1999 AAP CLASSIFICATION OF PERIODONTAL DISEASES-MERITS & DEMERITS

Made by: Prarthana Thaker

INTRODUCTION

3 dominant paradigms:1.Clinical features of the disease(1870-1920)

--C.G.Davis classification-1879--G.V Black-1886

2.Concepts of classical pathology(1920-1970)--studies by Gottlieb and Orbans--Orban classification 1942--1966 World Workshop- doubts about

“Periodontosis”

3.Infecton/host response paradigm(1970-present)

HISTORY…….

Periodontal disease caused by bacteria.

W.D Miller was an early proponent of infectious nature of periodontal disease.

1965-1968: study of classic experimental gingivitis by H.Loe et al.

1976-1977: concept of microbial specificity ( Newman et al).

[American Academy of Periodontology, 1966: 167–177]

1970-present: Infection/Host paradigm

HISTORY…….

1977- World Workshop Classification

1982- Page & Schroeder Classification

1986- Listgarten Classification

1988- Suzuki Classification

[American Academy of Periodontology, 1966: 167–177]

HISTORY……..

1989- World Workshop Classification

1990- Genco Classification

1993- Ranney European workshop Classification

1999- AAP International Workshop. [American Academy of Periodontology, 1966: 167–177]

GOALS OF 1999 WORLD WORKSHOP

Correct Problems associated with the 1989 system:

It did not include gingivitis or gingival disease category

Periodontitis category had non validated age dependent criteria

Extensive crossover in rates of progression of different categories of periodontitis

Extensive overlap in clinical characteristics of different categories

Refractory periodontitis, Pre pubertal periodontitis were heterogenous category

SHORTCOMINGS 1993 RANNEYS CLASSIFICAION

Lacked details necessary for adequate characterization of broad spectrum of periodontal diseases encountered in clinical practise.

1999 ClassificationGingival Diseases

Plaque induced gingival lesions

1. Gingivitis associated with dental plaque only

2. Gingival diseases modified by systemic factors(endocrine system or blood dyscrasias)

3. Gingival diseases modified by medication

4. Gingival diseases modified by malnutrition

CLASSIFICATION OF GINGIVAL DISEASESNON-PLAQUE INDUCED GINGIVAL LESIONS

1. Gingival diseases of specific bacterial origin

2. Gingival diseases of viral origin3. Gingival diseases of fungal

origin4. Gingival diseases of genetic

origin5. Gingival manifestations of

systemic conditions6. Traumatic lesions7. Foreign body reactions

CLASSIFICATION OF PERIODONTITIS 1.    Chronic Periodontitis

Localized Generalized

2.    Aggressive Periodontitis Localized Generalized

3.    Periodontitis Associated with Systemic Diseases

4.    Necrotizing Periodontal Diseases 5.    Abscesses of the Periodontium 6.    Periodontal Diseases associated with

Endodontic Lesions 7.    Developmental or Acquired Deformities

and Conditions *Can be further classified on basis of extent

and severity

I. Gingival DiseasesA. Dental plaque-induced gingival diseases*1. Gingivitis associated with dental plaque onlya. without other local contributing factorsb. with local contributing factors (See VIII A)

2. Gingival diseases modified by systemic factorsa. associated with the endocrine system1) puberty-associated gingivitis2) menstrual cycle-associated gingivitis3) pregnancy-associated

a) gingivitisb) pyogenic granuloma

4) diabetes mellitus-associated gingivitis

b. associated with blood dyscrasias1) leukemia-associated gingivitis2) other

3. Gingival diseases modified by medicationsa. drug-influenced gingival diseases 1) drug-influenced gingival enlargements 2) drug-influenced gingivitis a) oral contraceptive-associated gingivitis b) other

4. Gingival diseases modified by malnutrition a. ascorbic acid-deficiency gingivitis b. other

*-can occur on periodontium with no attachment loss or with attachment loss that is not progressing.

B. Non-plaque-induced gingival lesions1. Gingival diseases of specific bacterial origina. Neisseria gonorrhea-associated lesionsb. Treponema pallidum-associated lesionsc. streptococcal species-associated lesionsd. other2. Gingival diseases of viral origina. herpesvirus infections1) primary herpetic gingivostomatitis2) recurrent oral herpes3) varicella-zoster infectionsb. other3. Gingival diseases of fungal origina. Candida-species infections1) generalized gingival candidosisb. linear gingival erythemac. histoplasmosisd. other

4. Gingival lesions of genetic origina. hereditary gingival fibromatosisb. other5. Gingival manifestations of systemic conditionsa. mucocutaneous disorders1) lichen planus2) pemphigoid3) pemphigus vulgaris4) erythema multiforme5) lupus erythematosus6) drug-induced7) otherb. allergic reactions1) dental restorative materialsa) mercuryb) nickelc) acrylicd) other2) reactions attributable toa) toothpastes/dentifricesb) mouth rinses/mouthwashesc) chewing gum additivesd) foods and additives3) other

6. Traumatic lesions (factitious, iatrogenic,

accidental)a. chemical injuryb. physical injuryc. thermal injury

7. Foreign body reactions8. Not otherwise specified

(NOS)

II. Chronic Periodontitis

A. Localized- <30% of sites involved.B. Generalized- >30% of sites involved.

Can be characterized as SLIGHT- 1 to 2 mm of clinical attachment loss

MODERATE – 3-4 mm of clinical attachment lossSEVERE- > 5 mm of clinical attachment loss

Can be modified or associated with the following: Systemic diseases such as diabetes mellitus and HIV infection

Local factors predisposing to periodontitis Environmental factors such as cigarette smoking and emotional

stress.

IV. Periodontitis as a Manifestation of SystemicDiseasesA. Associated with hematological disorders1. Acquired neutropenia2. Leukemias3. Other

B. Associated with genetic disorders1. Familial and cyclic neutropenia2 Down syndrome3. Leukocyte adhesion deficiency syndromes4. Papillon-Lefèvre syndrome5. Chediak-Higashi syndrome6. Histiocytosis syndromes7. Glycogen storage disease8. Infantile genetic agranulocytosis9. Cohen syndrome10. Ehlers-Danlos syndrome (Types IV and VIII)11. Hypophosphatasia12. OtherC. Not otherwise specified (NOS)

V. Necrotizing Periodontal DiseasesA. Necrotizing ulcerative gingivitis (NUG)B. Necrotizing ulcerative periodontitis (NUP)

VI. Abscesses of the PeriodontiumA. Gingival abscessB. Periodontal abscessC. Pericoronal abscess

III. Aggressive PeriodontitisA. Localized-

-circumpubertal onset of disease-localized first molar or incisor disease with proximal attachment loss on atleast two permanent teeth, one of which is first molar.-robust serum antibody response to infecting agents

B. Generalized- -affects persons under 30 yrs -generalized proximal attachment loss affecting atleast 3 teeth other than first molars and incisors -Poor serum antibody response to infecting agents

VII. Periodontitis Associated With Endodontic LesionsA. Combined periodontic-endodontic lesions

VIII. Developmental or Acquired Deformities and ConditionsA. Localized tooth-related factors that modify or predisposeto plaque-induced gingival diseases/periodontitis1. Tooth anatomic factors2. Dental restorations/appliances3. Root fractures4. Cervical root resorption and cemental tears

B. Mucogingival deformities and conditions around teeth1. Gingival/soft tissue recessiona. facial or lingual surfacesb. interproximal (papillary)2. Lack of keratinized gingiva3. Decreased vestibular depth4. Aberrant frenum/muscle position

5. Gingival excessa. pseudopocketb. inconsistent gingival marginc. excessive gingival displayd. gingival enlargement 6. Abnormal color

C. Mucogingival deformities and conditions on edentulousridges1. Vertical and/or horizontal ridge deficiency2. Lack of gingiva/keratinized tissue3. Gingival/soft tissue enlargement4. Aberrant frenum/muscle position5. Decreased vestibular depth6. Abnormal color

D. Occlusal trauma1. Primary occlusal trauma2. Secondary occlusal trauma

MERITS OF 1999 WORLD WORKSHOP

Badly needed “gingivitis or gingival disease” category was added

Heterogenous categories of Pre pubertal, refractory and rapidly progressive periodontitis was eliminated as distinct or stand alone entities

Troublesome criteria of age and rate of progression were removed as a basis for classification

Replacement of ADULT PERIODONTITIS with CHRONIC PERIODONTITIS

17

CHRONIC PERIODONTITIS VS ADULT PERIODONTITIS

Adult bone loss patterns can be seen in adolescents and even in the primary dentition

The age at which a patient

presents for treatment does not necessarily reflect the age at which the disease began.

Replacement of “early onset periodontitis” with AGGRESSIVE PERIODONTITIS

Replacement of “Necrotizing ulcerative periodontitis” with NECROTIZING PERIODONTAL DISEASES

Addition of Category of “Abscesses”

Addition of category on “PERIO-ENDO LESIONS”

Addition of category on “DEVELOPMENTAL OR ACQUIRED DEFORMITIES & CONDITIONS”

MERITS OF 1999 WORLD WORKSHOP

THE GLOBAL ACCEPTANCE OF THE 1999 CLASSIFICATION

No overlap or confusion between various disease categories.

Patients could be included in any of the categories with ease.

No emphasis on the age of onset, or rate of progression

Clear classification criteria.Periodontology 2000,vol.30,2002,9-23

SHORTCOMINGS

Very long and extensive.

Removal of the term “Juvenile Periodontitis” is considered a retrograde step in periodontics.

No mention of “Recurrent Periodontitis”

FUTURE CHALLENGES

More “MECHANISTIC OR ETIOLOGICAL CLASSIFICATION” of periodontal diseases should be devised, based on the microbiological features of these infections or on genetic factors.

Eventually be able to subclassify the multiple forms of chronic periodontitis.

Necessary to address head on nagging questions ‘when are “HOST MODIFYING FACTORS(SMOKING, DIABETES)” so important that they should be a PART OF DISEASE CLASSIFICATION

SUMMARY

•Classification systems for periodontal diseases currently in use are firmly based on & dominated by infection/host response paradigm, retaining some features of older paradigms

•1999 International Workshop for classification of Periodontal diseases and conditions has corrected some of the problems associated with previous systems but is not perfect.

Provided a workable framework upon which to study and develop effective treatments for this complex group of infections.

Future revisions of the classification will be needed. The new classification of periodontal diseases has removed the dilemma with regard to some terms and has thus facilitated application in practice.

Ann Periodontol,vol 1,1999,1-5

SUMMARY

REFERENCES:

1.ANNALS OF PERIODONTOLOGY,19992.PERIODONTOLGY 2000, 2002

3.European Workshop on Periodontics. London: 1994: 120–126.

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