Based on journals released by AAP and workshop conducted in Chicago from 9-11 Nov,2017...

1. 2017 CLASSIFICATION
OF PERIODONTAL &
PERI-IMPLANT
DISEASES
Presented by
Bibina George

2. CONTENTS
• Introduction
• 1999 classification
– Limitations
• 2017 classification
– Features
– Staging of Periodontal disease
– Grading of Periodontal disease
• Mucogingival deformities/conditions
• Peri implant
• Conclusion

3. 1999 AAP CLASSIFICATION

4. LIMITATIONS OF 1999 CLASSIFICATION
• Understanding of periodontal disease is not complete enough to base our classification
on etiology.
• The 1999 classification system depends upon assessing the rate of progression spread
over multiple appointments in order to diagnose aggressive periodontitis. It is not
possible for patient to repeat clinical visits just to place him/her under a specific disease
entity such as aggressive or chronic periodontitis.
Flemingson J. Lazarus et al Periodontal Disease Classification:Controversies, Limitations and the Road
Ahead- A Proposed New Classification Journal of the International Academy of Periodontology 2012 14/4:84-
90.

5. • In spite of rapid advancement in the field of implantology, there is no provision in the
present classification for the diseases around implants, leaving a significant void
(Armitage, 1999; Devi and Pradeep, 2009)
• All the risk factors are not considered, e.g., smoking and diabetes (Armitage, 1999)
Jack G. Caton et al A new classification scheme for periodontal and peri‐implant diseases and conditions
– Introduction and key changes from the 1999 classification J Clin Periodontol. 2018;45:45(Suppl 20);S1–

7. The workshop reorganized
broad spectrum of non‐plaque
induced gingival diseases and
conditions based on primary
etiology

8. Periodontal Health and Gingival Health (Lang
NP, Bartold PM)

9. Dental plaque induced gingival conditions
REVISED CLASSIFICATION
1) description of the extent and severity
of the gingival inflammation,
2) description of the extent and severity
of gingival enlargements,
3) a reduction in gingival disease
taxonomy, and
4) discussion of whether mild localized
gingivitis should be considered a
disease or variant of health.

10. Non-plaque induced gingival diseases

11. FEATURES OF 2017 CLASSIFICATION
• Staging levels indicate the severity of the disease and the complexity of disease
management and is determined after considering several variables including clinical
attachment loss, amount and percentage of bone loss, probing depth, presence and
extent of angular bony defects and furcation involvement, tooth mobility, and tooth
loss due to periodontitis.
• Grading structure considers supplemental biologic characteristics of the patient in
estimating the rate and likelihood of periodontitis progression.

12. • The four categories of periodontitis staging are determined by a number of
variables and range from the least severe Stage I to most severe Stage IV.
• The three levels of periodontitis grading—which consider a patient’s overall health
status and risk factors such as smoking and metabolic control of diabetes—
indicate low risk of progression (Grade A), moderate risk of progression (Grade
B), and high risk of progression (Grade C).

14. Necrotizing Periodontal Diseases (Herrera D
et al)

18. Excessive occlusal forces
NEW
BIOLOGIC WIDTH - SUPRACRESTAL
ATTACHED TISSUES

19. Systemic diseases/conditions affecting
periodontal attachment apparatus

20. Periodontal Abscess
(Herrera D et al)

21. Endo-perio Lesions
(Herrera D et al)

22. Mucogingival conditions and deformities
(Cortellini & Bissada)
• Periodontal” “Biotype”/ “Morphotype” / “Phenotype
The distinction among different biotypes is based upon anatomic characteristics of
components of the masticatory complex, including:
1) Gingival biotype, which includes in its definition gingival thickness (GT) and
keratinized tissue width (KTW);
2) Bone morphotype (BM); and 3) Tooth dimension.

24. • A recent systematic review using the parameters reported previously, classified the
“biotypes” in three categories:
• Thin scalloped biotype in which there is a greater association with slender triangular crown,
subtle cervical convexity, interproximal contacts close to the incisal edge and a narrow zone of
KT, clear thin delicate gingiva, and a relatively thin alveolar bone.
• • Thick flat biotype showing more square‐shaped tooth crowns, pronounced cervical convexity,
large interproximal contact located more apically, a broad zone of KT, thick, fibrotic gingiva,
and a comparatively thick alveolar bone.
• • Thick scalloped biotype showing a thick fibrotic gingiva, slender teeth, narrow zone of KT,
and a pronounced gingival scalloping.

25. Gingival thickness, is assessed by:
– Transgingival probing
– Ultrasonic measurement.
– Probe visibility
• Gingiva was defined as thin (≤1.0 mm) or thick (>1 mm) upon the observation of the
periodontal probe visible through the gingiva.
• A color‐coded probe was proposed to identify four gingival biotypes (thin, medium,
thick and very thick).

26. • Keratinized tissue width(KTW)
– Thin biotype - 2.75 mm to 5.44mm
– Thick biotype - 5.09 mm to 6.65 mm
• Gingival thickness(GT)
– Thin biotype – 0.63mm
– Thick biotype - 1.79 mm.
• Bone morphotype
– Thin biotype – 0.343mm
– Thick biotype - 0.754 mm.

27. • Recession Type 1 (RT1):
Gingival recession with no loss of interproximal attachment. Interproximal CEJ is
clinically not detectable at both mesial and distal aspects of the tooth.
• Recession Type 2 (RT2):
Gingival recession associated with loss of interproximal attachment. The amount of
interproximal attachment loss (measured from the interproximal CEJ to the depth of
the interproximal sulcus/pocket) is less than or equal to the buccal attachment loss
(measured from the buccal CEJ to the apical end of the buccal sulcus/pocket).

28. • Recession Type 3 (RT3):
Gingival recession associated with loss of interproximal attachment. The amount of
interproximal attachment loss (measured from the interproximal CEJ to the apical end
of the sulcus/pocket) is greater than the buccal attachment loss (measured from the
buccal CEJ to the apical end of the buccal sulcus/pocket).
Cairo F, Nieri M, Cincinelli S, Mervelt J, Pagliaro U. The interproximal clinical attachment level to
classify gingival recessions and predict root coverage outcomes: an explorative and reliability study. J Clin
Periodontol. 2011;38:661–666.

29. Impact of Orthodontics in GR
• According to Kim DM et al, the direction of the tooth movement and the buccolingual
thickness of the gingiva may play important roles in soft tissue alteration during
orthodontic treatment.
– Higher probability of recession during tooth movement in areas with <2 mm of gingiva.
Gingival augmentation can be indicated before the initiation of orthodontic treatment in
areas with <2 mm.
– These conclusions are mainly based on historic clinical observations and recommendations
(low level of evidence).

32. Peri‐implant health:
• Was defined both clinically and histologically.
• Clinically, characterized by:
• an absence of visual signs of inflammation and bleeding on probing.
• Peri‐implant health can exist around implants with normal or reduced bone support.
• It is not possible to define a range of probing depths compatible with peri‐implant
health.

33. Peri‐implant mucositis:
• Characterized by bleeding on probing and visual signs of inflammation.
• While there is strong evidence that peri‐implant mucositis is caused by plaque, there
is very limited evidence for non‐plaque induced peri‐implant mucositis.
• It can be reversed with measures aimed at eliminating the plaque.

34. Peri‐implantitis:
• Peri‐implant mucositis is assumed to precede peri‐implantitis.
• Peri‐implantitis is associated with poor plaque control and with patients with a
history of severe periodontitis.
• Onset: May occur early following implant placement as indicated by
radiographic data.
• Peri‐implantitis, in the absence of treatment, seems to progress in a non‐linear
and accelerating pattern.

35. Hard and soft tissue implant site deficiencies
• Normal healing following tooth loss leads to diminished dimensions of the alveolar
process/ridge that result in both hard and soft tissue deficiencies.
• Larger ridge deficiencies can occur at sites associated with severe loss of periodontal
support, extraction trauma, endodontic infections, root fractures, thin buccal bone
plates, poor tooth position, injury and pneumatization of the maxillary sinuses.
• Other factors: medications and systemic diseases reducing the amount of naturally
formed bone, tooth agenesis, and pressure from prostheses.

36. References
1. Classification and diagnosis of aggressive periodontitis.Daniel H. Fine. J Clin
Periodontol. 2018;45(Suppl 20):S95–S111.
2. Mucogingival conditions in the natural dentition: Narrative review, case definitions, and
diagnostic considerations.Pierpaolo Cortellini. J Clin Periodontol. 2018;45(Suppl
20):S190–S198.
3. Periodontal health and gingival diseases and conditions on an intact and a reduced
periodontium: Consensus report of workgroup 1 of the 2017 World Workshop on the
Classification of Periodontal and Peri‐Implant Diseases and Conditions .Iain L.C.
Chapple. J Clin Periodontol. 2018;45(Suppl 20):S68–S77.
4. Papapanou PN, Sanz M, et al. Periodontitis: Consensus report of workgroup 2 of the
2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and
Conditions. J Clin Periodontol. 2018;45(Suppl 20):S162–S170.

37. 5. Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis:
Framework and proposal of a new classification and case definition. J Clin Periodontol.
2018;45(Suppl 20):S149–S161.
6. Cortellini P, Bissada NF. Mucogingival conditions in the natural dentition: Narrative
review, case definitions, and diagnostic considerations. J Clin Periodontol.
2018;45(Suppl 20):S199–S206.
7. Berglundh T, Armitage G, et al. Peri‐implant diseases and conditions: Consensus report
of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and
Peri‐Implant Diseases and Conditions. J Clin Periodontol. 2018;45(Suppl 20):S286–
S291.
8. Araujo MG, Lindhe J. Peri‐implant health. J Clin Periodontol. 2018;45(Suppl 20):S36–
S36.