Periodontitis Staging and Grading

Periodontitis is defined as a chronic multifactoral inflammatory disease associated with dysbiotic plaque biofilms and characterized by the progressive destruction of the tooth supporting apparatus.

In simple terms Periodontitis is the inflammation of the supporting structures of the tooth resulting in the loss of Periodontal attachments. Before we go into Staging and Grading Periodontal disease, it is important to determine what are the characteristics of Periodontitis. There are 3 main factors which determined Periodontitis.

1. CAL and RBL – CAL is Clinical attachment Loss and RBL is Radiographic bone loss these two are important to determine the alveolar bone loss clinically and Radiologically.
2. Gingival Bleeding on probing
3. Presence of Periodontal Pockets

In general Periodontitis is divided into 5 types based on the Cause:

1. Chronic Periodontitis – Prolonged gingivitis leading to Periodontitis which can be localised on Generalized (more than 30% involvement)
2. Aggressive Periodontitis – Bone loss seen in very short duration without much local factors like Calculus/tartar. Localized and Generalized.
3. Due to Systemic disease –
4. Necrotizing Periodontal Disease – Can be Necrotizing ulcerative gingivitis or Necrotizing ulcerative Periodontitis
5. Associated with Endodontic Lesions – Perio-Endo Lesions.

Staging of Periodontitis –

Stage 1 Periodontitis:

• Clinical Attachment Loss -1 to 2 mm
• Radiographic Bone Loss – Coronal third <15%
• Tooth Loss – No tooth loss due to Periodontitis
• Maximum Probing Depth – Less than or equal to 4mm
• Bone Loss type – Mostly Horizontal Bone loss

Stage 2 Periodontitis:

• Clinical Attachment Loss -3 to 4 mm
• Radiographic Bone Loss – Coronal third 15% to 33%
• Tooth Loss – No tooth loss due to Periodontitis
• Maximum Probing Depth – Less than or equal to 5mm
• Bone Loss type – Mostly Horizontal Bone loss

Stage 3 Periodontitis:

• Clinical Attachment Loss -Greater than or equal to 5mm
• Radiographic Bone Loss – Extending to middle third of the root or beyond
• Tooth Loss – Less than or equal to 4 teeth
• Maximum Probing Depth – Greater than or equal to 6mm
• Bone Loss type – Vertical Bone loss greater than or equal to 3mm
• Furcation Involvement – Class 2 or Class 3 type
• Moderate ridge defect

Stage 4 Periodontitis:

• Clinical Attachment Loss – Greater than or equal to 5mm
• Radiographic Bone Loss – Extending to middle third of the root and beyond
• Tooth Loss – Greater than or equal to 5 teeth
• Maximum Probing Depth – Greater than or equal to 6mm
• Bone Loss type – Vertical Bone loss greater than or equal to 3mm
• Furcation Involvement – Class 2 or Class 3 type
• Severe ridge defect
• Secondary Occlusal Trauma is seen with tooth mobility seen in more than 2 teeth
• 20 remaining teeth or 10 opposing pairs left
• Collapsed bite is seen along with Teeth flaring

Grading of Periodontitis –

Grading is to classify the rate of progression of Periodontitis based on factors such as percentage of bone loss based on age, Biofilm, risk factors such as smoking, diabetes etc.

Grade A:

• Bone Loss – No Radiographic Bone loss or Clinical Attachment Loss
• % of bone loss / Age – < 0.25
• Heavy Biofilm deposits with low level of destruction
• Risk factors – Non Smoker and Non Diabetic

Grade B:

• Bone Loss – Radiographic Bone loss or Clinical Attachment Loss is Less than or equal to 2mm over 5 years
• % of bone loss / Age – < 0.25 to 1.0
• Heavy Biofilm deposits with equal amount of destruction
• Smoker Less than 10 cigarettes per day
• Diabetic – HbA1c less than 7.0 %

Grade C:

• Bone Loss – RBL and CAL is greater than or equal to 2mm over 5 years
• % of bone loss / Age –  Greater than 1.0
• Destruction is more than Biofilm present, periods of Rapid progression of bone loss and Early onset of Bone loss
• Smoker – Greater than 10 cigarettes per day
• Diabetes – HbA1c – greater than 7%

The Treatment for Periodontitis is determined by the Stage and Grade at which the condition is, the various options for treatment are Deep Scaling and Root Planning, Curettage, Flap Surgery, Laser gum surgery. There might be need for any additional treatment planning like Extractions, restoring teeth, etc.