Received: 9 March 2018 Revised: 19 March 2018 Accepted: 19 March 2018

DOI: 10.1002/JPER.18-0157

2017 WORLD WORK SHOP

A new classification scheme for periodontal and peri-implant

diseases and conditions – Introduction and key changes
from the 1999 classification

Jack G. Caton1 Gary Armitage2 Tord Berglundh3 Iain L.C. Chapple4 Søren Jepsen5
Kenneth S. Kornman6 Brian L. Mealey7 Panos N. Papapanou8 Mariano Sanz9
Maurizio S. Tonetti10

1 Periodontics, Eastman Institute for Oral Health, University of Rochester, Rochester, NY, USA

2 School of Dentistry, University of California San Francisco, San Francisco, CA, USA

3 Department of Periodontology, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

4 Periodontal Research Group, Institute of Clinical Sciences, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK

5 Department of Periodontology, Operative and Preventive Dentistry, University of Bonn, Bonn, Germany

6 University of Michigan School of Dentistry, Ann Arbor, MI, USA

7 University of Texas Health Science Center, San Antonio, TX, USA

8 Columbia University College of Dental Medicine, New York, NY, USA

9 Facultad de Odontologia, Universidad Complutense Madrid, Madrid, Spain

10 Periodontology, Faculty of Dentistry, University of Hong Kong, Hong Kong, SAR China

Correspondence
Jack Caton, Professor and Chair, Department
Abstract
of Periodontology, Eastman Institute for Oral A classification scheme for periodontal and peri-implant diseases and conditions is
Health, University of Rochester, 625 Elmwood necessary for clinicians to properly diagnose and treat patients as well as for scientists
Avenue, Rochester, NY 14620
Email: [email protected] to investigate etiology, pathogenesis, natural history, and treatment of the diseases and
Sources of Funding conditions. This paper summarizes the proceedings of the World Workshop on the
The workshop was planned and Classification of Periodontal and Peri-implant Diseases and Conditions. The work-
conducted jointly by the American Academy
shop was co-sponsored by the American Academy of Periodontology (AAP) and the
of Periodontology and the European
Federation of Periodontology with financial European Federation of Periodontology (EFP) and included expert participants from
support from the American Academy of all over the world. Planning for the conference, which was held in Chicago on Novem-
Periodontology Foundation, Colgate, Johnson
& Johnson Consumer Inc., Geistlich
ber 9 to 11, 2017, began in early 2015.
Biomaterials, SUNSTAR, and Procter &
An organizing committee from the AAP and EFP commissioned 19 review papers and
Gamble Professional Oral Health.
The proceedings of the workshop were
four consensus reports covering relevant areas in periodontology and implant den-
jointly and simultaneously published in the tistry. The authors were charged with updating the 1999 classification of periodontal
Journal of Periodontology and Journal of diseases and conditions1 and developing a similar scheme for peri-implant diseases
Clinical Periodontology.
and conditions. Reviewers and workgroups were also asked to establish pertinent case
definitions and to provide diagnostic criteria to aid clinicians in the use of the new
classification. All findings and recommendations of the workshop were agreed to by
consensus.

© 2018 American Academy of Periodontology and European Federation of Periodontology

J Periodontol. 2018;89(Suppl 1):S1–S8. wileyonlinelibrary.com/journal/jper S1

S2 CATON ET AL.

This introductory paper presents an overview for the new classification of periodontal
and peri-implant diseases and conditions, along with a condensed scheme for each of
four workgroup sections, but readers are directed to the pertinent consensus reports
and review papers for a thorough discussion of the rationale, criteria, and interpreta-
tion of the proposed classification. Changes to the 1999 classification are highlighted
and discussed. Although the intent of the workshop was to base classification on the
strongest available scientific evidence, lower level evidence and expert opinion were
inevitably used whenever sufficient research data were unavailable.

The scope of this workshop was to align and update the classification scheme to
the current understanding of periodontal and peri-implant diseases and conditions.
This introductory overview presents the schematic tables for the new classification of
periodontal and peri-implant diseases and conditions and briefly highlights changes
made to the 1999 classification.1 It cannot present the wealth of information included
in the reviews, case definition papers, and consensus reports that has guided the devel-
opment of the new classification, and reference to the consensus and case definition
papers is necessary to provide a thorough understanding of its use for either case
management or scientific investigation. Therefore, it is strongly recommended that
the reader use this overview as an introduction to these subjects. Accessing this pub-
lication online will allow the reader to use the links in this overview and the tables to
view the source papers (Table 1).

KEYWORDS
classification, gingivitis, peri-implant mucositis, peri-implantitis, periodontal diseases, periodontitis

TABLE 1
CATON ET AL. S3

PE R IO D ON TAL H EA LTH , regard to cases of gingival health or inflammation after

G I NG I V I T I S , A N D G I NG I VA L completion of periodontitis treatment based on bleeding on
CO N D I T I O N S 2–6 probing and depth of the residual sulcus/pocket. This dis-
tinction was made to emphasize the need for a more com-
The workshop addressed unresolved issues with the previ- prehensive maintenance and surveillance of the successfully
ous classification by identifying the difference between pres- treated patient with periodontitis. It was accepted that a patient
ence of gingival inflammation at one or more sites and the with gingivitis can revert to a state of health, but a peri-
definition of a gingivitis case. It agreed that bleeding on odontitis patient remains a periodontitis patient for life, even
probing should be the primary parameter to set thresholds following successful therapy, and requires life-long support-
for gingivitis.2,5 The workshop also characterized periodon- ive care to prevent recurrence of disease.6 The workshop
tal health and gingival inflammation in a reduced periodon- also reorganized the broad spectrum of non-plaque induced
tium after completion of successful treatment of a patient gingival diseases and conditions based on primary etiology
with periodontitis. Specific definitions were agreed to with (Table 2).4

TABLE 2
S4 CATON ET AL.

A N E W C L A S S I F I CAT I O N O F new evidence to change the classification.10 Major changes

PERIODONTITIS were made in the 1999 classification of periodontitis,11–13
which has been in use for the last 19 years. Periodontitis
The 1989 workshop recognized that periodontitis had several was reclassified as chronic, aggressive (localized and gen-
distinct clinical presentations, different ages of onset and rates eralized), necrotizing and as a manifestation of systemic
of progression.7,8 Based on these variables the workshop cat- disease.
egorized periodontitis as prepubertal, juvenile (localized and Since the 1999 workshop, substantial new information has
generalized), adult, and rapidly progressive. The 1993 Euro- emerged from population studies, basic science investiga-
pean Workshop determined that the classification should be tions, and the evidence from prospective studies evaluating
simplified and proposed grouping of periodontitis into two environmental and systemic risk factors. The analysis of this
major headings: adult and early onset periodontitis.9 The 1996 evidence has prompted the 2017 workshop to develop a new
workshop participants determined that there was insufficient classification framework for periodontitis.14

TABLE 3
CATON ET AL. S5

In the last 30 years, the classification of periodonti- periodontal apparatus independent of dental plaque biofilm-
tis has been repeatedly modified in an attempt to align it induced periodontitis,21 and such clinical findings should also
with emerging scientific evidence. The workshop agreed be classified based on the primary systemic disease and be
that, consistent with current knowledge on pathophysiology, grouped as “Systemic Diseases or Conditions Affecting the
three forms of periodontitis can be identified: necrotizing Periodontal Supporting Tissues”. There are, however, com-
periodontitis,15 periodontitis as a manifestation of systemic mon systemic diseases, such as uncontrolled diabetes melli-
disease,16 and the forms of the disease previously recog- tus, with variable effects that modify the course of periodon-
nized as “chronic” or “aggressive”, now grouped under a sin- titis. These appear to be part of the multifactorial nature of
gle category, “periodontitis”.14,17–20 In revising the classifi- complex diseases such as periodontitis and are included in the
cation, the workshop agreed on a classification framework for new clinical classification of periodontitis as a descriptor in
periodontitis further characterized based on a multidimen- the staging and grading process.20 Although common mod-
sional staging and grading system that could be adapted over ifiers of periodontitis may substantially alter disease occur-
time as new evidence emerges.20 rence, severity, and response to treatment, current evidence
Staging is largely dependent upon the severity of disease does not support a unique pathophysiology in patients with
at presentation as well as on the complexity of disease man- diabetes and periodontitis.22
agement, while grading provides supplemental information
about biological features of the disease, including a history
based analysis of the rate of disease progression, assess-
CHANGES I N THE CLASSIFICATION
ment of the risk for further progression, anticipated poor out-
O F PERIO DO NTAL
comes of treatment, and assessment of the risk that the dis-
DEVELOPMENTAL AND ACQUIRED
ease or its treatment may negatively affect the general health
D E FO R M I T I E S A N D
of the patient.14,20 Staging involves four categories (stages
CO N D I T I O N S 21,23–25
1 through 4) and is determined after considering several
variables including clinical attachment loss, amount and per-
centage of bone loss, probing depth, presence and extent of Mucogingival conditions
angular bony defects and furcation involvement, tooth mobil-
The new case definitions related to treatment of gingival
ity, and tooth loss due to periodontitis. Grading includes three
recession are based on interproximal loss of clinical attach-
levels (grade A – low risk, grade B – moderate risk, grade
ment and also incorporate the assessment of the exposed
C – high risk for progression) and encompasses, in addi-
root and cemento-enamel junction.23 The consensus report
tion to aspects related to periodontitis progression, general
presents a new classification of gingival recession that com-
health status, and other exposures such as smoking or level of
bines clinical parameters including the gingival phenotype as
metabolic control in diabetes. Thus, grading allows the clin-
well as characteristics of the exposed root surface.21 In the
ician to incorporate individual patient factors into the diag-
consensus report the term periodontal biotype was replaced
nosis, which are crucial to comprehensive case management
by periodontal phenotype (Table 4).21
(Table 3). For a complete description of the new classifica-
tion scheme for periodontitis, the reader is directed to the
consensus report on periodontitis14 and the case definition Occlusal trauma and traumatic occlusal forces
paper on periodontitis.20 Traumatic occlusal force, replacing the term excessive
occlusal force, is the force that exceeds the adaptive capac-
ity of the periodontium and/or the teeth. Traumatic occlusal
SYSTEMIC DISEASES ASSOCIATED forces can result in occlusal trauma (the lesion) and excessive
WITH LOSS OF PERIODONTAL wear or fracture of the teeth.21 There is lack of evidence from
S U P P O RT ING T I SSU E S 16,21 human studies implicating occlusal trauma in the progression
of attachment loss in periodontitis (Table 4).24
The new classification of periodontal diseases and conditions
also includes systemic diseases and conditions that affect the
periodontal supporting tissues.16 It is recognized that there
Prosthesis- and tooth-related factors
are rare systemic disorders, such as Papillon Lefèvre Syn- The section on prostheses-related factors was expanded in the
drome, that generally result in the early presentation of severe new classification. The term biologic width was replaced by
periodontitis. Such conditions are grouped as “Periodontitis supracrestal attached tissues.21 Clinical procedures involved
as a Manifestation of Systemic Disease”, and classification in the fabrication of indirect restorations was added because of
should be based on the primary systemic disease.16 Other sys- new data indicating that these procedures may cause recession
temic conditions, such as neoplastic diseases, may affect the and loss of clinical attachment (Table 4).25
S6 CATON ET AL.

TABLE 4

A N E W C L A S S I F I CAT I O N FO R tions were developed for use by clinicians for individual case
PERI-IMPLANT DISEASES AND management and also for population studies.26,30
CO N D I T I O N S 26

A new classification for peri-implant health,27 peri-implant

Peri-implant health
mucositis28 and peri-implantitis29 was developed by the work- Peri-implant health was defined both clinically and
shop (Table 5). An effort was made to review all aspects of histologically.27 Clinically, peri-implant health is char-
peri-implant health, diseases, and relevant aspects of implant acterized by an absence of visual signs of inflammation and
site conditions and deformities to achieve a consensus for this bleeding on probing. Peri-implant health can exist around
classification that could be accepted worldwide. Case defini- implants with normal or reduced bone support. It is not
CATON ET AL. S7

TABLE 5 systemic diseases reducing the amount of naturally formed

bone, tooth agenesis, and pressure from prostheses.31

CO NC LU SI O N S

This overview introduces an updated classification of peri-

odontal diseases and conditions and a new classification of
peri-implant diseases and conditions. The publication rep-
resents the work of the worldwide community of scholars
and clinicians in periodontology and implant dentistry. This
paper presents an abbreviated overview of the outcome of the
consensus workshop, and the reader is encouraged to review
the entire publication to receive comprehensive information
about the rationale, criteria and implementation of the new
classifications.

ACKNOW LEDGMENTS AND DISCLOSURES

possible to define a range of probing depths compatible with The authors filed detailed disclosure of potential conflicts of
peri-implant health.26,30 interest relevant to the workshop topics, and these are kept on
file. Additional disclosures can be found in each of the four
Peri-implant mucositis consensus reports published in these proceedings.
Peri-implant mucositis is characterized by bleeding on prob-
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