PRESENTED BY

A.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 modified progress based that on need to be periodically and new current thinking

knowledge.

why Classification system necessary

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.

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 gumdisease.

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

1870-1920

The Clinical characteristics paradigm

Classical pathology paradigm Infection / Host response paradigm

1920-1970

1970-present

Clinical characteristic paradigm(1870-1920)

C.G Davis Classification

G.V Black Classification

Classical pathology paradigm ( 1920-1970)

Gottlieb Classification (1928)

Orbans Classification (1942)

WHO Classification (1961)

Page and Schroeder (1982) ADA Classification (1982) AAP (1986) Topics classification (1986) Grant Stern and Listgarten (1988) Suzuki (1988) World workshop in clinical periodontology (1989) Ranneys 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.

1. 2. 3. 4.

Gottlieb classified periodontal disease into four types: Schmutz pyorrhoe Alveolar atrophy or diffuse atrophy Paradental-pyorrhea 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.

I.

Inflammation Gingivitis : Local Systemic Periodontitis: Simplex Complex Degeneration I. Periodontosis : Systemic disturbances Hereditary Idiopathic

II.

 I.

Atrophy 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 classicalexperimental gingivitis studies published by Harald Le 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 19761977 of microbial specificity at sites with periodontosis. ( Newman et al -1976,1977)

This finding, coupled with the demonstration in 19771979 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

Evolution of the AAP periodontal disease classification system

1977 1986
I. Juvenile Periodontitis I. Juvenile Periodontitis II.Chronic Marginal Periodontitis
A. Prepubertal B. Localized juvenile periodontitis C. Generalized juvenile periodontitis

1989

I. Early-Onset Periodontitis
A. Prepubertal periodontitis B. Juvenile periodontitis C. Rapidly progressive periodontitis II. Adult Periodontitis III. Necrotizing Ulcerative Periodontitis IV. Refractory Periodontitis V. Periodontitis Associated

II. Adult Periodontitis

III. Necrotizing Ulcerative Gingivo-Periodontitis IV. Refractory Periodontitis

with Systemic Disease

Page & Schroeder (1982) suggested four different forms of

periodontitis.

1.

Prepubertal periodontitis: Localized Generalized

2. 3. 4.

Juvenile Periodontitis Rapidly progressive periodontitis 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
periodontitis

a separate

disease

category for refractory

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) b) ascorbic acid deficiency gingivitis 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

b. Allergic reactions
1) Dental restorative materials a. Mercury b. Nickel, c. Acrylic d. Other 2) Reactions attributable to

a. Toothpastes /dentifrices
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 enlargement 1 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 involvement is a common finding. tooth mobility. Furcation

Case Type V (refractory periodontitis) includes those patients that continue to demonstrate attachment loss after good conventional therapy.

Van der Velden in 2000

Classification based on the extent of the disease

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