Staging and grading of

periodontitis
Staging and grading of periodontitis: Framework and proposal of a new classification and case
definition (Maurizio S. Tonetti, Henry Greenwell, Kenneth S. Kornman), 2018, Journal of
Periodontology
2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and
Conditions
1999 Classification
-Wide spectrum of clinical presentations
-Emphasized unique features of different periodontitis phenotypes
-Recognized different periodontitis phenotypes as arising from different diseases, rather than
variations of the same disease:
-Aggressive Periodontitis
-Chronic Periodontitis
-Periodontitis as a manifestation of systemic disease
-Necrotizing Periodontitis
-Delineated criteria to differentiate aggressive vs chronic, and localized vs generalized
Problems with 1999 Classification
-Criteria are difficult to apply in practice

-Does not capture all dimensions of disease complexity and risk

-Does not acknowledge relationship between periodontitis and

systemic disease
Tonetti Et Al
‘”There is no evidence of specific pathophysiology that enables differentiation of cases that
would currently be classified as aggressive and chronic periodontitis”
“There is little consistent evidence that aggressive and chronic periodontitis are different
diseases, but there is evidence of multiple factors, and interactions among them that influence
clinically observable disease outcomes”
“specific segments of the population exhibit different levels of disease progression, as indicated
by greater severity of clinical attachment loss (CAL) in subsets of each age cohort relative to the
majority of individuals in the age cohort”
“classification system based only on disease severity fails to capture important dimensions of an
individual's disease”
 1999 vs 2017
-Aggressive Periodontitis -Periodontitis (with staging and
grading)
-Chronic Periodontitis
-Periodontitis as a manifestation of
-Periodontitis as a manifestation of systemic disease
systemic disease
-Necrotizing Periodontitis
-Necrotizing Periodontitis
2017 Definition of Periodontitis
“definition system should include three components”

- Identification of periodontitis
- Identification between periodontitis, periodontitis as a manifestation of systemic disease and
necrotizing periodontitis
- Description of clinical presentation and other elements that affect clinical management,
prognosis and influences on systemic health
How to identify periodontitis ?
-Using CAL; initial periodontitis is difficult to diagnosis
-Use of radiographic bone loss misses milder and moderate forms

A patient is a periodontitis case in the context of clinical care if:

1. Interdental CAL is detectable at ≥2 non-adjacent teeth, or
2. Buccal or oral CAL ≥3 mm with pocketing >3 mm is detectable at ≥2 teeth
Not due to non-periodontal causes

-Intra-examiner reliability is poor

How to identify specific form of perio?
-NP:
> Pain
> Ulceration of gingival margin
> (Exposure of marginal Alveolar Bone)
> Typically symptoms ameliorate following antimicrobial treatment

-Periodontitis as a manifestation of systemic disease:

> Classified according to primary disease
How to characterize periodontitis
-
How to characterize periodontitis
More than just disease
severity
-
How to characterize periodontitis
-
How to characterize periodontitis
-
How to characterize periodontitis
-
How to characterize periodontitis
-
Staging (I-IV)

> Borrowed from oncology

> Classifies severity and extent

> Assess complexity

Grading (A, B, C)
> Estimate future risk of disease progression

> Estimate Potential Health Impact of Periodontitis on systemic

disease