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Cited by 3,239Oral microbiology and periodontitis researchPeriodontal Regeneration and TreatmentsDental Implant Techniques and Outcomes

Staging and grading of periodontitis: Framework and proposal of a new classification and case definition

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Tonetti, Maurizio S., Greenwell, Henry, Kornman, Kenneth S.·2018·Journal of Periodontology
DOI 10.1002/jper.18-0006
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Abstract

Background: Authors were assigned the task to develop case definitions for periodontitis in the context of the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions. The aim of this manuscript is to review evidence and rationale for a revision of the current classification, to provide a framework for case definition that fully implicates state‐of‐the‐art knowledge and can be adapted as new evidence emerges, and to suggest a case definition system that can be implemented in clinical practice, research and epidemiologic surveillance. Methods: Evidence gathered in four commissioned reviews was analyzed and interpreted with special emphasis to changes with regards to the understanding available prior to the 1999 classification. Authors analyzed case definition systems employed for a variety of chronic diseases and identified key criteria for a classification/case definition of periodontitis. Results: The manuscript discusses the merits of a periodontitis case definition system based on Staging and Grading and proposes a case definition framework. Stage I to IV of periodontitis is defined based on severity (primarily periodontal breakdown with reference to root length and periodontitis‐associated tooth loss), complexity of management (pocket depth, infrabony defects, furcation involvement, tooth hypermobility, masticatory dysfunction) and additionally described as extent (localized or generalized). Grade of periodontitis is estimated with direct or indirect evidence of progression rate in three categories: slow, moderate and rapid progression (Grade A‐C). Risk factor analysis is used as grade modifier. Conclusions: The paper describes a simple matrix based on stage and grade to appropriately define periodontitis in an individual patient. The proposed case definition extends beyond description based on severity to include characterization of biological features of the disease and represents a first step towards adoption of precision medicine concepts to the management of periodontitis. It also provides the necessary framework for introduction of biomarkers in diagnosis and prognosis.

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Crossref · 10.1002/jper.18-0006

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  • oPMN level can potentially serve as a diagnostic risk marker for periodontitis.

    “These findings suggest that oPMN level can potentially serve as a diagnostic risk marker for periodontitis; as such its inclusion in the grading table 8 should be considered.”

    From Prognostic utility of oral neutrophil counts in high-risk periodontitis: A retrospective study (2025) · cites this paper as [8]

    The ‘Integrating biomarkers in a case definition system’ section says biomarkers may improve early diagnosis and assessment of periodontitis grade. The grading-table note also allows for specific biomarkers as evidence becomes available. Neither passage identifies oPMN level as a diagnostic risk marker, so the source supports the general proposal but not the oPMN-specific claim. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

  • An increase in the mean number of sites with PD >6 mm was found between S2P/S3P only (p < 0.01).

    “Also, an increase in the mean number of sites with PD > 6 mm was found between S2P/S3P only (p < 0.01), which is consistent with the current diagnostic scheme. 8”

    From Prognostic utility of oral neutrophil counts in high-risk periodontitis: A retrospective study (2025) · cites this paper as [8]

  • Periodontal diagnoses were obtained retrospectively, and patients without a recorded diagnosis were excluded to minimize the risk of selection bias.

    “Periodontal diagnoses 6 , 8 were obtained retrospectively; patients without a recorded diagnosis were excluded to minimize the risk of selection bias.”

    From Prognostic utility of oral neutrophil counts in high-risk periodontitis: A retrospective study (2025) · cites this paper as [8]

    The paper’s “Definition of a patient as a periodontitis case” section discusses diagnostic criteria and accuracy, but not retrospective collection of diagnoses. The “Grade of periodontitis” section discusses a different potential bias concerning missing teeth; no passage found addresses excluding patients without a recorded diagnosis to minimize selection bias (searched for retrospective diagnoses, missing records, exclusions, and selection bias). (LLM, conf=0.74)

    Experimental — accuracy not yet measured

  • Common systemic diseases such as uncontrolled diabetes mellitus have variable effects that modify the course of periodontitis.

    “There are, however, common systemic diseases, such as uncontrolled diabetes mellitus, with variable effects that modify the course of periodontitis.”

    From A new classification scheme for periodontal and peri‐implant diseases and conditions – Introduction and key changes from the 1999 classification (2018) · cites this paper as [20]

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Cites

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Research works printed but not linked: 6

  1. S 1. Proceedings of the World Workshop in Clinical Periodontics. Princeton, New Jersey, July 23-27, 1989. In: Nevins M, Becker W, Kornman K, eds. Chicago: American Academy of Periodontology; 1989.
  2. Proceedings of the 1st European Workshop on Periodontics, 1993. London: Quintessence; 1994.
  3. Lang NP, Bartold PM, Cullinan M, et al. Consensus report: aggres- sive periodontitis. Ann Periodontol. 1999;4:53.
  4. Lindhe J, Ranney R, Lamster I, et al. Consensus report: chronic peri- odontitis. Ann Periodontol. 1999;4:38.
  5. Lang NP, Hill RW. Radiographs in periodontics. J Clin Periodontol. 1977;4:16-28.
  6. European Federation of Periodontology and American Academy of Periodontology. Periodontitis and systemic diseases -Proceedings of a workshop jointly held by the European Federation of Periodon- tology and American Academy of Periodontology.

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Authors
Tonetti, M. S., Greenwell, H., & Kornman, K. S.
Affiliations
  • University of Hong Kong (HK)
  • University of Louisville (US)
  • University of Michigan (US)
Corresponding author
Tonetti, Maurizio S.
ORCID
Venue
Journal of Periodontology
Publisher
Wiley
Published
2018-06
Volume
89
Issue
S1
Pages
S159-S172
ISSN
  • 0022-3492 (ISSN-L)
  • 1943-3670
DOI
10.1002/jper.18-0006
OpenAlex
W2809048536
Cited by
3,239
References
71
Citations by year
2026: 272 · 2025: 450 · 2024: 523 · 2023: 576 · 2022: 474 · 2021: 440 · 2020: 326 · 2019: 146 · 2018: 22 · 2015: 2 · 2013: 1 · 2012: 2
FWCI
34.59
Type
journal article
Language
en
Update notices
correction (2018-11-29)
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor, 20 d)
Locations
  • Journal of Periodontology (publishedVersion)
  • PubMed (publishedVersion)
  • Deep Blue (University of Michigan) (submittedVersion)
Funders
  • Procter and Gamble
  • Unilever
  • Osteology Foundation
Topics
  • Health Sciences › Dentistry › Periodontics › Oral microbiology and periodontitis research
  • Health Sciences › Medicine › Urology › Periodontal Regeneration and Treatments
  • Health Sciences › Dentistry › Oral Surgery › Dental Implant Techniques and Outcomes
Keywords
periodontitis, case definition, periodontal disease classification, disease progression rate, risk factors, tooth loss, probing depth, furcation involvement, masticatory dysfunction, biomarkers, precision medicine
MeSH terms
Humans, Periodontitis, Prognosis, Risk Factors, Tooth Loss, Disease Progression

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