tooth related factors that predispose to plaque induced gingival diseases or periodontitis Mucogingival deformities and conditions around teeth Mucogingival deformities and conditions on edentulous ridges Occlusal trauma

GINGIVAL DISEASES
Dental plaque - Induced gingival diseases
These diseases may occur on a periodontium with no attachment loss or on one with attachment loss that is stable and not progressing. I. Gingivitis associated with dental plaque only A. Without local contributing factors B. With local contributing factors II. Gingival diseases modified by systemic factors A. Associated with endocrine system 1. Puberty associated gingivitis 2. Menstrual cycle associated gingivitis 3. Pregnancy associated a. Gingivitis b. Pyogenic granuloma 4. Diabetes mellitus associated gingivitis B. Associated with blood dyscrasias 1. Leukemia associated gingivitis 2. Other III. Gingival diseases modified by medications A. Drug influenced gingival diseases 1. Drug influenced gingival enlargements 2. Drug influenced gingivitis a. Oral contraceptive associated gingivitis b. Other IV. Gingival diseases modified by malnutrition A. Ascorbic acid deficiency gingivitis B. Other

Non Plaque induced gingival diseases

I. Gingival diseases of specific bacterial origin A. Neisseria gonorrhea B. Treponema pallidum C. Streptococcal species D. Other II. Gingival diseases of viral origin A. Herpes virus infections a. Primary herpetic gingivostomatitis b. Recurrent oral herpes c. Varicella Zoster B. Other III. Gingival diseases of fungal origin A. Candida - species infections: Generalized gingival candidiasis B. Linear gingival erythema C. Histoplasmosis D. Other IV. Gingival diseases of genetic origin A. Hereditary gingival fibromatosis B. Other

V. Gingival manifestations of systemic conditions A. Mucocutaneous lesions 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. Toothpastes or dentifrices b. Mouthrinses or mouthwashes c. Chewing gum additives d. Food and additives 3. Other VI. Traumatic lesions ( factitious, iatrogenic,or accidental) A. Chemical injury B. Physical injury C. Thermal injury VII. Foreign body reactions VIII. Not otherwise specified

DEVELOPMENTAL/ACQUIRED DEFORMITIES AND CONDITIONS

Developmental or acquired deformities and conditions Localized tooth related factors that modify or predispose to plaque induced gingival diseases or periodontitis 1. Tooth anatomic factors 2. Dental restorations or appliances 3. Root fractures 4. Cervical root resorption and cemental tears Mucogingival deformities and conditions around teeth 1. Gingival or soft tissue recession A. Facial or lingual surfaces B. Interproximal (papillary) 2. Lack of keratinized gingiva 3. Decreased vestibular depth 4. Aberrant frenum or muscle position 5. Gingival excess A. Pseudopocket B. Inconsistent gingival margin C. Excessive gingival display D. Gingival enlargement E. Abnormal color Mucogingival deformities and conditions on edentulous edges I. Vertical and or horizontal ridge deficiency II. Lack of gingiva or keratinized tissue III. Gingival or soft tissue enlargements IV. Aberrant frenum or muscle position V. Decreased vestibular depth VI. Abnormal color Occlusal trauma

1. Primary occlusal trauma 2. Secondary occlusal trauma

Main features of AAP 1999 classification system are: i. Comprehensive section of gingival diseases is included in this classification. ii. There is replacement of the term adult periodontitis with chronic periodontitis, since epidemiological evidence suggests that chronic periodontitis may also be seen in adolescents. iii. There is elimination of separate categories of rapidly progressive periodontitis and refractory periodontitis because of the lack of evidence that they represent separate conditions. iv. There is replacement of the term early onset periodontitis with aggressive periodontitis largely because of the clinical difficulties in determining the age of onset in many of these cases. The author of this new classification also questions the use of the term juvenile periodontitis for the same reasons. They have replaced the term with localized and generalized aggressive periodontitis. The term aggressive was added because bone and tissue destruction occurs rapidly as compared with other periodontitis. v. A new classification group of periodontitis as a manifestation of systemic disease has been created and this includes those cases of prepubertal periodontitis directly resulting from known systemic diseases. vi. There are also new group categories of abscesses of the periodontium, periodontic endodontic lesions and evelopmental/acquired deformities/conditions.