Chapter 6

Classification of Periodontal Diseases

Aim

This chapter aims to explain the necessity for classification systems and how such systems have evolved in periodontology to the present day. The faults with existing systems will be highlighted and a simplified classification proposed for general dental practice.

Outcome

The outcome of reading this chapter should be that the practitioner understands the chronological relationship between old and current diagnostic terms in periodontology, and is able to introduce a logical system of classification into their own clinical practice.

Why Do We Need Classification Systems?

This chapter is the simplest in the book in terms of concepts, but proved the hardest to write, owing to the broad controversy that surrounds classification systems for periodontal diseases.

Traditionally, classification systems were simple. Owing to a paucity of knowledge and evidence from research, little was known about these diseases and thus simple terms were applied, by necessity. During the 1970s, 1980s and early 1990s, research into periodontal diseases exploded and our knowledge base broadened dramatically. The classification categories of the 1970s, 1980s and early 1990s therefore expanded to encompass new diseases for which there was putative evidence, based largely on case reports. However, there are important differences between having knowledge and having understanding. As a consequence (as with most things in the modern world), the wheel has turned almost full circle and the 1999 International Workshop on Periodontal Disease Classification has re-reduced the number of common disease categories – reflecting our lack of genuine understanding of these complex diseases and what differentiates them – and increased the number of less-common disease categories.

Classification systems are essential, largely because without them it is not possible to arrive at an informed diagnosis. Without a robust diagnosis, appropriate therapy cannot be implemented. Classification systems also:

• Direct research aimed at learning more about the diseases concerned.

• Help determine the evidence base for better-targeted therapy.

• Guide practitioners towards the best method for treating a disease.

• Enable the international community to communicate in a common language.

• Guide public health planning and targeting of therapy.

• Help practitioners plan treatment protocols to maximise benefit to all their patients.

Basic Terms that Appear in Such Systems

When designing classification systems, a series of traditional terms is often used as the basis for sub-categorisation.

Acute

The term “acute” is one of the most frequently used in medical disease classification. “Acute” is a term that describes a short-lived, intense, brisk experience that is often a distressing one and is assumed to require immediate action. Recent classifications have thus removed it from the titles of diseases like AUG, which became ANUG, but has now been replaced by the term NUG. The situation is similar for the acute lateral periodontal abscess, now called a “lateral periodontal abscess”. Acute diseases may often be curable, e.g. acute lymphoblastic/cytic leukaemia in children. Eliminating the infective agent can cure the majority of acute infections.

Chronic

If a disease is not acute, then by default it is a chronic process. “Chronic” diseases have a longer “time course” and are generally not immediately life-threatening. However, the evidence base for the “time course” that designates a disease acute or chronic varies from one human system to the next, and in the periodontium there is no consensus on what a short or long time course may be. Chronic diseases are generally incurable, and management involves the control of symptoms, or the prevention of more serious complications. For example, diabetes mellitus and HIV disease are managed to prevent systemic complications and prolong life-expectancy to as close to normal as possible. Rheumatoid arthritis and Crohn’s disease are managed symptomatically. Periodontal diseases are largely chronic and cannot currently be cured, but they can be controlled.

Aggressive

“Aggressive” is a term that describes a rapid progression over a short period of time (months or a few years). Previously the term “rapidly progressing” was used in this manner.

Juvenile

“Juvenile” is a term used to describe a disease whose onset occurred during juvenile years.

Localised

“Localised” is a term used to designate a disease involving a small number of teeth (see below).

Generalised

“Generalised” is the term used to describe diseases involving the majority of teeth present in the mouth.

Historical Perspective pre-1999

Many different terms have been used for periodontal diseases over the years. In Sir Wilfred Fish’s 1952 text, Parodontal Disease: A Manual of Treatment and Atlas of Pathology (2nd edn.), the diseases were classified as:

Degenerative/abnormalities of growth – these included senile alveolar resorption (osteoporotic changes), odontoclasia (root apex resorption) and hypercementosis.

Inflammations – these included traumatic inflammations, acute ulcerative stomatitis (now called NUG), sub-acute marginal gingivitis, chronic marginal gingivitis (which included drug-induced overgrowths), pyorrhoea simplex (mild periodontitis) and pyorrhoea profunda (advanced periodontitis).

Neoplasia – which included odontoclastoma, cementoma and fibrous epulis.

It can be seen from the current international system (Tables 6-1 and 6-2), how little some things have changed in fifty years!

A. Dental plaque-induced gingival diseases

1. Gingivitis associated with dental plaque only

   1. without other local contributing factors

   2. with local contributing factors (G.1 Table 6-3)

2. Gingival diseases modified by systemic factors

   1. associated with the endocrine system

      1. puberty-associated gingivitis

      2. menstrual cycle-associated gingivitis

      3. pregnancy-associated

         1. gingivitis

         2. pyogenic granuloma

      4. diabetes mellitus-associated gingivitis

   2. associated with blood dyscrasias

      1. leukemia-associated gingivitis

      2. other

3. Gingival diseases modified by medications

   1. drug-influenced gingival diseases

      1. drug-influenced gingival enlargements

      2. drug-influenced gingivitis

         1. oral contraceptive-associated gingivitis

         2. other

4. Gingival diseases modified by malnutrition

   1. ascorbic acid-deficiency gingivitis

   2. other

B. Non-plaque-induced gingival lesions

1. Gingival diseases of specific bacterial origin

   1. Neisseria gonorrhea-associated lesions

   2. Treponema pallidum-associated lesions

   3. streptococcal species-associated lesions

   4. other

2. Gingival diseases of viral origin

   1. herpes virus infections

      1. primary herpetic gingivostomatitis

      2. recurrent oral herpes

      3. varicella-zoster infections

   2. other

3. Gingival diseases of fungal origin

   1. Candida-species infections

      1. generalized gingival candidosis

      2. linear gingival erythema

      3. histoplasmosis

      4. other

4. Gingival lesions of genetic origin

   1. hereditary gingival fibromatosis

   2. other

5. Gingival manifestations of systemic conditions

   1. mucocutaneous disorders

      1. lichen planus

      2. pemphigoid

      3. pemphigus vulgaris

      4. erythema multiforme

      5. lupus erythematosus

      6. drug-induced

      7. other

   2. allergic reactions

      1. dental restorative materials

         1. mercury

         2. nickel

         3. acrylic

         4. other

      2. reactions attributable to

         1. toothpastes/dentifrices

         2. mouthrinses/mouthwashes

         3. chewing gum additives

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