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.1,2

Table 1. Periodontitis: Staging.
Stage periodontitis Stage I Stage II Stage IV
Severity Interdental CAL (at site of greatest loss) 1 – 2 mm 3 – 4 mm ≥5 mm
RBL Coronal third (<15%) Coronal third (15% – 33%) Extending to middle third of root and beyond
Tooth Loss (due to periodontitis) No tooth loss ≥5 teeth
Complexity Local • Max. probing depth ≤4 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 rehabilitatin due to:
  - Masticatory dysfunction
  - Secondary occlusal trauma (tooth mobility degree ≥2)   - Severe ridge defects
  - Bite collapse, drifting, flaring
  - <20 remaining teeth (10 opposing pairs)
Extent and Distribution Add To Stage As Descriptor 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.1,2

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
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
Diabetes Normoglycemic/no diagnosis of diabetes HbA1c <7.0% in patients with diabetes HbA1c ≥7.0% in patients with diabetes
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.
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
deep periodontal pocket.

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.

characteristics of periodontal disease.

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.”