eriodontitis: Consensus report of workgroup 2 of

he 2017 World Workshop on the Classification of

Periodontal and Peri-Implant Diseases
and Conditions

ANNIE LIZ MANUEL

I MDS
DEPARTMENT OF PERIODONT
INTRODUCTION

• Periodontitis - chronic multifactorial inflammatory disease associated with plaque

biofilms and characterized by progressive destruction of the tooth-supporting
apparatus. Features-
o loss of periodontal tissue support (CAL, alveolar bone loss)
o periodontal pocketing
o gingival bleeding.

• A new periodontitis classification which classify “chronic” and “aggressive” into one,
and further characterized based on a multi-dimensional staging and grading system.
According to the periodontitis classification scheme (Armitage 1999),periodontitis is further
subdivided as follows

Chronic Periodontitis

Aggressive Periodontitis

Periodontitis as a
manifestation of
systemic disease

Necrotizing periodontal
diseases

Periodontal Abscesses
Limitations of 1999 classification of Periodontal Diseases

• Categorizing periodontitis was difficult .

• No mention of peri implant diseases.

• No proper acknowledgement of risk factors like smoking and diabetes mellitus.

• Terms “localized and generalized” without any data backing giving varying results.

• Confusion in diagnosing a case of plaque induced gingival inflammation in a normal

healthy but reduced periodontium.

(Caton JG et al 2018)
 Objectives of Workshop 2

• Revisiting current classification system of periodontitis

• Incorporate new knowledge relevant to its epidemiology, etiology and

pathogenesis

To this end, five position papers were commissioned, authored, peer-reviewed,

and accepted.
1. Classification and diagnosis of aggressive periodontitis (Fine et al.2018)

2. Age dependent distribution of clinical attachment loss in two population-

representative, cross-sectional studies (Billings et al. 2018)

3. Progression data of clinical attachment loss from existing prospective,

longitudinal studies (Needleman at al. 2018)

4. Diagnosis, pathobiology, and clinical presentation of acute periodontal

lesions (Herrera et al. 2018);

5. Periodontitis case definitions (Tonetti et al.2018)

Summary

1. The conflicting literature findings on aggressive periodontitis are primarily due

to the fact that
(i) Current Broad Classification

(ii) the disease has not been studied from its inception, and

(iii) there is paucity of longitudinal studies

The position paper argued that a more restrictive definition might be better
suited to take advantage of modern methodologies to enhance knowledge on
the diagnosis, pathogenesis, and management of this form of periodontitis
2) common patterns of CAL were identified across different ages,
along with consistencies in the relative contribution of recession and
pocket depth to CAL.
3)
• Longitudinal mean annual attachment level change was found
to vary considerably both within and between populations.

• Neither age nor sex had any discernible effects on CAL change.
4)Necrotizing periodontal diseases are characterized by
three typical clinical features

• papilla necrosis

• bleeding

• pain
and are associated with host immune response impairments, which
should be considered in the classification of these conditions
2017 Classification of NPDs
Endodontic-periodontal lesions -a pathological communication between the
pulpal and periodontal tissues at a given tooth, occur in either an acute or a
chronic form

Primary signs
• Deep periodontal pockets extending to the root apex

• Negative/altered response to pulp vitality tests.

Other signs/symptoms

• Radiographic evidence of bone loss in the apical or furcation region

• Spontaneous pain or pain on palpation/percussion,
• Purulent exudate
• tooth mobility
• sinus tract/fistula
• crown /gingival color alterations or both
Signs observed in endo-periodontal lesions with traumatic and/or
iatrogenic factors

• Root perforation
• Fracture
• External root resorption.

These conditions drastically impair the prognosis of the involved

tooth.
Classification of endo-periodontal lesions
(Papapanou 2017)
Periodontal abscess - Localized accumulation of pus located
within the gingival wall of the periodontal pocket/sulcus,
resulting in a significant tissue breakdown.
The primary detectable sign

• Ovoid elevation in the gingiva along lateral part of the root

• Bleeding on probing.

Other signs/symptoms
• Pain
• Suppuration on probing
• Deep periodontal pocket
• Increased tooth mobility.
• A periodontal abscess may develop in a pre-existing periodontal pocket,
e.g., in patients with untreated periodontitis,
under supportive therapy or after scaling and root planing or
systemic antimicrobial therapy.

• A periodontal abscess occurring at a previously periodontally healthy site is

commonly associated with a history of impaction or harmful habits
Periodontal abscesses, lesions from necrotizing periodontal
diseases and acute presentations of endo-periodontal lesions,
share the following features that differentiate them from
periodontitis lesions:

• Rapid onset

• Rapid destruction of periodontal tissues

• Pain or discomfort.
Classification of periodontal abscesses based on Etiology
(Papanau et al 2017)
5)

Identification of a patient
as a periodontitis case

A
periodontitis
case Identification of the
definition specific type of
periodontitis
system
should
Description of the clinical
include presentation and other
elements that affect clinical
three management, prognosis,
components and potentially broader
influences on both oral
and systemic health
Staging is largely dependent upon the severity of disease at
presentation as well as on the complexity of disease management.

Goals of Staging of Periodontitis

• Classify Severity and Extent of an individual’s disease based

on currently measurable extent of destroyed and damaged
tissue attributable to periodontitis.

• Assess Complexity. Assess specific factors that may determine

complexity of controlling current disease and managing long-
term function and esthetics of the patient's dentition

(Maurizio S. Tonetti et al 2018)

Classifation of periodontitis into stages
Grading gives information about

• History based analysis of the rate of periodontitis progression

• Assessment of the risk for further progression

• Analysis of possible poor outcomes of treatment

• Assessment of the risk that the disease or its treatment.

Classification of Periodontitis into Grades
 When can a patient be identified as a Periodontitis Case?
• Interdental CAL is detectable at ≥ 2 non-adjacent teeth
• Buccal or oral CAL ≥ 3 mm with pocketing ≥3 mm
is detectable at ≥ 2 teeth but the observed CAL
cannot be ascribed to non-periodontitis-related
causes
such as
[Link] recession due to trauma

(Heasman PA et al 2015)
2) dental caries extending in the cervical area of the tooth
 3) the presence of CAL on the distal aspect of a second molar
and associated with malposition or extraction of a third molar
4)An endodontic lesion draining through the marginal
periodontium
5) the occurrence of a vertical root fracture.
 Based on
pathophysiolog
y

Periodontitis as
Necrotising a manifestation
Periodontitis
periodontitis of systemic
disease
 Necrotising Periodontal Diseases

Necrotising Cancum
Necrotising Necrotising
Periodontiti Oris
Gingivits Stomatitis
s (Noma)

considered stages of the same condition due to their shared etiology and clinical presentation

(Gasner et al 2022)
Features of NPDs

• Pain

• Gingival necrosis

• Interdental ulceration

• Osteonecrosis (advanced stages)

Differentiating Necrotizing gingivitis from other periodontal lesions

Necrotizing gingivitis lesions are characterized by the presence of ulcers within

the stratified squamous epithelium and the superficial layer of the gingival
connective tissue, surrounded by a non-specific acute inflammatory infiltrate.
Four zones have been described:

(1) superficial bacterial zone,

(2) neutrophil-rich zone,

(3) necrotic zone and

(4) a spirochetal/bacterial infiltration zone.

Necrotizing periodontal diseases are strongly associated with impairment
of the host immune system ,as follows:

(1) in chronically, severely compromised patients (e.g., AIDS patients,

children suffering from severe malnourishment, extreme living conditions,
or severe infections and may constitute a severe or even life-threating condition)

(2) in temporarily and/or moderately compromised patients (e.g., in smokers

or psycho-socially stressed adult patients).
Necrotizing gingivitis - acute inflammatory process of the gingival tissues
characterized by presence of necrosis or ulcer of the interdental papillae,
gingival bleeding, and pain.
Other signs/symptoms associated with this condition may include

• halitosis,
• pseudomembranes,
• regional lymphadenopathy,
• fever
• sialorrhea (in children).
Necrotizing periodontitis -inflammatory process of the periodontium
characterized by presence of necrosis/ulcer of the interdental papillae,
gingival bleeding, halitosis, pain, and rapid bone loss.
Other signs/symptoms associated with this condition may include

• pseudomembrane formation

• lymphadenopathy

• fever.
Necrotizing stomatitis -severe inflammatory condition of the periodontium
and the oral cavity in which soft tissue necrosis extends beyond the gingiva
and bone denudation may occur through the alveolar mucosa, with larger
areas of osteitis and formation of bone sequestrum. It typically occurs in

• severely systemically compromised patients and among young malnourished

children in developing countries.

• Atypical cases have also been reported, in which necrotizing stomatitis may develop
without prior appearance of necrotizing gingivitis or periodontitis lesions.
Future research should:

1. Develop improved methodologies to assess more accurately the

longitudinal soft and hard tissue changes associated with periodontitis
progression

2. Identify genetic, microbial, and host response-associated markers that

differentiate between distinct periodontitis phenotypes, or which can
reflect the initiation and progression of periodontitis.
3. Expand existing epidemiological databases to include world regions
currently underrepresented, utilizing consistent, standardized
methodologies, and capturing and reporting detailed data on both patient-
related, oral, and periodontal variables. Open access to the detailed data is
crucial to facilitate comprehensive analyses.

4. Integrate multi-dimensional data platforms to facilitate systems biology

approaches to the study of periodontal and peri-implant diseases and
conditions
5. Use existing databases or develop new databases that will facilitate
the implementation, validation and continuous refinement of the newly
introduced periodontitis classification system.
Thank You!