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There has been a debate on the diagnosis and ÔThe essentialistÕs hankering after a unified con-
classification of periodontal diseases since dentists cept of diseases as a class of agents causing ill-
first became interested in periodontology. In this ness, is mistaken and misleading for several good
respect, periodontology is not unique; comparable reasons: many diseases remain of unknown
discussions can be encountered in many fields of cause; known causes are of diverse types; caus-
medicine, especially in complex diseases. Diagnosis ation may be complex, with interplay of several
is defined as the act of identifying a disease from factors, intrinsic; and, more generally, an effect –
its signs and symptoms, whereas classification is the disease – should not be confused with its
defined as the act or method of distribution into own cause’.
groups. The present article deals with the perio-
dontal condition which is clinically characterized by The counterpart of essentialism is nominalism,
three symptoms: loss of connective tissue attach- which implies that a disease name is just a name given
ment, loss of alveolar bone support, and inflamed to a group of subjects who share a group of well-
pathological pockets. On the basis of these three defined signs and symptoms. Scadding supports the
symptoms one diagnostic name for this condition nominalistic concept and states: ÔThe names of dis-
would be appropriate, e.g. destructive periodontal eases are a convenient way of stating briefly the
disease. However, if age, distribution of lesions, endpoint of a diagnostic process that progresses from
degree of gingival inflammation, putative rate of assessment of symptoms and signs towards know-
breakdown, response to therapy, etc., are also taken ledge of causationÕ. Ideally, a nominalistic disease
into account, numerous diagnostic names are nee- definition describes a set of criteria that are ful-
ded. In order to be able to communicate about filled by all persons said to have the disease, but not
patients, clinicians have always felt the need for fulfilled by persons that are considered free from the
diagnostic names and classifications for these dis- disease (40). This set of criteria is dependent on the
eases, preferably on the basis of putative etiologic level of knowledge of a given disease. For example, if
factors. At present, controversies about definitions the etiology is known, e.g. cholera, then the key cri-
of diseases continues, not only in the periodontal terion for the disease is the presence of Vibrio chol-
field but also in medicine. erae. However, for many diseases the etiology is
An interesting contribution to the discussion on complex or not known, and consequently a large
disease terminology is a paper by Scadding (31) number of diseases are defined as syndromes. A
entitled: ÔEssentialism and nominalism in medicine: syndrome constitutes a distinct group of symptoms
logic of diagnosis in disease terminologyÕ. In this and signs which together form a characteristic clinical
paper the clear distinction between these two types picture or entity. In this respect periodontitis is a good
of definitions is highlighted. The essentialistic idea example of a syndromically defined disease (10, 36).
implies the real existence of a disease. Essentialist
definitions typically start ÔX is …Õ, implying a priori
the existence of something that can be identified as X. Need for classification
Thus the doctor’s skills consist in identifying the
causal disease and then prescribing the appropriate Syndromic classification(s) are needed to cluster
treatment. In relation to this, Scadding states: similar disease phenotypes in more homogeneous
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van der Velden
syndromes. This is the prerequisite to establish dontal disease into four types (16–18): Schmutz-
etiology and susceptibility traits, and thus separate Pyorrhöe, alveolar atrophy or diffuse atrophy,
truly different forms of disease or conversely link Paradental-Pyorrhöe, and occlusal trauma. Schmutz-
different different phenotypic variations to the same Pyorrhöe was thought to be the result of the
underlying disease (35). accumulation of deposits on the teeth and was
As mentioned above, the names of a disease are a characterized by inflammation, shallow pockets, and
convenient way of stating briefly the endpoint of a resorption of the alveolar crest. Alveolar atrophy or
diagnostic process that progresses from the assess- diffuse atrophy was described as a noninflammatory
ment of symptoms and signs towards knowledge of disease exhibiting loosening of teeth, elongation, and
causation (31). In other words, in order to obtain wandering of teeth in individuals who were generally
more knowledge about the causation of periodontal free of carious lesions and dental deposits. In this
diseases the various forms of the disease have to be disease, manifesting pockets are formed only in later
classified. The term Ôperiodontal diseaseÕ has referred stages. Paradental-Pyorrhöe was characterized by
for some time to all diseases which affect one or more irregularly distributed pockets varying from shallow
tissues from the periodontium (2). However, in 1964 to extremely deep. This form of disease may have
Sherp (32) noted: started as Schmutz-Pyorrhöe or as diffuse atrophy.
The fourth type was occlusal trauma, a form of
ÔDiscussions of periodontal disease commonly physical overload which was believed to result in
begin with the tacit assumption that all partici- resorption of the alveolar bone and loosening of
pants are considering the same entity. Since the teeth.
variations of periodontal diseases are almost More or less at the same time, McCall & Box (24)
limitless, depending on oneÕs taste for subclas- introduced the term periodontitis to denote those
sification, this unqualified usage often leads to inflammatory diseases in which all three components
fruitless semantic misunderstandings. What is of the periodontium, i.e. the gingiva, bone, and per-
usually meant is the most common form of iodontal ligament, were affected. This is in contrast to
periodontal disease – a chronic, slowly progres- the lesions of occlusal traumatism and atrophic
sive and destructive inflammatory process lesions, in which only the bone and periodontal
affecting one or more of the supporting tissues of ligament may be involved. Periodontitis was sub-
the teeth – the gingival tissue, the periodontal classified, on the basis of presumed etiologic factors,
membrane, and the alveolar bone’. into Simplex periodontitis, considered to be the result
from local bacterial factors, and Complex period-
This statement, made 40 years ago, is still valid ontitis, a result of systemic etiologic factors.
today; it also highlights one of the most frequent Becks (11) made a distinction between parade-
premises in periodontal diagnosis: the assumptions ntitis, a disease which Ôoriginates from the gum tissue
concerning previous disease progression. In this re- in the form of gingivitisÕ and genuine paradentosis,
spect, age has always been an important parameter in which Ôoriginates in the bony alveolus, perhaps in the
periodontal diagnosis. form of an osteopathyÕ. Orban & Weinmann (25)
adopted this nomenclature using the anglicized term
periodontosis to designate this Ônoninflammatory
Previous classifications diseaseÕ. Periodontosis was considered a separate
disease entity, distinctly different from periodontitis,
Almost all ancient medical works refer to the various which was considered the sequela of gingivitis of the
diseases of the teeth and their supporting tissues but deeper periodontal structures, and therefore of
without using any particular terminology. The first inflammatory origin. It is remarkable that in relation
specific name for periodontal disease was introduced to the issue of degenerative disease it is not men-
by Fauchard in 1723 using the term Ôscurvy of the tioned specifically that this was a disease entity par-
gumsÕ (15). Ever since, researchers have introduced ticular to young subjects (23).
names for diseases of the periodontium on the basis During the 1950s and 1960s the importance of
of etiologic factors, pathologic changes or clinical dental plaque as the major etiologic factor for
manifestations. periodontal diseases became more and more evi-
Gottlieb is generally considered to be the first dent. The ultimate proof of the association between
author who clearly distinguished various forms of plaque and gingival inflammation was shown by
periodontal disease. In the 1920s he classified perio- Löe and coworkers in their experimental gingivitis
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Periodontal disease classification
studies (22, 34). The influence of this way of IV Adult onset periodontitis: slowly progressive;
thinking was clearly evident during the 1966 rapidly progressive
Workshop in Periodontics when the entity perio- V Periodontitis associated with systemic diseases
dontosis was revisited (13). In the committee report such as diabetes, scurvy, immunodeficiencies
it was concluded: (including AIDS), immunosuppressive states,
blood dyscrasias
ÔEvidence to support the conventional concept of VI Traumatic periodontitis, e.g. gingival recession
periodontosis is unsubstantiated. It was the and loss of attachment as a result of abrasion
consensus of the section that the term perio- during oral hygiene practice (toothbrushing,
dontosis is ambiguous and that the term should wood sticks, charcoal, brick dust; trauma from
be eliminated from periodontal nomenclature. occlusion)
Nevertheless, the committee is aware that some VII Iatrogenic periodontitis, due to inappropriate
evidence exists to indicate that a clinical entity restorations or inappropriate instrumentation of
different from adult periodontitis may occur in the gingival crevice.
adolescents and young adultsÕ. At the same time a new classification was proposed
by Suzuki (33). Suzuki stated that ÔAdditional clinical
Therefore it is not surprising that soon after the observations in our laboratories during investigation
Workshop a study was published by Butler (12) on the mode of inheritance of juvenile and rapidly
introducing the name juvenile periodontitis instead progressive periodontitis have suggested that further
of periodontosis when describing the periodontal qualifications can be madeÕ. Based on factors such as
condition of young individuals with severe perio- age, microbial deposits, and the autologous mixed
dontal bone loss. According to Butler there was no lymphocyte reaction, rapidly progressive periodonti-
proof of any degenerative process, as the suffix ÔosisÕ tis, as introduced by Page & Schroeder (28), can be
would imply. subdivided into type A and type B. In addition, the
Numerous classifications have since been pub- term postjuvenile periodontitis delineated a slow-
lished. Page & Schroeder (28) defined periodontitis progression-type of juvenile periodontitis.
as an inflammatory disease of the periodontium One year later it was stated in the 1989 World
characterized by the presence of periodontal pock- Workshop in Clinical Periodontics that Ôalthough the
et(s) and active bone resorption with acute in- AAP classification was adopted, legitimizing the idea
flammation. They suggested at least four distinctly that different forms of periodontal diseases exist,
different forms of periodontitis in humans: more recently acquired data mandate modification
prepubertal, juvenile, rapidly progressive, adult and revisionÕ (4). The following classification was
periodontitis, and acute necrotizing ulcerative gin- recommended:
givo-periodontitis (ANUG ⁄ P). In this classification, I Adult periodontitis
with the exception of ANUG ⁄ P, the age of onset is II Early onset periodontitis
of decisive importance. This item is adopted in A Prepubertal periodontits
almost all subsequent classifications. In 1986 the 1 Generalized
American Academy of Periodontology (AAP) adop- 2 Localized
ted the following classification (3): B Juvenile periodontitis
I Juvenile periodontits 1 Generalized
A Prepubertal periodontitis 2 Localized
B Localized juvenile periodontitis C Rapidly progressive periodontitis
C Generalized juvenile periodontitis III Periodontitis associated with systemic diseases
II Adult periodontis IV Necrotizing ulcerative periodontitis
III Necrotizing ulcerative gingivo-periodontitis V Refractory periodontitis.
IV Refractory periodontitis. Volume 2 of Periodontology 2000, issued in 1993,
In an attempt to detect groups and individuals at was dedicated to the classification and epidemiology
high risk for periodontal disease, Johnson et al. (20) of periodontal diseases. In the contribution of Ran-
presented a more extensive classification: ney (30) four major disease categories were proposed,
I Childhood periodontitis including specific syn- i.e. adult periodontitis, early onset periodontitis,
dromes such as Papillon-Levèfre necrotizing ulcerative periodontitis, and periodontal
II Juvenile periodontitis: localized; generalized abscess including a large number of subcategories
III Post-juvenile periodontitis mainly based on systemic factors. Also in 1993, the
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van der Velden
first European Workshop on Periodontology was ories and subcategories and was certainly an
organized. In session I the following position papers improvement with regard to the category gingival
were presented. Papapanou: epidemiology and nat- diseases. However, a number of subcategories pre-
ural history of periodontal disease (29), Claffey: Gold sent in the majority of the previous classifications
Standard – Clinical and radiographical assessment of were eliminated, i.e. prepubertal periodontitis,
disease activity (14), Tonetti: Etiology and patho- juvenile periodontis, postjuvenile periodontitis, rap-
genesis (35) and Johnson: Risk factors and diagnostic idly progressive periodontitis, early onset periodon-
tests for destructive periodontitis (19). On the basis of titis and refractory periodontitis. Amongst others it
these comprehensive reviews a consensus report was was argued that:
produced (9) that included the following statement
regarding the classification of periodontal diseases: Ôin case of early onset periodontitis (prepubertal
periodontitis, juvenile periodontitis, postjuvenile
ÔThere is insufficient knowledge to separate truly periodontitis and rapidly progressive periodon-
different diseases (disease heterogeneity) from titis), one must have temporal knowledge of
differences in the presentation ⁄ severity of the when the disease started. In addition, there is
same disease (phenotypic variation). Because of considerable uncertainty about arbitrarily setting
this, existing classifications are unsatisfactory. an upper age limit for patients with so-called
Disadvantages of present classifications (e.g. AAP early onset periodontitis. For example, how does
1989) include 1. extensive overlap between the one classify the type of periodontal disease in a
different diagnostic categories, 2. need for 21-year old patient with the classical incisor-first
assumptions concerning previous disease pro- molar pattern of Localized Juvenile Periodontitis
gression, 3. the necessity for detailed information (LJP)? Since the patient is not a juvenile, should
on the quality of treatment provided previously the age of the patient be ignored and the disease
and the patient response to this therapy, and 4. classified as LJP anyway?Õ
the apparent lack of a consistent basis for clas-
sification. Ideally classifications should be based On the basis of this and other arguments the
on etiologic and host response factors. In order workshop participants decided that it was wise to
to deal with the present confusion, a simple discard classification terminologies that were age-
classification distinguishing between 1. Early dependent or required knowledge of rates of pro-
onset periodontitis, 2. Adult periodontitis, 3. gression (6). Therefore it was proposed to re-name
Necrotizing periodontitis, might be preferable. the disease formerly considered under the umbrella
Provided that the relevant information is avail- early onset periodontitis and other forms of rapidly
able, as many as possible additional secondary progressive disease by aggressive periodontitis. Al-
descriptors should be used to further define the though not clearly stated, it can be concluded from
clinical situation. These include distribution the report that the term aggressive periodontitis is
within the dentition, rate of progression, re- only applicable for patients with severe periodontal
sponse to treatment, relation to systemic dis- breakdown. However, it can be argued that this new
eases, microbiological characteristics, ethnic classification does not solve the problems because it
group and other factorsÕ. is not clear how severe a case must be in order to
be classified as aggressive periodontitis, and know-
Although, in my opinion, the conclusion Ôthere is ledge about the rate of progression is still needed.
insufficient knowledge to separate truly different In the same Workshop, adult periodontitis was re-
diseases (disease heterogeneity) from differences in named chronic periodontitis on the basis of the
the presentation ⁄ severity of the same disease assumption that slowly progressive disease can be
(phenotypic variation)Õ from the European Workshop present at any age, i.e. in adults as well as in ado-
on Periodontology in 1993 (9) still holds true today, it lescents. But again it can be argued that for this
was concluded in the 1996 World Workshop in Peri- classification, knowledge about the rate of progres-
odontics that there was a clear need for a revised sion is still needed.
classification system for periodontal diseases (5). This The problems related to the prediction of the rate
resulted in a new classification which was agreed of progression in the future or assumptions on the
upon at the International Workshop for a Classifica- rate of progression in the past are clearly illustrated
tion of Periodontal Diseases and Conditions in 1999 by the study of Albandar et al. (1). In this longitudinal
(6). This classification included many disease categ- study, young individuals, mean age at baseline
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Periodontal disease classification
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van der Velden
Severe
Moderate PD 4 mm + AL 1 mm
PD 4 mm + AL 2 mm
PD 4 mm + AL 4 mm
Minor
Fig. 4. Estimation of the severity
of the periodontal problem in rela-
10 20 30 40 50 60
tion to age. PD ¼ pocket depth.
Age AL ¼ attachment level.
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Periodontal disease classification
Table 1. Classification based on the extent of the disease. If teeth are missing, the class description should still
reflect the clinical image of the patient. Therefore it was decided for cases with £ 14 teeth to omit the class semi-
generalized and to change the number of teeth for the generalized class to 8–14
Permanent ⁄ mixed dentition Primary dentition
No. of teeth present
n ‡ 14 n £ 14
Incidental 1 tooth 1 tooth 1 tooth
Localized 2–7 teeth 2–7 teeth 2–4 teeth
Semi-generalized 8–13 teeth – 5–9 teeth
Generalized ‡ 14 teeth 8–14 teeth ‡ 10 teeth
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van der Velden
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Periodontal disease classification
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