Focus

Dening and classifying periodontitis:

need for a paradigm shift?
Vibeke Baelum, Rodrigo Lopez
Department of Community Oral Health and
Pediatric Dentistry, Faculty of Health Sciences,
University of Aarhus, Aarhus, Denmark
Almost 40 yr ago, Scherp (1) noted that Discussions of
periodontal disease commonly begin with the tacit
assumption that all participants are considering the same
entity. Since the varieties of periodontal diseases are
almost limitless, depending on ones taste for subclassi-
cation, this unqualied usage often leads to fruitless
semantic misunderstandings. This quote epitomizes a
problem that remains prominent in periodontology: the
lack of a unied and joint understanding of the diseases
under study. While some of the disagreements may
reect the adherence to dierent disease paradigms (2),
variation may be discerned even among proponents of
the same paradigm. There is thus a great reluctance to
specify the clinical features that document periodontitis
any further than this example shows: These [features]
include probing pocket depth, gingival recession, pro-
bing attachment level, gingival width, furcation involve-
ment, tooth mobility, and radiographically determined
bone changes (3). As a result, the literature is charac-
terized by the use of a vast array of dierent criteria for
the diagnosis of periodontitis (2, 4), and this has ham-
pered attempts to review the literature and synthesize
current knowledge.
Further evidence that Scherps statement still holds
may be found in the numerous proposals published for
the classication of periodontitis. Just considering the
past 20 yr, at least 10 dierent periodontitis classica-
tions have been proposed and published (513). Even
though some of these classications (6, 11) have been
advocated by scientic societies their survival time has,
nevertheless, been quite short.
We submit that the large number of periodontitis
classications proposed and the large variability of the
methods used to record and document periodontitis
indicate that the basis for the denition and classication
of periodontitis needs to be carefully reconsidered. We
argue that the problems largely result from the implicit
adherence to an essentialistic disease concept (14, 15).
We also argue that the driving force underlying the
many periodontitis classications is an unjustied
belief in the existence of a diagnostic truth for perio-
dontitis. We thus submit that a nominalistic approach
(14, 15) to the denition of periodontitis and the
recognition of periodontitis as a syndromically dened
disease will be helpful in bringing periodontology for-
ward towards a unied and common understanding of
periodontitis.
Essentialism in periodontitis definitions
Although the tacit assumption (1) of a common under-
standing of periodontitis has frequently been invoked,
explicit disease denitions have been oered. In the mid-
1960s, when the gingivitis-periodontitis continuum was
central to the dominant periodontal disease paradigm
(2), Scherp (1) dened the most common form of
periodontal disease as an inammatory process aecting
one or more of the supporting tissues of the teeth the
gingival tissue, the periodontal membrane, and the
alveolar bone. In the early 1980s, Page & Schroeder (5)
dened periodontitis as an inammatory disease of the
periodontium characterized by the presence of (a) peri-
odontal pocket(s) and active bone resorption with acute
inammation. Most recently, the American Academy of
Periodontology (AAP) (16) dened chronic periodontitis
Baelum V, Lopez R. Dening and classifying periodontitis: need for a paradigm shift?.
Eur J Oral Sci 2003; 111: 26. Eur J Oral Sci, 2003
The past two decades have witnessed a large number of proposals for the classication
of periodontitis. These proposals are all founded in an essentialistic disease concept,
according to which periodontitis is a link between the causes and the signs and
symptoms of periodontitis. Essentialistic denitions are necessarily rather imprecise
and thereby subject to multiple interpretations. Consequently, it remains unknown to
what extent current knowledge regarding dierent forms of periodontitis is based on
the same type of patients. However, periodontitis is a syndrome, the clinical mani-
festations of which may come in all sizes. Thereby, periodontitis has no diagnostic
truth, just as there is no natural basis for a sharp distinction between health and
disease or between dierent forms of periodontitis. Recognition of these facts and
adoption of a nominalistic approach to the denition of periodontitis is needed to
provide a rational framework for the development of a classication system that meets
the needs of both clinicians and scientists.
Vibeke Baelum, Department of Community
Oral Health and Pediatric Dentistry,
Faculty of Health Sciences,
University of Aarhus,
Vennelyst Boulevard 9, DK)8000 Aarhus C,
Denmark
Telefax: +4586136550
E-mail: baelum@odont.au.dk
Key words: classification; diagnosis; disease;
periodontitis; syndrome
Accepted for publication November 2002
Eur J Oral Sci 2003; 111: 26
Printed in UK. All rights reserved
Copyright Eur J Oral Sci 2003
European Journal of
Oral Sciences
ISSN 0909-8836
as an infectious disease resulting in inammation within
the supporting tissues of the teeth, progressive attach-
ment and bone loss characterized by pocket formation
and/or recession of the gingiva.
The wording of these disease denitions provides a key
hint to the reasons why none of them have translated
into uniform and operational criteria for the presence of
periodontal disease/periodontitis/chronic periodontitis.
All three denitions reect a disease concept that has
been termed essentialistic or demonic because it holds
that a given disease has an independent existence (14, 15).
A denition which begins Periodontitis is an inamma-
tory disease of the periodontium implies a priori the
existence of something that can be identied as perio-
dontitis. When the denition subsequently states that the
disease results in attachment and bone loss and is
characterized by the presence of periodontal pockets, it
appears as knowledge that periodontitis is an essence
that may produce the symptoms pockets and bone loss.
The core theme of the essentialistic disease concept has
been summarized by Scadding (15): Essentialist ideas
about disease are implicit in colloquial speech. Diseases
are regarded as causes of illness. The doctors skill con-
sists in identifying the causal disease and then prescribing
the treatment. However, the essentialistic disease con-
cept leads to circular reasoning (15): The essentialist
hankering after a unied concept of disease as a class of
agents causing illness is mistaken and misleading for
several good reasons: many diseases remain of unknown
cause; known causes are of diverse types; causation may
be complex, with interplay of several factors, intrinsic
and extrinsic; and, more generally, an eect the disease
should not be confused with its own cause.
The essentialistic reasoning is Causes Disease
Signs and Symptoms. The periodontitis denitions pre-
viously cited illustrate how an essentialistic belief in the
existence of a disease essence that links the causes and
the signs and symptoms results in non-operational peri-
odontitis denitions. Rigid application of the denition
provided by Scherp (1) will result in everybody being
considered a case. The denition provided by Page &
Schroeder (5) is non-operational because features such
as active bone resorption and acute inammation have
no practically observable and measurable expressions.
Finally, the AAP denition (16) is non-operational
because progressive attachment loss has no practical
expression at a given point in time (assessment of pro-
gression necessitates two observations spaced in time),
and because very few adults are completely free from
signs of attachment loss, bone loss, pockets or recession.
However, it is precisely the lack of specicity and the
high level of abstraction inherent in the essentialistic
periodontitis denitions that allow periodontitis to be
construed as an essential link between the causes and the
signs and symptoms.
Nominalism and periodontitis
The essentialistic disease concept has a counterpart in
what has been called the nominalistic disease concept
(14, 15, 17). According to this, the term periodontitis is
just a term used to label a group of individuals that share
certain dening characteristics. The name chosen to label
the group (e.g. periodontitis) is just a brief statement of
the common abnormality by which the particular group
of periodontitis-patients can be identied. Importantly,
the disease periodontitis is not restricted to encompass
only those signs and symptoms that are made explicit by
the label (the disease name), but encompasses the whole
range of signs and symptoms that may be observed in
periodontitis-patients. The implications of this are per-
haps best understood using an alternative example such
as mitral stenosis, which refers to the complex of
symptoms and signs observed in persons with narrow
mitral valves and not simply to the narrowed mitral
valve (17). More generally, disease names have been
described as no more than a convenient way of stating
briey the endpoint of a diagnostic process that pro-
gresses from assessment of symptoms and signs towards
knowledge of causation. They may have gone no fur-
ther than recognition of a familiar pattern; they may
have progressed to detection of underlying disorders of
structure or of function; or they may have identied
specic causes (15).
It is central to the nominalistic disease concept that
diseases have no existence apart from that of patients
with them (15). The old dictum that there are no dis-
eases, only sick people, is thus a core theme. Methodo-
logically, nominalistic disease denitions specify disease
based on observable and measurable phenomena (17)
and it is essential to the nominalist disease denition that
there are norms for these phenomena with which the
characteristics of the patient can be compared in order to
accept or discard the tentative diagnosis.
The basis for defining disease
The use of the term disease in colloquial speech is based
on the comfortable delusion that everyone knows what
it means (17). However, a formal denition is required
for use in a scientic context. Scadding (17) has pro-
posed the following denition: A disease is the sum of
abnormal phenomena displayed by a group of living
organisms in association with a specied common char-
acteristic or set of characteristics by which they dier
from the norm for their species in such a way as to place
them at a biological disadvantage. This denition
necessitates the establishment of normal standards, and
implies a statistical basis for the assessment of abnor-
mality (17), a strategy which is well known from a
number of diagnostic elds (e.g. routine blood tests).
Although the term biological disadvantage is necessarily
rather vague, it species that abnormalities may indeed
exist which are not disease-related.
Ideally, a nominalistic disease denition describes a
set of criteria that are fullled by all persons said to have
the disease, but not fullled by persons that are con-
sidered free from the disease (18). This framework
accommodates diseases that are anatomically dened,
such as breast cancer, diseases that are metabolically or
Dening and classifying periodontitis 3
physiologically dened, such as arterial hypertension,
and diseases that are etiologically dened, such as chol-
era (18). However, many disease denitions do not meet
these requirements, and a large number of diseases are
dened as syndromes. A simple syndrome is diagnosed
when a xed combination of clinical signs and symptoms
are present simultaneously, while an etiologically or
anatomically dened disease has been excluded as a
dierential diagnostic possibility (since syndromes are
subordinate to such diseases) (18). For a composite syn-
drome, no single sign or symptom is necessary for
the diagnosis. Well-known examples of composite syn-
dromes are rheumatoid arthritis and systemic lupus
erythematosus, both of which have explicit dening cri-
teria (Table 1). Rheumatoid arthritis is diagnosed when
at least four of seven criteria are simultaneously fullled
(19), whereas the diagnosis of systemic lupus erythema-
tosus requires the simultaneous presence of at least four
of eleven criteria (Table 1) (20). It follows that two
patients with systemic lupus erythematosus need not
have any signs or symptoms in common, whereas two
rheumatoid arthritis patients have a least a single com-
mon nding.
Periodontitis is a syndrome that may come
in all sizes
Periodontitis is a good example of a syndromically
dened disease (21). Although there is a general agree-
ment that the dening characteristics for periodontitis
are to be found among the features inamed gingivae,
pocket formation, gingival recession, clinical attachment
loss, alveolar bone loss, tooth mobility, and tooth drift
(3, 16), more explicit and commonly accepted dening
criteria for periodontitis have not (as yet) been estab-
lished. Moreover, each of these dening characteristics
may vary considerably between individuals, in terms of
both the extent and the severity. Marshall-Day et al.
(22) noted that signs and symptoms of periodontitis are
ubiquitous among adults. Beyond the age of 35 yr most
persons in a population will display signs of periodon-
tal destruction (2), and the prevalence of periodontal
destruction in the form of clinical attachment loss
approaches 100% (2). On a population basis, the extent
(number of teeth aected) and the severity (degree of
destruction per tooth) increases with increased age,
although the distribution of both the extent and the
severity of periodontal signs and symptoms tends to be
rather skewed in all age-groups (2). These characteristics
necessarily imply that the idea of a sharp distinction
between health and disease is a medical artifact for which
nature, if consulted, provides no support (23). In cor-
roboration of this statement, Machtei et al. (24) noted
that none of the attachment or pocket depth levels
considered yielded a bi-modal distribution which might
be compatible with health and disease. Similarly, epi-
demiological studies clearly show that the absence or
low severity of clinical attachment loss merges imper-
ceptibly into high severity of clinical attachment loss
(25).
Essentialism and the clinical problem
diagnostic variation
Although periodontitis appears in all degrees, with low
merging imperceptibly into high (25), and although no
explicit dening criteria for periodontitis have yet been
established, dental practitioners are faced with diagnostic
and therapeutic decisions on a daily basis. Diagnostic
and therapeutic decisions are yes/no decisions and the
clinical management of periodontitis requires unam-
biguous case/non-case labels. While thousands of such
labels are issued by dental practitioners every day, the
reluctance to explicate and formalize the dening criteria
for periodontitis leaves the diagnostic decisions in the
hands of the art of dentistry, the likely result of which is
diagnostic variation between practitioners. Such vari-
ation is problematic since the diagnosis case/non-case,
and hence the decision whether and how to intervene, is
meant to have bearing on the health outcome. Provided
that periodontal therapy is eective, a dierent diagnosis
(e.g. case or non-case) assigned to the same patient will
result in dierent health outcomes, with the non-case
patient experiencing an inferior health outcome.
In view of the fact that practitioners have to issue case/
non-case labels routinely, it should be possible to make
explicit quantitative statements about the dening char-
acteristics for periodontitis. Indeed, the denitions pro-
posed by Machtei et al. (24) and by van der Velden
(12) represent such explicit quantitative statements,
although none of these proposals have gained popu-
larity. The continuous nature of periodontitis means that
no matter how carefully chosen, explicit dening criteria
will have elements of arbitrariness (17), just as the de-
ning criteria cannot reect some underlying natural
denition of periodontitis (23), because none exists.
However, decisions that are based on a single, commonly
accepted set of criteria have the potential to be superior
Table 1
Dening criteria for the diagnosis of the composite clinical
syndrome rheumatoid arthritis (19) and systemic lupus
erythematosus (20). If four or more symptoms are present,
a positive diagnosis may be made
Rheumatoid
arthritis
Systemic lupus
erythematosus
Morning stiness Malar rash
Arthritis of at least
three joint areas
Discoid rash
Arthritis of hand joints Photosensitivity
Symmetric arthritis Oral ulcers
Rheumatoid nodules Arthritis
Serum rheumatoid factor Serositis
Radiographic changes Renal symptoms
Neurological symptoms
Neurological symptoms
Immunological symptoms
Antinuclear antibody
All the symptoms are described in more detail in other publi-
cations (19, 20).
4 Baelum & Lopez
to decisions that are based on a multitude of individual,
possibly informal criteria.
Essentialism and the scientific problem
etiological defining characteristics?
Most of the periodontitis classications that have been
proposed over just a short period of time (513) reect a
belief that diseases are objects like animals, plants and
bacteria, which can be dissected and analysed to yield
features by which they can be classied (17). The
underlying belief is that the continued dissection of
periodontitis, in terms of its clinical and laboratory
characteristics, will ultimately lead to a complete
understanding of a nite number of distinct forms of
periodontitis, with each having their own sucient cau-
sal constellation. It has thus been stated that one goal of
periodontal investigation should be to move as quickly
as possible toward the ultimate classication of perio-
dontal diseases based on their etiology (26). This state-
ment is founded on a belief that the number of sucient
causes will be limited and fully identiable. However, to
date, all indications have been that the causal web for
periodontitis is so complex and involves so many factors
in so many dierent constellations (27) that a classica-
tion of periodontitis based on etiology is eectively
precluded.
Therefore, in the absence of an etiological basis for the
denition and classication, periodontitis must be con-
strued as a composite syndrome, which is dened by
its universal outcome periodontal destruction and
brought about by contributing factors that might be
many and varied, and perhaps even peculiar to each
individual. Being a syndromically dened disease, peri-
odontitis has no diagnostic truth (14) in the sense that no
external, independent diagnostic method exists which
may be used to establish the truth of the diagnosis. This
means that whenever a new sign or symptom or labor-
atory nding is described and subsequently used diag-
nostically, it merely leads to changes in the syndrome
denition or, as has frequently been the case for perio-
dontitis, the disease classication. A good example of
this is the recent change from a classication system
focusing on age (early onset and adult periodontitis) to a
classication systems that places emphasis on the rate of
periodontal destruction (aggressive and chronic perio-
dontitis) (28, 29).
Concluding remarks
Scherp (1) was very precise stating that the varieties of
periodontal diseases are almost limitless, depending on
ones taste for subclassication. The past two decades
have witnessed many new periodontitis classications
(513), some of which have been widely adopted. These
classication systems have all but one been based on an
essentialistic disease concept, which has rendered them
susceptible to multiple interpretations. It is therefore
unclear to what extent studies investigating the etiology
of periodontitis or the eect of periodontal treatment are
based on the study of the same type of patients.
This unfortunate situation is likely to remain until it is
realized that periodontitis is a syndrome for which there
is no diagnostic truth. Moreover, it must be acknow-
ledged that nature provides no basis for a sharp dis-
tinction between periodontal health and disease or
between dierent periodontal disease forms. Failure to
recognize this will only result in continued preference
being given to hazy essentialistic periodontitis denitions
at the expense of precise nominalistic denitions. The
periodontal literature is full of examples of great reluct-
ance to set arbitrary thresholds, and the issue of case
denitions is described as thorny (30). However, it is
possible to overcome this if the strong belief in a under-
lying (undiscovered) truth is abandoned, and the con-
tinuous nature of the distribution of periodontal signs
and symptoms is recognized.
It is frequently argued that periodontitis classication
systems are needed to give clinicians a way to organize
the health care needs of their patients (11), and to pro-
vide a framework in which to scientically study the eti-
ology, pathogenesis, and treatment of diseases in an
orderly fashion (11). Adherence to a nominalistic perio-
dontitis concept does not conict with these objectives. In
fact, the explicit description in terms of observable and
measurable phenomena that are testable against a norm
of the signs and symptoms that warrant the diagnosis
periodontitis would be extremely useful for the purpose of
avoiding multiple interpretations. The periodontitis
classication system proposed by van der Velden (12)
comes very close to being a potentially useful classica-
tion system based on nominalistic principles.
In conclusion, we agree with Wulff (14) that the
diagnosis is often more elusive than we care to admit
and, in the case of clinical syndromes and many ana-
tomically dened diseases, it may be worthwhile to
consider the consequences of making the diagnosis
rather than dwell on the truth of the diagnosis. We
therefore suggest that future attempts to rene the de-
nition and classication of periodontitis are based on
considerations of the therapeutic and prognostic impli-
cations of the changes considered. The proposal by
van der Velden (12) shows the way, but the number of
diagnostic categories needed should be determined on
the basis of documented dierences regarding the
consequences of the diagnoses. The adoption of a
nominalistic approach to the denition of periodontitis
is needed to provide a rational framework for develop-
ment of a classication system that meets the needs of
both clinicians and scientists.
Acknowledgements We sincerely thank Professor Sven
Poulsen, University of Aarhus, for valuable suggestions on
earlier versions of this manuscript.
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