Classification of

Periodontal Diseases
Hayder Alwaeli: BDS, M.Sc. & J. Board
Gingiva
-Fibrous mucosa surrounding the teeth & covering the coronal of the
alveolar process Consists of 3 parts
1. Free Gingiva
2. Attached Gingiva
3. Interdental Gingiva
Clinical Features of Normal (Healthy) Gingiva
New Classification System
1999 International Workshop for the
Classification of Periodontal Diseases

Classification of
Periodontal Diseases

American Academy of
Periodontology (AAP)

The International
Workshop 1999
Characteristics common to all gingival diseases
1. Signs & symptoms are confined to gingiva
2. The presence of dental plaque to initiate & / or exacerbte the severity
of the lesion
3. Clinically signs of inflammation:

Enlarged gingival contour : edematous or fibrotic
Red in color &/ or bluish red
Bleeding upon stimulating
gingival exudates
Pathological in sulcular depth
No radiographic evidence

4. Reversibility of the disease by removing the etiology (ies)
5. Possible role as a precursor to attachment loss around tooth
Periodontitis
-An inflammatory disease of the supporting tissue of the teeth caused by specific
microorganisms or specific group, resulting in progressive destruction of
periodontal ligament & alveolar bone with pocket formation, recession, or both
- The primary clinical features of periodontitis
a. Clinical attachment loss
b. alveolar bone loss
c. periodontal pocketing
d. gingival inflammation( enlargement or recession )
e. increased mobility, drifting & / tooth exfoliation may occur
h. progress continuously as chronic inflammation or by burst of activity
-Several bacterial species associated with periodontitis
. P. gingivalis . T. denticola
. Actinobcillus actinomycetumcmitans . E. corrodens
. P. intermedia . E. nodatum
. C. rectus
. B. forsythus


Addition of a Section on Gingival
Diseases

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. Endocrine system
1. Puberty-associated
2. Menstrual cycle-
associated
3. Pregnancy associated
a. Gingivitis
b. Pyogenic
granuloma
4. Diabetes mellitus-
associated

B. Blood dyscrasias
1. Leukemia-associated
gingivitis
2. Other
II. Gingival diseases modified
by systemic factors

A. Endocrine system
1. Puberty-associated
2. Menstrual cycle-
associated
3. Pregnancy associated
a- Gingivitis
b. Pyogenic
granuloma
4. Diabetes mellitus-
associated

B. Blood dyscrasias
1. Leukemia-associated
gingivitis
2. Other

II. Gingival diseases modified
by systemic factors

A. Endocrine system
1. Puberty-associated
2. Menstrual cycle-
associated
3. Pregnancy associated
a- Gingivitis
b. Pyogenic
granuloma
4. Diabetes mellitus-
associated

B. Blood dyscrasias
1. Leukemia-associated
gingivitis
2. Other

II. Gingival diseases modified
by systemic factors

A. Endocrine system
1. Puberty-associated
2. Menstrual cycle-
associated
3. Pregnancy associated
a- Gingivitis
b. Pyogenic
granuloma
4. Diabetes mellitus-
associated

B. Blood dyscrasias
1. Leukemia-associated
gingivitis
2. Other

II. Gingival diseases modified
by systemic factors

A. Endocrine system
1. Puberty-associated
2. Menstrual cycle-
associated
3. Pregnancy associated
a- Gingivitis
b. Pyogenic
granuloma
4. Diabetes mellitus-
associated

B. Blood dyscrasias
1. Leukemia-associated
gingivitis
2. Other

II. Gingival diseases modified
by systemic factors

A. Endocrine system
1. Puberty-associated
2. Menstrual cycle-
associated
3. Pregnancy associated
a- Gingivitis
b. Pyogenic
granuloma
4. Diabetes mellitus-
associated

B. Blood dyscrasias
1. Leukemia-associated
gingivitis
2. Other

II. Gingival diseases modified
by systemic factors

A. Endocrine system
1. Puberty-associated
2. Menstrual cycle-
associated
3. Pregnancy associated
a- Gingivitis
b. Pyogenic
granuloma
4. Diabetes mellitus-
associated

B. Blood dyscrasias
1. Leukemia-associated
gingivitis
2. Other

Ill. Gingival diseases modified by
medications

1. Drug-influenced gingival
enlargements

a. Anticonvulsant
Phenytoin

b. Immunosupressent
Cyclosporin A

c. Calcium Channel
Blockers Nifedipine,
Verapamil, Diltiazem, &
Sodium Valporate

2- Drug-influenced gingivitis
a. Oral contraceptive-associated
gingivitis

b. Other
Ill. Gingival diseases modified by
medications

1. Drug-influenced gingival
enlargements

a. Anticonvulsant
Phenytoin

b. Immunosupressent
Cyclosporin A

c. Calcium Channel
Blockers Nifedipine,
Verapamil, Diltiazem, &
Sodium Valporate

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 Lesions
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. Herpesvirus infections
1. Primary herpetic
gingivostomatitis
2. Recurrent oral herpes
3. Varicella zoster
B. Other
III. Gingival diseases of
fungal origin
A. Candida-species
infections: Generalized
gingival candidosis

B. Linear gingival erythema

C. Histoplasmosis

D. Other

IV- Gingival lesions 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
(mercury, acrylic, nickel)
2. Reactions attributable to
a- tooth pastes
b- mouth washes
c- chewing gum
d- foods and additives

VI: traumatic lesions:
Factitious, Iatrogenic, & Accidental
A- chemical injury
B- physical injury
C- thermal injury

VII: Foreign body reactions

VIII: not otherwise specified
Hereditary Gingival Fibromatosis
Clinical Features:
no sex predilection
apparent when the teeth are erupting,
usually enlargement begins in puberty
gingival overgrowth, gingiva may cover
the teeth possibly completely
more common in posterior mandibular
areas
pink, firm, smooth and uniform
asymptomatic, nonhemorrhagic,
nonexudative
possible apparent delay in dental
eruption
malpositioning of teeth, retention of
deciduous teeth, esthetic and functional
problems
Classification of
Periodontal Diseases

American Academy of
Periodontology (AAP)

The International
Workshop 1999
Periodontitis
The Old Classifications
World Workshop in Clinical Periodontics (1989)


Form of Priodontitis Basic Characteristics
Adult Periodontitis >35 years
Slow rate of progression
No defects in host defenses
Early onset Periodontitis
- Prepubertal
- Juvenile
- Rapidly progressive
< 35 years
Rapid rate of progression
Defects in host defenses
Associated with specific microflora
Periodontitis associated with
systemic diseases
Systemic diseases that predispose to
rapid rates of destruction (e.g.
Diabetes)
Necrotizing Ulcerative
Periodontitis
Similar to NUG but with clinical
attachment loss
European Classification (1993)
Form of Priodontitis Basic Characteristics
Adult Periodontitis 4
th
decade
Slow rate of progression
No defects in host defenses
Early onset Periodontitis
- Prepubertal
- Juvenile
- Rapidly progressive
Prior to 4
th
decade
Rapid rate of progression
Defects in host defenses

Periodontitis associated with
systemic diseases
Systemic diseases that predispose to
rapid rates of destruction (e.g.
Diabetes)
Necrotizing Ulcerative
Periodontitis
Tissue necrosis with clinical
attachment loss & bone loss
Drawbacks of the old classifications
Form of Priodontitis Basic Characteristics
Adult Periodontitis 4
th
decade
Slow rate of progression
No defects in host defenses
Early onset Periodontitis
- Prepubertal
- Juvenile
- Rapidly progressive
Prior to 4
th
decade
Rapid rate of progression
Defects in host defenses

Periodontitis associated with
systemic diseases
Systemic diseases that predispose to
rapid rates of destruction (e.g.
Diabetes)
Necrotizing Ulcerative
Periodontitis
Tissue necrosis with attachment
clinical attachment & bone loss
Considerable overlap in disease categories
Drawbacks of the old classifications
Form of Priodontitis Basic Characteristics
Adult Periodontitis 4
th
decade
Slow rate of progression
No defects in host defenses
Early onset Periodontitis
- Prepubertal
- Juvenile
- Rapidly progressive
Prior to 4
th
decade
Rapid rate of progression
Defects in host defenses

Periodontitis associated with
systemic diseases
Systemic diseases that predispose to
rapid rates of destruction (e.g.
Diabetes)
Necrotizing Ulcerative
Periodontitis
Tissue necrosis with attachment
clinical attachment & bone loss
Absence of a gingival disease component
Drawbacks of the old classifications
Form of Priodontitis Basic Characteristics
Adult Periodontitis 4
th
decade
Slow rate of progression
No defects in host defenses
Early onset Periodontitis
- Prepubertal
- Juvenile
- Rapidly progressive
Prior to 4
th
decade
Rapid rate of progression
Defects in host defenses

Periodontitis associated with
systemic diseases
Systemic diseases that predispose to
rapid rates of destruction (e.g.
Diabetes)
Necrotizing Ulcerative
Periodontitis
Tissue necrosis with attachment
clinical attachment & bone loss

Inappropriate emphasis on age of
onset of disease and rates of progression

Drawbacks of the old classifications
Form of Priodontitis Basic Characteristics
Adult Periodontitis 4
th
decade
Slow rate of progression
No defects in host defenses
Early onset Periodontitis
- Prepubertal
- Juvenile
- Rapidly progressive
Prior to 4
th
decade
Rapid rate of progression
Defects in host defenses

Periodontitis associated with
systemic diseases
Systemic diseases that predispose to
rapid rates of destruction (e.g.
Diabetes)
Necrotizing Ulcerative
Periodontitis
Tissue necrosis with attachment
clinical attachment & bone loss

Inadequate or inappropriate classification criteria

Periodontitis
Chronic
Aggressive
Periodontitis as a manifestations of
systemic diseases
The most prevalent form in adults
Amount of destruction consistent with local factors
Associated with a variable microbial pattern
Subgingival calculus frequently found
Slow to moderate rate of progression
Possibly modified by or associated with the
following:
Systemic diseases
Local factors predisposing factors
Environmental factors
Chronic periodontitis

Chronic periodontitis

Localized form: <30% of sites involved
Generalized form: >30% of sites involved

Slight: 1-2 mm of clinical attachment loss
Moderate: 3-4 mm of clinical attachment loss
Severe: 5 mm of clinical attachment loss
Generalized Severe Chronic Periodontitis
Generalized Severe Chronic Periodontitis
Generalized Severe Chronic Periodontitis
Generalized Severe Chronic Periodontitis
Aggressive Periodontitis

Primary Features
Except for the presence of periodontitis,
patients are otherwise clinically healthy

Rapid attachment loss and bone destruction

Familial aggregation
Aggressive Periodontitis
Secondary Features
Amounts of microbial deposits are inconsistent with
the severity of periodontal tissue destruction

Elevated proportions of Aa and, in some populations,
P. gingivalis may be elevated

Phagocyte abnormalities

Hyper-responsive macrophage phenotype, including
elevated levels of PGE2 and IL-1

Progression of attachment loss and bone loss may
be self-arresting
Localized Aggressive Periodontitis

Circumpubertal onset of
disease

Localized presentation with
interproximal attachment
loss on at least two
permanent teeth, one of
which is a first molar, and
involving no more than
two teeth other than first
molars and incisors


Robust serum antibody
response to infecting agents

Localized Aggressive Periodontitis


Generalized Aggressive Periodontitis

Usually affects persons under
30 years of age

Generalized proximal attachment
loss affecting at least three
teeth other than first molars and
incisors

Pronounced episodic nature of
periodontal destruction

Poor serum antibody response to
infecting agents
Generalized Aggressive Periodontitis


Periodontitis as a Manifestation of Systemic Diseases
1. Hematologic disorders

a. Acquired neutropenia
b. Leukemias
c. Other

2. Genetic disorders

a. Familial and cyclic neutropenia
b. Down syndrome
c. Leukocyte adhesion deficiency
syndromes
d. Papillon-Lefevre syndrome
e. Chediak-Higashi syndrome
f. Histiocytosis syndromes
g- Glycogen storage disease
h. Infantile genetic agranulocytosis
i. Cohen syndrome
j. Ehlers-Danlos syndrome
k. Hypophosphatasia
l. Other

3. Not otherwise specified
Hematologic disorders

Agranulocytosis
Neutropenia
Genetic disorders
Necrotizing Periodontal Diseases
Necrotizing ulcerative gingivitis
Necrotizing ulcerative periodontitis
Abscesses of the periodontium
Gingival
Periodontal
Pericoronal
Periodontitis associated with
endodontic lesions
Combined perio-endo lesions
Developmental or acquired
deformities and conditions
A. Localized tooth-related factors that modify or predispose
to plaque-induced gingival diseases/periodontitis
1. Tooth anatomic factors
a. Enamel Pearls; Associated with attachment
loss specially in furcation areas
b. Cervical Enamel Projections;
found 15 % to 24 % of mandibular molars
found 9 % to 25 % of maxillary molars
2. Dental restorations/appliances
3. Root fractures
4. Cervical root resorption and cemental tears
Developmental or acquired
deformities and conditions
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
E. Abnormal color

Developmental or acquired
deformities and conditions
C. Mucogingival deformities and conditions on
edentulous ridges
1. Vertical and/or horizontal ridge deficiency
2. Lack of gingiva/keratinized tissue
3. Gingival/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



Please read;


Chapter 4
pages; 64 72

Classification of Diseases
and Condition Affecting
the Periodontium
FINALLY ,,