The language of perio

The classifications for periodontal disease have changed twice since the 1969 standards. What is the best way to communicate a patient's disease, particularly to insurers?

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by Debra Seidel-Bittke, RDH, BS

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For many years, dental professionals used one system of classifying periodontal pathology. The system has fallen under attack for various deficiencies. The faults are so severe, in fact, that new systems of classification have been proposed. Dental professionals should be familiar with both the new and old systems.

Since 1969, the American Academy of Periodontology has used the following classifications for periodontal disease:

• Class I: Gingivitis
• Class II: Slight periodontitis
• Class III: Moderate periodontitis
• Class IV: Severe periodontitis
• Class V: Refractory periodontitis

This classification system has been faulty for various reasons, not the least of which is an extensive overlap between the diseases. For example, the classification system divides the plaque-induced periodontitis diagnosis into two categories: gingivitis and periodontitis.

Gingivitis is the presence of inflammation without loss of connective tissue replacement. Periodontitis is a gingival inflammation at sites where a pathological detachment of collagen fibers from cementum has occurred and the junctional epithelium has migrated apically. In addition, inflammation occurs in association with connective tissue attachment loss, which leads to the resorption of coronal portions of tooth supporting alveolar bone.1

This general division between gingivitis and various forms of periodontitis seemed clear initially. But questions arose when periodontal disease had been successfully treated, and the patient later developed gingival inflammation. Did these sites have recurrent periodontitis, or did they have gingivitis imposed on a reduced but stable periodontium? It is important to note that not all sites with gingivitis develop areas of attachment loss, so it is reasonable to assume that gingivitis can occur on a reduced periodontium where periodontal destruction is not active.

It was proposed that each of these classifications be further divided into subgroups, such as pre-puberty and juvenile periodontitis, or subgroups based on association with various etiologies and pathologies as well as anatomical factors.

Additionally, the forms could be localized or generalized.2 This solved nothing. A problem similar to that identified above appeared when the term "periodontitis" was employed to classify areas with attachment loss and periodontal pockets when ongoing destruction was not occurring.3

Obviously, the old classification system had problems in limiting the use of certain terms to specific forms of periodontal disease. In 1989 at an international meeting, a completely new classification system was proposed. At that workshop, the following classifications for periodontal diseases were introduced:

o Adult periodontitis
o Early onset periodontitis
o Periodontitis associated with systemic diseases
o Necrotizing ulcerative periodontitis
o Refractory periodontitis

The point was made that dental professionals should document additional attachment loss that has occurred between two points in time. When one examines a patient for the first time, it may not be possible to have two sets of documentation on hand. The majority of clinicians will diagnose inflamed sites that also demonstrate signs of attachment and bone loss as periodontitis. This is appropriate because these sites may actively progress into, or may be at increased risk for, further destruction of the periodontium.

Although periodontal etiology and pathogenesis of perio infections is well known, the diagnosis of these diseases is almost entirely based on traditional clinical assessments. In order to make a diagnosis, the dentist must rely on factors such as:

• Presence and/or absence of inflammation (bleeding upon probing)
• Probing depths
• Clinical attachment and bone (for example, recession, mucogingival involvement, and furcation involvement)
• Patients' medical and dental histories
• Presence or absence of miscellaneous signs and symptoms, including pain, ulceration, and amount of observable plaque and calculus

In 1999, yet another reclassification of the periodontal diseases and conditions occurred. This classification grouped different forms of plaque-induced periodontal diseases.4 The revised classification includes seven different types of plaque-induced periodontal diseases:

• Gingivitis
• Chronic periodontitis
• Aggressive periodontitis
• Periodontitis, as manifestation of systemic diseases
• Necrotizing periodontal diseases
• Abscesses of the periodontium
• Periodontitis associated with endodontic lesions

Two new terms were introduced in the third reclassification process:

• "Chronic periodontitis," which replaces the term "adult periodontitis"

• "Aggressive periodontitis," which has itself been replaced as "early onset" periodontitis

In the third reclassification, all forms of periodontal diseases can progress rapidly or slowly and can be nonresponsive to therapy. The classification also acknowledges that periodontitis can occur on a reduced but stable periodontium.

All of this new classification information should not be confused with previously suggested case types for third party insurance payments. Those case types for periodontal types still employ the 1969 classifications (as mentioned above).

When billing for periodontal treatment, one needs to recall that all insurance companies do not yet recognize the most recently proposed classifications. It is imperative to provide on the insurance form the original classification (such as Type II slight periodontitis) and the appropriate terminology from the new classification. For example, the practitioner could state:

• Case Type I gingivitis
Gingival diseases associated with pregnancy

• Case Type III moderate periodontitis
Chronic periodontitis associated with a manifestation of diabetes Type I

More information about the AAP periodontal classifications can be obtained at

Ultimately, the professional's goal is to provide the best dental care to the patient while maximizing the efficiency and profitability that a modern dental office may provide. At the present time, the simple truth remains that the professional is obliged to speak and write fluently in all three of the classification systems. Dental professionals new to dentistry may have learned only the later versions, yet they will need to be able to bill insurance carriers using the older terminology. Experienced practitioners, on the other hand, may be completely familiar with the 1969 classification system. Those terms, as we now know, are outdated and will eventually fall to the wayside. For the current time, the only logical course is to gain a working knowledge of all three systems.

Debra Seidel-Bittke, RDH, BS, is a part-time clinician, and author. Debbie speaks nationally on periodontal therapy and is a practice management consultant. She may be reached at: or (866) 206-6364.

1. Armitage GC, Clinical Evaluation Of Periodontal Diseases.J Periodontol 2000; 7: 39-53
2. Armitage, GC, Periodontal Diseases: Diagnosis. A. Periodontol 1996; 1:1-932,
3. Armitage, GC, Development Of A Classification System For Periodontal Diseases And Conditions. A. Periodontol 1999; 4-6
4. Lang NP, Joss A, Tonetti MS, Monitoring Disease Supportive Periodontal Treatment By Bleeding On Probing. J Periodontol 2000 1996: 12: 44 - 48
5. Position Paper: "Diagnosis Of Periodontal Diagnosis" J. Periodontol 2003; 74: 1237-1247

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