2017 classification system of

periodontal diseases and

conditions
Assist. Prof. Dr. Ali A Abdulkareem
BDS, MSc, PhD

Department of Periodontics,
College of Dentistry, University of Baghdad
CEJ

Gingival sulcus
Gingiva
Junctional epithelium

Gingival fibers

cementum
Bone
PDL
 Supracrestal
attachment
OR
Biologic width
(2.04 mm)
Epithelial and
connective tissue
attachment coronal to
the alveolar bone
Healthy Periodontium

• Normal sulcus (0 to 3mm)

• JE attached to CEJ
Case definition for healthy periodontium

Health:
BOP: < 10%
PPD: ≤ 3 mm
CAL: No (intact)
Yes (reduced)
Radiographic bone loss: No (intact), Possible (reduced)
For reduced: No history of periodontitis
Biofilm-induced gingivitis
Inflammation confined to gingiva

False pocket (hypertrophied gingiva)

Oedema, redness, loss of architecture

No evidence of bone loss

Case definition for gingivitis)

Gingivitis:
BOP ≥ 10%-30% (localized), > 30% (generalized)
PPD: ≤ 3 mm
CAL: No (intact)
Yes (reduced)
Radiographic bone loss: No (intact), Possible (reduced)
For reduced: No history of periodontitis
 Periodontitis

Recession could be detected

True pocket formation
Loss of attachment
and apical migration of JE

Radiographic evidence of bone loss

PPD CAL
CAL calculation
Scenario 1 Scenario 2 Scenario 3
Gingival margin at CEJ
Enlarged gingiva = 3 mm

Rec = 3 mm PPD = 5 mm
PPD = 6 mm

PPD = 5 mm

CAL= Rec + PPD CAL= PPD – Enlarged gingiva CAL= PPD

= 3 + 5 = 8 mm = 5 – 3 = 2 mm = 6 mm
 Case definition (Periodontitis)
1 Interdental CAL ≥ 2 non‐adjacent teeth
OR
2 Buccal or oral CAL ≥3 mm with pocketing
>3 mm is detectable at ≥2 teeth
Probing: direction and sites

Distobuccal
Buccal
Mesiobuccal
Mesiolingual
Lingual
Distolingual
 20%, 60%, 80%, …..

1 01 1 0 0 1 00 1 10 1 0 1 0 0 0 00 0 1 1 0 0 0 0 0 0 0 1 0 0 0 1 1
001 1 0 0 1 00 1 1 1 0 0 1 0 0 0 00 0 10 0 0 1 0 0 0 0 1 0 0 0 1 1 XX
Bleeding on probing (BOP) index
Assess each quadrant for the presence (1) or absence (0) of bleeding, and calculate a
percentage score for the whole mouth as follows:

% BOP score= Number of surfaces with bleeding X 100/ Total number of teeth X 6
 20%, 60%, 80%, …..

1 01 1 0 0 1 00 1 10 1 0 1 0 0 0 00 0 1 1 0 0 0 0 0 0 0 1 0 0 0 1 1
001 1 0 0 1 00 1 1 1 0 0 1 0 0 0 00 0 10 0 0 1 0 0 0 0 1 0 0 0 1 1 XX
Example
Number of teeth = 20
Total number of surfaces = 20 X 6 = 120
Number of bleeding surfaces = 45
% BOP = 45/120 X 100 = 37.5
5 5 4

6
4 4

4 7 3 4

3 1 5 4
Diagnosis (periodontitis)
Extent

Periodontitis molar/incisor pattern: bone loss is isolated to molar and incisor

Localized periodontitis: < 30% of teeth have periodontal disease associated bone loss

Generalized periodontitis: bone loss exceeds 30% of teeth

Once a periodontitis has been identified, the next step is to ‘stage’ the
patient.
Disease staging

Staging aims to indicate the severity of disease, which will reflect the complexity of
patient management.

Staging utilizes the bone loss at the worst site due to periodontal disease

Assessed either by:

• Radiograph
• Clinically by measuring CAL
• Do not include teeth involved with perio-endo lesion
Measuring the severity of bone loss
In this example, root length is assumed to be 15 mm
Note: root length of each tooth must be calculated according to crown : root ratio or radiograph

STAGE Clinical/Radiographic
% of bone loss is
about 50
IV Apical 1/3 This will be used in
the next step
(Grading)
III Middle 1/3
Supracrestal attachment= 2 mm
PPD = 4 mm
II Coronal 1/3
Recession = 2 mm
I 1 to 2 mm
Bone loss = 8 mm

Roots length (Crown root

ratio= 1:2) or radiograph
CAL= 1-2 mm

CAL= 3-4 mm

CAL= ≥ 5 mm
Disease grading

‘Grading’ aims to help identify how susceptible a patient is to periodontal disease

Grading assessed by using the worst site of bone loss due to periodontal disease along
with the patient’s age. This will give an assessment of the rate of progression.

It is calculated according to the following formula:

% Bone loss
Patient’s age
 < 0.5 0.5-1.0 > 1.0

Grade A Grade B Grade C

Slow rate of Moderate rate Rapid rate of

progression of progression progression

In the previous example, the % of bone loss (at worst site)= 50%
Assuming the age was 30 years then the result will be > 1.0 (Grade C)
If the age was 60 years then the result will be 0.5-1.0 (Grade B)
Disease status

‘Status’ aims to determine the patient’s current disease status.

Patients who have had a history of periodontal disease are at higher risk of further
periodontal disease progression and require long-term maintenance.

Currently Currently
Stable Unstable
• BOP < 10% • PPD ≥ 5mm
• PPD ≤ 4mm or
• No BOP at • PPD ≥ 4mm
4mm sites and BOP
Identification of ‘risk factors’

Certain risk factors have the potential to impact development and progression of
periodontal disease directly.

• Poorly controlled type 2 diabetes

• Smoking
Start Interdental CAL ≥2 teeth No Facial/lingual CAL ≥2 teeth

Yes PPD >3 mm Yes No

Periodontitis Yes No Reduced Intact

Record full chart BOP, PPD, CAL Record BOP

Define <10% Healthy periodontium

Extent, Stage, Grade, Status, Risk factor 10%-30% Localized gingivitis
>30% Generalized gingivitis
Disclose and allow to rinse.
A probe may be used to confirm the presence of plaque.
Scores recorded on four surfaces; distal, mid and mesial points on the facial (buccal) and
lingual (palatal) aspects.
Score as follows:
• 0 = no plaque (left blank)
• 1 = plaque present (recorded √)
Calculate the % of plaque as follows:

Number of surfaces with plaque

X 100
Total number of teeth X 4

According to previous example, plaque present on 30 surfaces out of 112

The plaque %= 26.7% (27%)
Sites in concern
Local factors
• Subgingival caries
• Overhang filling
• Tooth surface anomalies
• Tilted tooth
• Etc……
 Remember
Diagnosis statement

Healthy : intact or reduced

Gingivitis : intact or reduced + localaized or generalized

Periodontitis : localized or generalized + stage + grade + stability + risk factor

History
A 55-year old woman referred by general
dentist for a periodontal evaluation.
CC: bad breath, bleeding, and flaring of teeth.
MH: chronic autoimmune thyroiditis, she has
been an ex-smoker for five years.
Examination
• The gingiva presents an evident increase in size, change in
colour, inflammation as well as loss of the scalloping and
texture.
• Panoramic x-ray shows evidence of bone loss
• Interproximal CAL > 4mm at <30% of sites
• Some sites with PPD> 4mm exhibit BOP

Localized periodontitis, Stage 3, Grade B, currently unstable, No risk factors

History
70-year-old male, regular attender, never smoker
Manual brushes x2/day, no interdental cleaning
Previous tooth loss due to periodontal disease
Poorly controlled type 2 diabetic

Examination
Plaque score 20%
BOP <10% of sites
Obvious interdental recession affecting 80% of teeth Diagnosis, extent ?
Staging ? (8 mm + 2 mm PPD + 2 mm supracrestal)
PPD (2 mm for all teeth)
Grading ? (80% bone loss)
Recession (worst site = 8 mm)
Status?
Risk factor?

Generalized periodontitis, Stage 4, Grade c, currently stable, unstable diabetic

History
30-year-old female, symptomatic attender
Pregnant with no other relevant medical history, never smoker
Manual brushes x1/day
Previous loss of teeth due to excessive mobility

Examination
Plaque score 70%
BOP 80% of sites
Obvious loss of interdental papillae
Diagnosis, extent ?
PPD (> 5 mm for all teeth) Staging ? (Radiographic bone loss at apical 1/3 and apex)
CAL ? Grading ? (90% bone loss in some teeth)
Status? (PPD > 5 + 80% BOP)
Risk factor?
Generalized periodontitis, Stage 4, Grade c, currently unstable, no specific risk factors
Please note!

• Antibiotic NEVER prescribed for patients with gingivitis or

periodontitis EXCEPT for Periodontitis stage 4, Grade C,

Unstable at a young age (<30%)

• Combination of Amoxillin + Metronidazole