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
3. Free Gingiva
4. Attached Gingiva
5. 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
 Signs & symptoms are confined to gingiva
 The presence of dental plaque to initiate & / or exacerbte the severity
of the lesion
 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
 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
III. Gingival diseases of
fungal origin
A. Candida-species
infections: Generalized
gingival candidosis
B. Linear gingival erythema

II. Gingival diseases of viral origin

C. Histoplasmosis
A. Herpesvirus infections
1. Primary herpetic
gingivostomatitis D. Other
2. Recurrent oral herpes
3. Varicella zoster
B. 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
Adult Periodontitis
Early onset Periodontitis
- Prepubertal
- Juvenile
- Rapidly progressive
Periodontitis associated with
systemic diseases
Necrotizing Ulcerative
Periodontitis
Basic Characteristics
 >35 years
 Slow rate of progression
 No defects in host defenses
 < 35 years
 Rapid rate of progression
 Defects in host defenses
Associated with specific microflora
Systemic diseases that predispose to
rapid rates of destruction (e.g.
Diabetes)
Similar to NUG but with clinical
attachment loss
 European Classification (1993)
Form of Priodontitis
Adult Periodontitis
Early onset Periodontitis
- Prepubertal
- Juvenile
- Rapidly progressive
Periodontitis associated with
systemic diseases
Necrotizing Ulcerative
Periodontitis
Basic Characteristics
 4th decade
 Slow rate of progression
 No defects in host defenses
 Prior to 4th decade
 Rapid rate of progression
 Defects in host defenses
Systemic diseases that predispose to
rapid rates of destruction (e.g.
Diabetes)
Tissue necrosis with clinical
attachment loss & bone loss
 Drawbacks of the old classifications
Form of Priodontitis Basic Characteristics
Adult Periodontitis  4th decade
 Slow rate of progression
 No defects in host defenses
Early onset Periodontitis  Prior to 4th decade
- Prepubertal  Rapid rate of progression
- Juvenile  Defects in host defenses
- Rapidly progressive
Periodontitis associated with Systemic diseases that predispose to
Considerable
systemic diseases overlap inrates
rapid disease categories
of destruction (e.g.
Diabetes)
Necrotizing Ulcerative Tissue necrosis with attachment
Periodontitis clinical attachment & bone loss
 Drawbacks of the old classifications
Form of Priodontitis Basic Characteristics
Adult Periodontitis  4th decade
 Slow rate of progression
 No defects in host defenses
Early onset Periodontitis  Prior to 4th decade
- Prepubertal  Rapid rate of progression
- Juvenile  Defects in host defenses
- Rapidly progressive
Periodontitis associated with Systemic diseases that predispose to
systemicAbsence
diseases of a gingival
rapiddisease component
rates of destruction (e.g.
Diabetes)
Necrotizing Ulcerative Tissue necrosis with attachment
Periodontitis clinical attachment & bone loss
 Drawbacks of the old classifications
Form of Priodontitis Basic Characteristics
Adult Periodontitis  4th decade
 Slow rate of progression
 No defects in host defenses
Early onset Periodontitis  Prior to 4th decade
- Prepubertal  Rapid rate of progression
- Juvenile  Defects in host defenses
- Rapidly progressive
PeriodontitisInappropriate
associated with emphasis
Systemic diseases that predispose
on age of to
systemic diseases rapid rates of destruction (e.g.
onset of disease and rates of progression
Diabetes)
Necrotizing Ulcerative Tissue necrosis with attachment
Periodontitis clinical attachment & bone loss
 Drawbacks of the old classifications
Form of Priodontitis Basic Characteristics
Adult Periodontitis  4th decade
 Slow rate of progression
 No defects in host defenses
Early onset Periodontitis  Prior to 4th decade
- Prepubertal  Rapid rate of progression
- Juvenile  Defects in host defenses
- Rapidly progressive
Periodontitis associated with Systemic diseases that predispose to
Inadequate
systemic diseases or inappropriate classification
rapid rates criteria
of destruction (e.g.
Diabetes)
Necrotizing Ulcerative Tissue necrosis with attachment
Periodontitis clinical attachment & bone loss
 Periodontitis

• Chronic
• Aggressive
• Periodontitis as a manifestations of
systemic diseases
 Chronic periodontitis

• 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

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-1β

• 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 2. Genetic disorders

a. Acquired neutropenia a. Familial and cyclic neutropenia

b. Leukemias b. Down syndrome
c. Other 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
 FINALLY ,,

Please read;

• Chapter 4
pages; 64 – 72

Classification of
Diseases and
Condition Affecting
the Periodontium