Classifications of Periodontal Diseases

Staging and Grading Periodontitis

The 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions developed a classification of periodontitis that includes a staging and grading system. For more complete information visit the website at: perio.org/2017wwdc.

Staging looks at classifying the extent of and severity of periodontal disease in a patient. It utilizes the measurable amount of destroyed or damaged tissue due to periodontitis and to look at specific factors that can contribute to long term case management. Initially, the stage should be assessed using clinical attachment loss (CAL). If that is not available, then radiographic bone loss (RBL) can be used. Tooth loss due to periodontitis can alter the staging. If one or more complexity factors are present, then the stage may go to a higher level.^3,4

Table 1. Periodontitis: Staging.

Periodontitis	Stage I	Stage II	Stage III	Stage IV
Severity
Interdental CAL (at site of greatest loss)	1 – 2 mm	3 – 4 mm	≥5 mm	≥5 mm
Radiographic Bone Loss	Coronal third (<15%)	Coronal third (15% – 33%)	Extending to middle third of root and beyond	Extending to middle third of root and beyond
Tooth Loss(due to periodontitis)	No tooth loss due to periodontitis		≥4 teeth	≥5 teeth
Complexity
Local	• Max. probing depth ≤4 mm • Mostly Horizontal bone loss	• Max. probing depth ≤5 mm • Mostly Horizontal bone loss	In addition to Stage II Complexity: • Probing depths ≥6 mm • Vertical bone loss ≥3 mm • Furcation Involvement Class II or III • Moderate ridge defects	In addition to Stage III complexity: • Need for complex rehabilitation due to: - Masticatory dysfunction - Secondary occlusal trauma (tooth mobility degree ≥2) - Severe ridge defects - Bite collapse, drifting, flaring - Less than 20 remaining teeth (10 opposing pairs)
Extent and Distribution	For each stage, describe extent as: Localized (<30% of teeth involved); Generalized; or Molar/incisor pattern

This information is from: The 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions was co-presented by the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP).

Tables from Tonetti, Greenwell, Kornman. J Periodontol 2018;89 (Suppl 1): S159-S172.

Grading is a process which rates the progression of periodontitis in a patient and its response to standard treatment and therapies. It also attempts to determine its effect on systemic health. When starting, the clinician should assign a grade of B disease and determine if there are factors with specific evidence in order to shift to a grade of A or C.^3,4

Table 2. Periodontitis: Grading.

	Progression		Grade A: Slow Rate	Grade B: Moderate Rate	Grade C: Rapid Rate
*Primary Criteria*	Direct Evidence of Progression	Radiographic Bone Loss or CAL	No Loss Over 5 years	≥2 mm over 5 years	≥2 mm over 5 years
	Indirect Evidence of Progression	% Boss Loss/Age	<0.25	0.25 to 1	>1.0
	Indirect Evidence of Progression	Case Phenotype	Heavy Biofilm Deposits with Low Levels of Destruction	Destruction commensurate with biofilm deposits	Destruction exceeds expectations given biofilm deposits; specific clinical patterns suggestive of periods of rapid progression and/or early onset disease
*Grade Modifiers*	Risk Factors	Smoking	Non-smoker	<10 cigarettes/day	≥10 cigarettes/day
*Grade Modifiers*	Risk Factors	Diabetes	Normoglycemic/no diagnosis of diabetes	HbA1c <7.0% in patients with diabetes	HbA1c ≥7.0% in patients with diabetes

Tables from Tonetti, Greenwell, Kornman. J Periodontol 2018;89 (Suppl 1): S159-S172.

Table 3. Steps in Staging and Grading a Patient.

Step 1: Initial Case Overview to Assess Disease	Screen: • Full mouth probing depths • Full mouth radiographs • Missing teeth Mild to moderate periodontitis will typically be either Stage III or Stage II Severe to very severe periodontitis will typically be either Stage III or Stage IV
Step 2: Establish Stage	For mild to moderate periodontitis (typically Stage I or Stage II): • Confirm clinical attachment loss (CAL) • Rule out non-periodontitis causes of CAL (e.g., cervical restorations or caries, root fractures, CAL due to traumatic causes) • Determine maximum CAL or radiographic bone loss (RBL) • Confirm RBL patterns For moderate to severe periodontitis (typically Stage III or Stage IV): • Determine maximum CAL or RBL • Confirm RBL patterns • Assess tooth loss due to periodontitis • Evaluate case complexity factors
Step 3: Establish Grade	• Calculate RBL (% of root length x 100) divided by age • Assess risk factors (e.g., smoking, diabetes) • Measure response to scaling and root planing and plaque control • Assess expected rate of bone loss • Conduct detailed risk assessment • Account for medical and systemic inflammatory considerations

ce542 - Content - Classifications of Periodontal Diseases - Figure 1

Upon performing the periodontal screening on Emmett, Jessica found that his periodontal pocket depths had increased from 2-3 mm to greater than 5 mm in most areas. Jessica completes her scaling and polishing of Emmett’s teeth and updates a plan for his oral health instructions that she will deliver to him after Dr. Jay does her clinical examination.

Dr. Jay to Mr. Davis: “Emmett, I can see from the data Jessica collected, that your periodontal pockets have increased significantly, and in looking at your radiographs, you have some bone loss. This is the reason that some of your teeth are loose and your gums are bleeding and tender. Unfortunately, your condition has progressed from gingivitis to periodontal disease (periodontitis). Have you experienced any bad breath?”

Mr. Davis to Dr. Jay: “Well, yes I have. I just thought it might be something I was eating.”

Dr. Jay to Mr. Davis: “Actually, bad breath can also be a sign of periodontal disease.”

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