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Received: 11 March 2019    Accepted: 11 March 2019

DOI: 10.1111/jcpe.13104

C L I N I C A L I N N OVAT I O N R E P O R T

Implementation of the new classification of periodontal

diseases: Decision‐making algorithms for clinical practice and
education

Maurizio S. Tonetti1,2  | Mariano Sanz2,3

1
Periodontology, Faculty of Dentistry, Hong
Kong University, Hong Kong, Hong Kong Abstract
SAR, China Background: Implementation of the new classification of periodontal diseases re‐
2
European Research Group on
quires careful navigation of the new case definitions and organization of the diagnos‐
Periodontology, Genova, Italy
3
ETEP Research Group, Faculty of
tic process along rationale and easily applicable algorithms. The aim of this report
Odontology, University Complutense of was to describe the rationale for one such approach designed for clinical practice and
Madrid, Madrid, Spain
education.
Correspondence Methods: The authors developed empiric decision‐making algorithms based on the
Maurizio S. Tonetti, Periodontology, Faculty
of Dentistry, Prince Philip Dental Hospital,
new classification to effectively discriminate between the key periodontal diagnoses
Hong Kong University, Hong Kong, Hong of periodontal health, gingivitis and periodontitis.
Kong SAR, China.
Email: Tonetti@hku.hk
Results: A stepwise approach is proposed that includes (a) a sensitive screening step
able to discriminate periodontal health, gingivitis and suspect periodontitis; (b) a spe‐
Funding information
This study was supported by the European cific confirmation step to provide differential diagnosis between periodontitis and
Research Group on Periodontology
the other conditions characterized by attachment loss; (c) a step to assess the sever‐
(ERGOPerio) and the University of Hong
Kong Periodontal Research Fund. ity and complexity of management of the periodontitis case (staging); and (d) a step
to assess the risk profile of the case (grading). Specific decision‐making algorithms
are described for all steps of the diagnostic process.
Conclusions: The proposed process allows discrimination between the different case
definitions of periodontal health and disease. The diagnostic accuracy and cost‐effec‐
tiveness of the process need to be validated in prospective trials generalizable to op‐
erators with different level of expertise, different populations and clinical settings.

KEYWORDS
case definition, diagnosis, gingivitis, periodontal diseases, periodontal health, periodontitis,
periodontitis grading, periodontitis staging

1 | I NTRO D U C TI O N
The recently introduced classification of periodontal diseases (Caton
et al., 2018) aims to identify well‐defined clinical entities using clear
criteria that are able to link diagnosis with prevention and treatment,
thus moving towards precision and individualized dentistry. It de‐
fines specific criteria for the following diagnoses: (a) periodontal
health (Lang and Bartold, 2018); (b) gingivitis (Trombelli, Farina, Silva,
& Tatakis, 2018); (c) reduced but healthy periodontium (successfully
treated periodontitis); (d) gingival inflammation in a periodontitis pa‐
tient (treated periodontitis with persistent inflammation) (Chapple
et al., 2018); (e) periodontitis (Papapanou et al., 2018; Tonetti,
Greenwell, & Kornman, 2018); (f) periodontitis as a manifestation
of systemic diseases (Albandar, Susin, & Hughes, 2018; Jepsen et

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© 2019 John Wiley & Sons A/S. J Clin Periodontol. 2019;46:398–405.
Published by John Wiley & Sons Ltd
TONETTI and SANZ
al., 2018); and (g) necrotizing periodontal disease (Herrera, Retamal‐
Valdes, Alonso, & Feres, 2018).
This concept is a major change from the previous classification
system (Armitage, 1999) that recognized different forms of peri‐
odontitis (chronic, aggressive, manifestation of systemic diseases)
and created difficulties in implementation and imprecision in the
diagnosis due to overlap in the definition of the various entities.
Furthermore, a thorough evaluation of the scientific evidence con‐
ducted as part of the due diligence process in preparation of the
classification workshop did not support the existence of different
forms of periodontitis based on clear differences in pathobiology
(Papapanou et al., 2018). At present, there is neither adequate
knowledge of unique mechanisms nor evidence to support the need
for specific treatments to justify the distinction between aggressive
and chronic periodontitis (Fine, Patil, & Loos, 2018; Lang et al., 1999;
Lindhe et al., 1999; Needleman et al., 2018; Tonetti et al., 2018).
A critical improvement is the focus on the definition of specific
cases: subjects meeting the criteria for a specific diagnosis. It defines
three new case diagnoses including (a) periodontal health; (b) reduced
but healthy periodontium (successfully treated periodontitis); and (c)
gingival inflammation in a periodontitis patient (treated periodontitis
with persistent inflammation) (Albandar et al., 2018; Chapple et al.,
2018; Jepsen et al., 2018). It also recognizes three periodontitis di‐
agnoses: necrotizing periodontal diseases (Herrera et al., 2018), peri‐
odontitis (Tonetti et al., 2018) and periodontitis as a manifestation of
systemic diseases. Once the diagnosis is made, periodontitis cases
need to be characterized by the newly introduced process of staging
and grading (Papapanou et al., 2018; Tonetti et al., 2018). Periodontitis
stages are a simple description of the severity and complexity of man‐
agement of the individual case, while periodontitis grades capture the
risk of progression and the risk factor profile. With respect to previ‐
ously utilized descriptions of periodontitis severity, the newly intro‐
duced system aims to identify, on one side of the spectrum, cases as
early as possible through the identification of initial signs of attach‐
ment loss (stage I) and on the other side the more advanced cases
requiring more advanced periodontal therapy (stage III) or complex
periodontal and oral rehabilitation (stage IV). The identification of a
periodontitis grade must involve the accumulated knowledge of direct
or indirect evidence of disease progression or the presence of risk fac‐
tors with clear evidence of modifying the prognosis and case manage‐
ment (Lang, Suvan, & Tonetti, 2015; Tonetti et al., 2015).
Introducing this new classification in clinical practice and edu‐
cation, however, requires careful planning and the introduction of a
novel, yet simple, way of thinking, which introduces new diagnostic
tools and a new decision‐making algorithm to support the process
leading to diagnosis and case definition.
2 | D I AG N OS TI C TO O L S
The classification workshop has indicated that bleeding on probing
(BOP) is the most reliable and validated diagnostic tool for the as‐
sessment of gingival inflammation (Murakami, Mealey, Mariotti, &
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Clinical Relevance
Scientific rationale for the study: Implementation of the new
classification of periodontal diseases requires modification
of the current way of thinking to optimize diagnosis in clini‐
cal practice and education.
Principal findings: This report illustrates step by step deci‐
sion‐making algorithms that guide the clinician and the
learner through the sequential decisions needed to cor‐
rectly assign cases to the correct periodontal diagnosis.
Practical implications: The application of four diagnostic
steps allows correct case assignment for periodontal
health, gingivitis and periodontitis.
Chapple, 2018; Trombelli et al., 2018) and has incorporated it in the
case definition of periodontal health, gingivitis, reduced but healthy
periodontium and gingival inflammation in a treated periodontitis
patient (Chapple et al., 2018). The workshop also identified spe‐
cific threshold for the values in BOP to define periodontal health
and gingivitis (10% BOP in the absence of attachment loss) as well
as reduced but healthy periodontium after completion of treatment
(BOP ≤10% in the presence of attachment loss but no probing depth
higher than 3 mm) and gingival inflammation in a periodontitis patient
(BOP >10% in the presence of attachment loss but no probing depth
higher than 3 mm). This requires the introduction of BOP as a part
of the routine dental examination to identify cases of periodontal
health and gingivitis and monitor treated subjects. Previously used
simplified recording screening systems, based on the community
periodontal index (CPI) (Ainamo et al., 1982), allowed the identifica‐
tion of patients with periodontal health, gingivitis and periodontitis,
but without using clear diagnostic criteria able to establish specific
case definitions. The classification requires the identification of 10%
BOP sites to distinguish between periodontal health and gingivitis
and therefore requires full‐mouth assessment and recording. Such
approach represents an important opportunity since, besides the
need for diagnosis, recording of BOP together with plaque repre‐
sents the key approach to assess the patient oral hygiene and to plan
individualized preventive programmes.
Secondly, the classification workshop highlighted the need to es‐
tablish clinical attachment loss (CAL) as the primary definition of peri‐
odontitis (with the understanding that when marginal alveolar bone
loss is apparent on diagnostic quality radiographs, it may be an ade‐
quate proxy measure of CAL). This is important as the use of probing
pocket depths (PPDs) does not allow discrimination of periodontal
health, gingivitis, periodontitis, reduced but healthy periodontium,
gingival inflammation in a periodontitis patient. During their exam‐
ination, therefore, clinicians must recognize the signs of CAL and
discriminate them from other clinical conditions also associated with
CAL such as gingival recession, vertical root fractures, endo‐peri‐
odontal lesions, loss on the distal of the lower second molars asso‐
ciated with impacted wisdom teeth, or attachment loss secondary
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400       TONETTI and SANZ
to cervical decay or restorations. Recognition of the presence of
inter‐dental attachment loss in the presence of periodontitis is eas‐
ier than usually appreciated and requires establishing whether or not
the inter‐dental cemento‐enamel junction is visible, or the tip of the
periodontal probe reaches the root surface in the inter‐dental space.
Another important element is the need to explore the reasons
for tooth loss with the individual patient to recognize tooth loss due
to periodontitis. This is an important aspect of the new classification
since lack of implication of this parameter in case definition and di‐
agnosis leads to the paradox that periodontitis severity may improve
as the most compromised teeth are lost. In this respect, there are no
established criteria other than questioning the patient of whether
or not the tooth was lost or extracted because it was lose or if the
extracted tooth was “healthy”—not compromised by caries.
3 |  E PI D E M I O LO G Y A N D D I AG N OS I S
In order to use resources efficiently, an appropriate strategy to de‐
tect specific cases in the population needs to be informed by the epi‐
demiology of the condition as it defines the pre‐test probability of
disease and the utility of the test. Data indicate that roughly one in
10 adults suffers from “severe” (stage III or IV) periodontitis and that
another 10% of the population is periodontally healthy, while 80%
of subjects suffer from either gingivitis or mild to moderate (Stage I
or II) periodontitis. Stage III and IV periodontitis can be easily identi‐
fied but the differential diagnosis between gingivitis and the milder
forms of periodontitis requires the assessment of inter‐dental CAL
to separate gingivitis from periodontitis. This is the major rationale
for starting any periodontal health assessment with the detection of
attachment loss (or bone loss).
4 | C LI N I C A L D EC I S I O N A LG O R ITH M S
Differentiating between periodontal health and diseases must be
performed during routine dental examination in primary care set‐
tings in all subjects undergoing dental care. In this manner, the time
that dentists can devote to gathering complex diagnostic data and
the associated costs will be limited to those subjects requiring such
data for subsequent management. It is therefore rationale to sug‐
gest that the diagnostic process leading to case definition should be
performed in a sequence of steps.
4.1 | Step 1 new patient
When seeing a patient for the first time, the first question relates
to the availability of full‐mouth radiographs of diagnostic quality
(Figure 1). If available, the clinician should assess if there is detect‐
able marginal bone in any area of the dentition. If bone loss is de‐
tectable, the clinician should suspect the presence of periodontitis
and move forward to step 2. If no radiographs are available or if no
bone loss is detectable, it is imperative that the clinician assesses the
whole dentition for the presence of signs of inter‐dental CAL. Such
signs may be either the presence of visible CEJ in the inter‐dental
space or the stopping of the tip of the periodontal probe on the root
surface in the inter‐dental space. If inter‐dental CAL is detectable,
the clinician should suspect the presence of periodontitis.
F I G U R E 1   Diagnosis step 1
TONETTI and SANZ
If inter‐dental CAL is not detected, the clinician should evalu‐
ate the presence of buccal or oral recessions with PPDs higher than
3 mm. If yes, then the clinician should suspect the presence of peri‐
odontitis. If there is no buccal PPD higher than 3 mm, the clinician
must evaluate and record full‐mouth BOP and if present in more than
10% of the sites, a diagnosis of gingivitis is made. If BOP is present in
<10%, the diagnosis is periodontal health. It is important to empha‐
size that this step uses available radiographs to assess the presence
of bone loss but that there is no need to take radiographs in this step.
4.2 | Step 2 suspect periodontitis diagnosis
When the presence of inter‐dental CAL or marginal bone loss in
the oral examination has identified the patient as a potential peri‐
odontitis case, the clinician needs to ascertain whether this CAL is
due to local factors only, such as endo‐periodontal lesions, vertical
root fractures, presence of caries or restorations or impacted third
molars. In such cases, the clinician needs to go back to step 1 and
assess gingival health for the remaining of the dentition. If the ob‐
served CAL cannot be attributed to local factors, the clinician needs
to ascertain that the inter‐dental CAL is present in more than one
non‐adjacent tooth (Figure 2). If not, the clinician needs to go back
to step 1, assess gingival health and carefully monitor the patient
to ensure that s/he does not develop additional lesions that would
qualify for a periodontitis diagnosis. If CAL involves two or more
non‐adjacent teeth, the clinician makes a diagnosis of periodontitis
patient and needs to do a comprehensive periodontal assessment
through periodontal charting and full‐mouth radiographs. If the peri‐
odontal charting does not reveal PPD of 4 mm or more, then the
clinician needs to evaluate the full‐mouth BOP. When BOP is higher
F I G U R E 2   Diagnosis step 2
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than or equal to 10%, the diagnosis is gingival Inflammation in a peri‐
odontitis patient and if less, the diagnosis is patient with a reduced
but healthy periodontium. If the periodontal charting shows PPD of
4 mm or more, the diagnosis is a periodontitis case that needs to be
further assessed by staging and grading.
4.3 | Step 3A. Patient is a periodontitis case that
needs to be staged
For staging of a periodontitis case, the following information is
needed full‐mouth radiographs, a periodontal chart and a periodon‐
tal history of tooth loss (PTL) (Figure 3). Based on the information,
the clinician shall assess the extent of the disease, by determining
whether the CAL/BL affects <30% of the teeth (localized) of 30% or
more (generalized). Then, s/he shall define the stage of the disease
by assessing severity through CAL, BL and PTL, and complexity by
assessing PPD, furcation and intrabony lesions, tooth hypermobility,
secondary occlusal trauma, bite collapse, drifting, flaring or having
<10 occluding pairs.
4.4 | Step 3B. Staging III and IV versus I and II
When the evaluation of CAL is higher than 5 mm or if the BL af‐
fects the middle third of the root or beyond, the diagnosis is either
stage III or IV periodontitis (Figure 3b). If CAL is <5 mm, the clinician
should look for the presence of class II or III furcation involvement. If
present, the diagnosis is either stage III or IV. If no furcation involve‐
ment is present, the clinician should check PPD. If PPD is >5 mm,
then the diagnosis is either stage III or IV. Clinical judgement should
be applied to use PPD to upgrade from Stages I & II to Stage III. For
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402       TONETTI and SANZ

(a)

(b)

(c)

F I G U R E 3   (a) Diagnosis step 3a, (b) Diagnosis step 3b, (c) Diagnosis step 3c.
TONETTI and SANZ
F I G U R E 4   (a). Diagnosis step 4a, (b)
Diagnosis step 4b.
(a)
(b)
example, in the presence of pseudo pockets, the periodontitis case
should stay as Stage II. If PPD are between 3 and 5 mm, then assess
history of tooth loss due to periodontitis. If there is history of PTL,
the diagnosis is either stage III or IV. If not, then the diagnosis is
stage I or II.
4.5 | Step 3C. Diagnosis of stage I, II, III or IV
Staging for I and II will be based upon the level of CAL and BL. When
BL is <15% and CAL is between 1 and 2 mm, the diagnosis is stage I
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(Figure 3c). When BL is between 15% and 33% and CAL is between
3 and 4 mm, the diagnosis is stage II.
When BL affects the middle third of the root or beyond and CAL
is 5 mm or more, if PTL is 4 teeth or less and in the presence of 10 or
more occluding pairs, in the absence of bite collapse, drifting, flaring
or a severe ridge defect, then the diagnosis is stage III.
When BL affects the middle third of the root or beyond and CAL
is 5 mm or more, if PTL is more than 4 teeth and in the absence of 10
occluding pairs, or when existing bite collapse, drifting, flaring or a
severe ridge defect, then the diagnosis is stage IV. Once the correct
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404       TONETTI and SANZ
periodontitis stage has been determined, the clinician should pro‐
ceed to determine the grade.
4.6 | Step 4A. Grading when there are existing
previous records
When the patient previous periodontal records are available, the
rate of periodontitis progression in the previous 5 years should be
estimated (Figure 4a). If progression is <2 mm, the diagnosis is Grade
B Periodontitis. If there has been no progression in 5 years, the diag‐
nosis is Grade A Periodontitis. When the progression has been 2 mm
or more the diagnosis is Grade C Periodontitis. Grades A and B can
be upgraded to a higher grade in the presence of recognized risk fac‐
tors (smoking and diabetes). If the patient smokes 10 or more ciga‐
rettes per day, it will be upgraded to Grade C, while if s/he smokes
<10 cigarettes, the diagnosis will be upgraded to Grade B. Similarly, if
the subject presents with diabetes as a comorbidity and the glycated
haemoglobin (HbA1c) is <7.0, the grade will be upgraded to B, or to
C if HbA1c is 7.0 or more.
4.7 | Step 4B. Grading in the absence of
previous records
When previous periodontal records are not available, the bone/age
(BL/A) ratio should be calculated from the full‐mouth radiographs
(Figure 4b). The worst affected tooth is used for this assessment. If
BL/A is between 0.25 and 1.0, the diagnosis is Grade B Periodontitis. If
<0.25, the diagnosis is Grade A Periodontitis, and if higher than 1.0, the
diagnosis is Grade C Periodontitis. Grades A and B can be upgraded to
a higher grade if the patient smokes or has diabetes as a comorbidity.
5 |  D I S CU S S I O N
This report provides the detailed description of the diagnostic tools
and clinical decision trees needed for accurate implementation of
the new classification system of periodontal diseases (Caton et al.,
2018) in clinical practice and education. Reaching a proper diagno‐
sis and case assignment should facilitate an individualized preven‐
tive programme or treatment plan both in primary care and specialist
practice. This has been defined as one of the key goals to improve
periodontal health of mankind in a recently published global call
to action endorsed by 40 periodontal professional organization
(Tonetti, Jepsen, Jin, & Otomo‐Corgel, 2017). The approach rec‐
ognizes four specific diagnostic steps that need to be adopted in a
sequential manner and the diagnostic tools and decision algorithms
needed for proper periodontal health assessment, case assignment
and management.
The first step is a highly sensitive screening based on the identi‐
fication of presence or absence of CAL or bone loss on radiographs.
This step allows for the choice of using either diagnostic quality ra‐
diographs or CAL as the trigger sign to suspect the presence of peri‐
odontitis, but stipulates that in the absence of radiographic evidence
of marginal alveolar bone loss, assessment of CAL is needed. This is
due to the fact that radiographs are not a sensitive diagnostic tool
to identify the presence of attachment loss due to periodontitis, and
therefore, lack of evidence of radiographic marginal bone loss is un‐
able to exclude the presence of CAL and periodontitis (Lang & Hill,
1977). When subjects are positive for CAL or bone loss, they need to
be further evaluated in the second step, while subjects without signs
of the pathognomonic sign of periodontitis (CAL/marginal bone loss)
need to be further assessed for the presence and extent of gingival
inflammation to allow differentiation between periodontal health
and gingivitis. It is important to highlight that in order to accurately
discriminate between gingivitis and the initial stages of periodontitis
(based on epidemiology the vast majority of adults) screening tests
based on probing depths (such as those based on CPI) are unable to
accurately discriminate between the two conditions.
The second step requires the specific assessment of the nature
of the observed CAL or bone loss. A critical component of this step
is the differential diagnosis between CAL or bone loss due to peri‐
odontitis or due to other local factors such as root fracture, cervical
decay or restoration and impacted wisdom teeth.
If the observed CAL/bone loss cannot be attributed to such
local factors and CAL involves at least two teeth (Eke, Page, Wei,
Thornton‐Evans, & Genco, 2012; Tonetti & Claffey, 2005; Tonetti
et al., 2018), the patient is defined as a periodontitis patient and re‐
quires a full periodontal examination with charting and radiographs.
When such examination observes only probing depths up to 3 mm,
this periodontitis patient may have received previous periodontal
therapy and a diagnosis of either reduced but healthy periodontium
or gingival inflammation in a periodontitis patient is made based on
BOP. If periodontal pockets are present, then the subject meets the
criteria for being diagnosed as a periodontitis case that will need to
be staged and graded in steps 3 and 4.
The validity of the proposed decision trees will have to be as‐
sessed with specific research that evaluates their diagnostic
accuracy and their cost‐effectiveness. Such research should be per‐
formed with clinicians with different levels of experience (students,
general dental practitioners, specialists), operating in different set‐
tings (primary care, dental hospitals, specialist practice) and in differ‐
ent areas of the world.
C O N FL I C T O F I N T E R E S T
Authors report no conflict of interest related to this study.
ORCID
Maurizio S. Tonetti  https://orcid.org/0000-0002-2743-0137
Mariano Sanz  https://orcid.org/0000-0002-6293-5755
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How to cite this article: Tonetti MS, Sanz M. Implementation
of the new classification of periodontal diseases: Decision‐
making algorithms for clinical practice and education. J Clin
Periodontol. 2019;46:398–405. https://doi.org/10.1111/
jcpe.13104