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Requirements of a Periodontitis Case 

In order for an individual to be diagnosed as a periodontitis case, there are three essential requirements:12

  1. Detectable clinical attachment loss (CAL) at two (2) non-adjacent teeth.
  2. Identification of the form of periodontitis i.e., necrotizing periodontitis, periodontitis as a manifestation of systemic disease, or periodontitis.
  3. Description of the case characteristics and aggressiveness of the disease by Stage and Grade.
Table 9. Periodontitis Stages.
Periodontal Stage Stage I Stage II Stage III Stage IV
Severity Interdental CAL at site of greatest loss 1-2mm 3-4mm ≥5mm ≥5mm
Radiographic Bone Loss Coronal third (<15%) Coronal third (15%-33%) Extending to mid-third of root and beyond Extending to mid-third of root and beyond
Tooth Loss No tooth loss due to Periodontitis No tooth loss due to Periodontitis Tooth loss due to Periodontitis of ≤4 teeth Tooth loss due to Periodontitis of ≥5 teeth
Complexity Local Maximum Probing Depth ≤4mm
Mostly horizontal bone loss
Maximum Probing Depth ≤5mm
Mostly horizontal bone loss
In addition to Stage II complexity:
Probing depth ≥6mm
Vertical bone loss ≥3mm
Furcation involvement
Class II or III
Moderate ridge defect
In addition to Stage III complexity:
Need for complex rehabilitation due to:
Masticatory dysfunction
Secondary occlusal trauma
(tooth mobility degree ≥2)
Severe ridge defect
Bite collapse, drifting, flaring
Less than 20 remaining teeth
(10 opposing pairs)
Extent and distribution Add to Stage as Descriptor For each stage, describe extent as localized (<30% teeth involved), generalized, or molar/incisor pattern
Adapted from Tonetti et al.12
Table 10. Periodontitis Grade.
Periodontitis Grade Grade A
Slow rate of progression
Grade B
Moderate rate of progression
Grade C
Rapid rate of progression
Primary Criteria Direct Evidence of Progression Longitudinal data
(Radiographic bone loss or CAL)
Evidence of no loss over 5 years <2mm over 5 years ≥2mm over 5 years
Indirect Evidence of Progression % Bone Loss <0.25 0.25 - 1.0 >1.0
Case Phenotype Heavy biofilm deposits with low levels of destruction Destruction commensurate with biofilm deposits Destruction exceeds expectation given biofilm deposits; specific clinical patterns suggestive of periods of rapid progression and/or early-onset disease (e.g., molar/incisor pattern; lack of expected response to standard bacterial control therapies)
Grade Modifiers Risk Factors Smoking Non-smoker Smoker <10 cigarettes/day Smoker ≥10 cigarettes/day
Diabetes Normoglycemic/no diagnosis of diabetes HbA1c <7.0% HbA1c ≥7.0% in patients with diabetes
Adapted from Tonetti et al.12