02.

Periodontitis:
clinical decision tree
for staging and grading

Guidance for clinicians

Authors Mariano Sanz and Maurizio Tonetti

Published March 2019 European

Federation of
© European Federation of Periodontology Periodontology
 STEP 1
New patient

When seeing a patient for the first time, we should first ask if there is a full-mouth radiograph of
adequate quality. If yes, we should assess whether there is detectable marginal bone in any area of the
dentition. If bone loss (BL) is detectable, the patient is suspected of having periodontitis. At the same
time, irrespective of radiographic records, we must clinically explore the patient and assess interdental
clinical attachment loss (CAL). If CAL is detectable, the patient is a possible case of periodontitis.
If interdental CAL is not detected, we must evaluate the presence of buccal recessions with probing
pocket depths (PPD) greater than 3mm. If such recessions are present, the patient is a possible
periodontitis case. If there are no buccal PPD greater than 3mm, we must evaluate full-mouth bleeding
on probing (BoP). If this is present in more than 10% of the sites, the patient is diagnosed with gingivitis
and if present in less than 10% of sites, the patient is diagnosed with periodontal health.

Diagnostic Detectable
X-Rays Yes Yes
New patient quality & marginal bone
available full-mouth loss

No No No

Yes

Assess
interdental CAL Yes
loss

No Yes Suspect
periodontitis

Buccal or
oral rec & Yes
PPD ˃3mm
Localised
gingivitis

No

BoP 10-30%

Periodontal <10% Measure ≥10% Gingivitis

health BoP

BoP ˃30%

Generalised
gingivitis

Proceed to
Step 2

Periodontitis: clinical decision tree for staging and grading

Based on:
Tonetti, MS & Sanz M.
Implementation of the New Classification of Periodontal Diseases: Decision-making Algorithms for Clinical Practice and Education.
Journal of Clinical Periodontology, 2019.

Periodontitis: clinical decision tree for staging and grading Guidance for clinicians 2
 STEP 2
Patient suspected of periodontitis

When the presence of interdental CAL in the oral examination has identified the patient as a
suspected case of periodontitis, we need to ascertain whether this CAL is caused by local factors
only – endo-perio lesions, vertical root fractures, caries, restorations, or impacted third molars. If not,
we need to ascertain that the interdental CAL is present in more than one non-adjacent tooth. If this is
the case, we have a periodontitis patient and we need to make a comprehensive periodontal diagnosis
through periodontal charting and full-mouth radiographs. If the periodontal charting does not show
PPD of 4mm or more, we need to evaluate full-mouth BoP. When BoP is higher than 10%, the diagnosis
is gingival inflammation in a periodontitis patient; when it is lower than 10%, the diagnosis is a patient
with a reduced but healthy periodontium. If the periodontal charting shows PPD of 4mm or more, the
diagnosis is a periodontitis case that needs to be assessed according to stage and grade.

Endo-perio
lesion

Vertical root
fracture
Suspect Local factors Yes
periodontitis only
Caries or
restoration

No
Impacted
wisdom tooth

Assess gingivitis No CAL loss Suspect

and monitor ˃1 N-A tooth periodontitis

Step 1: Step 1:
Periodontal Measure
Measure charting &
BoP BoP
radiographs

BoP No PPD 4mm Yes Periodontitis

or more case

No BoP BoP +
Periodontal
& bone
appraisal
Reduced but healthy Gingival inflammation
periodontium patient in periodontitis patient

Staging &
grading

Periodontitis: clinical decision tree for staging and grading Guidance for clinicians 3
 STEP 3a
Patient is a periodontitis case whose stage needs to be established

To establish the stage of an individual case of periodontitis, the following information is needed: full
mouth x-rays, a periodontal chart, and a periodontal history of tooth loss (PTL). First, we assess the
extent of the disease, by assessing whether the CAL/BL affects less than 30% of the teeth (local) or 30%
or more (generalised). Then, we define the stage of the disease by assessing severity (using CAL, BL, and
PTL) and complexity (by assessing PPD, furcation and intrabony lesions, tooth hypermobility, secondary
occlusal trauma, bite collapse, drifting, flaring, or having fewer than 10 occluding pairs of teeth).

Periodontitis
case
Periodontal
chart
Periodontal
history (PTL)
Full mouth
x-rays
< 30% Periodontitis
case
Periodontal Extent
& bone (% teeth)
appraisal
30% Periodontitis
or more case
Severity & complexity

Severity of CAL loss, bone loss,

breakdown periodontal tooth loss

Pocket depth, intrabony defects,

furcation, tooth hypermobility,
Complexity of secondary occlusal trauma,
management
bite collapse, drifting, flaring,
<10 occluding pairs

Stage I Stage II Stage III Stage IV

periodontitis periodontitis periodontitis periodontitis

Proceed to
grading

Periodontitis: clinical decision tree for staging and grading Guidance for clinicians 4
 STEP 3b
Stages III and IV versus I and II

If CAL is greater than 5mm or if the BL affects the middle third of the root or beyond in more than two
adjacent teeth, the diagnosis is either Stage III or IV. If CAL is 5mm or less in fewer than two teeth,
we should look for furcation lesions (degrees II and III). If these are present, the diagnosis is either
Stage III or IV. If absent, we should check PPD and if these are greater than 5mm in more than two
adjacent teeth, the diagnosis is either Stage III or IV. If PPD are between 3-5 mm, we should assess PTL.
If there is PTL, the diagnosis is either Stage III or IV. If not, the diagnosis is Stage I or II. Regarding pocket
depth, clinical judgement should be applied to use this criterion to upgrade from Stages I & II to Stage III.
For example, in the presence of pseudo pockets, the periodontitis case should stay as Stage II.

Periodontitis
case

< 30% Localised

Periodontal
& bone Extent
appraisal (% teeth)

˃ 30% Generalised
Severity & complexity

Class II or III
Coronal Level of
third bone/CAL
furcation < 5 mm loss
No

Yes

Pocket ˃ 5 mm
depth*

Stage III or IV
periodontitis
3-5 mm

Periodontal Yes
tooth loss

No

Stage I or II
periodontitis

Proceed to
grading

* Clinical judgement should be applied to use this criterion to upgrade from

Stages I & II to Stage III. For example, in the presence of pseudo pockets,
the periodontitis case should stay as Stage II.

Periodontitis: clinical decision tree for staging and grading Guidance for clinicians 5
 STEP 3c
Stages I, II, III, and IV

Stages I and II are based on the level of CAL and BL. The diagnosis is Stage I if: (a) BL is less than 15%
and (b) CAL is between 1-2mm. The diagnosis is Stage II if: (a) BL is between 15% and 33% and (b) CAL
is between 3-4mm. The diagnosis is Stage III if: (a) BL affects the middle third of the root or beyond,
(b) CAL is 5mm or more, (c) PTL is four teeth or fewer, (d) 10 or more occluding pairs are present,
and (e) in the absence of bite collapse, drifting, flaring, or a severe ridge defect. The diagnosis is Stage IV
if: (a) BL affects the middle third of the root or beyond, (b) CAL is 5mm or more, (c) PTL is more than four
teeth, (d) there are fewer than 10 occluding pairs, or (e) when there is bite collapse, drifting, flaring, or a
severe ridge defect.

Periodontitis
case

< 30% Localised

Periodontal
& bone Extent
appraisal (% teeth)

˃ 30% Generalised
Severity & complexity

BL coronal third Level of

Class II or III Perio tooth
CAL < 5mm bone/CAL ˃4
furcation loss loss
No

1-4
BL middle third CAL
CAL 5mm or more

Yes

Pocket 10 or more
˃5 mm occluding No
depth
pairs

3-5 mm Yes Stage IV

periodontitis

Bite
Periodontal Stage III or IV collapse, Yes
Yes drifting,
tooth loss periodontitis
flaring

No No

Stage I or II Level of
periodontitis bone/CAL
loss Severe Yes
ridge effect

No
BL <15% BL 15-33%
CAL 1-2 mm CAL 3-4 mm
Stage III
periodontitis

Stage I Stage II Proceed to

periodontitis periodontitis grading

Periodontitis: clinical decision tree for staging and grading Guidance for clinicians 6
 STEP 4a
Grading when there are no existing records

When previous periodontal records are not available, the bone loss/age (BL/A) ratio should be calculated
from the full-mouth radiographs. If BL/A is between 0.25 and 1.0, the diagnosis is Grade B periodontitis.
If less than 0.25, the diagnosis is Grade A periodontitis: if higher than 1.0, the diagnosis is Grade C
periodontitis. Grades A and B can be modified if the patient smokes or is diabetic. A patient who smokes
10 or more cigarettes per day will be changed to Grade C, while one who smokes fewer than 10 cigarettes
will be upgraded to B. Similarly, a diabetic patient with HbA1c below 7.0 will be upgraded to B and one
with HbA1c of 7.0 or more upgraded to C.

Periodontitis
case

Grade A
periodontitis
<0.25

Previous Grade B Apply

Bone
records No 0.25-1.0
periodontitis grade
available loss/age modifiers

Yes ˃1.0
Grade C
periodontitis

Estimate
progression
(5 years)

Smoking Diabetes
No diabetes
Proceed
to 4b

No smoking <10/day 10 or more/day Yes Yes

HbA1c<7.0 HbA1c 7.0
or more

No change Upgrade Upgrade

in grade to B to C

Periodontitis: clinical decision tree for staging and grading Guidance for clinicians 7
 STEP 4b
Grading when there are existing records

When the patient’s periodontal records are available, the rate of periodontitis progression over the
previous five years should be calculated. If progression is less than 2mm, the diagnosis is Grade B
periodontitis. If there has been no progression in five years, the diagnosis is Grade A periodontitis.
When the progression has been 2mm or more, the diagnosis is Grade C periodontitis. Grades A and
B can be upgraded to a higher grade if the patient smokes or is diabetic. A patient who smokes 10 or
more cigarettes per day will be changed to Grade C, while one who smokes fewer than 10 cigarettes will
be upgraded to B. Similarly, a diabetic patient with HbA1c below 7.0 will be upgraded to B and one with
HbA1c of 7.0 or more upgraded to C.

Periodontitis
case

Grade A
periodontitis
No progression

Previous Level of Grade B Apply

records Yes progression <2 mm
periodontitis grade
available (5 years) modifiers

No 2 mm or more
Grade C
periodontitis

Estimate
bone loss
by age

Smoking Diabetes
No diabetes
Proceed
to 4a

No smoking <10/day 10 or more/day Yes Yes

HbA1c<7.0 HbA1c 7.0
or more

No change Upgrade Upgrade

in grade to B to C

Periodontitis: clinical decision tree for staging and grading Guidance for clinicians 8
 Further reading Proceedings of the World Workshop on the Classification of Periodontal and Peri-implant
Diseases and Conditions,
co-edited by Kenneth S. Kornman and Maurizio S. Tonetti.
Journal of Clinical Periodontology, Volume 45, Issue S20, June 2018.

Proceedings include:

--Papapanou PN, Sanz M, et al. Periodontitis: Consensus report of workgroup 2 of the

2017 World Workshop on the Classification of Periodontal and Peri-implant Diseases
and Conditions, S162-S170.
--Herrera D, Retamal-Valdes B, Alonso B, Feres M. Acute periodontal lesions (periodontal
abscesses and necrotising periodontal diseases) and endo-periodontal lesions, S78-S94.
--Fine DH, Patil AG, Loos BG. Classification and diagnosis of aggressive periodontitis,
S95-S111.
--Needleman I, Garcia R, Gkranias N, et al. Mean annual attachment, bone level, and
tooth loss: A systematic review, S112-S129.
--Billings M, Holtfreter B, Papapanou PN, Mitnik GL, Kocher T, Dye BA. Age-dependent
distribution of periodontitis in two countries: Findings from NHANES 2009 to 2014 and
SHIP-TREND 2008 to 2012, S130-S148.
--Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework
and proposal of a new classification and case definition, pages S149-S161.

Tonetti, MS & Sanz M. Implementation of the New Classification of Periodontal Diseases:

Decision-making Algorithms for Clinical Practice and Education. Journal of Clinical
Periodontology, 2019.

Authors

Mariano Maurizio
Sanz Tonetti

Mariano Sanz is professor and chair of periodontology at the University

Complutense of Madrid and a professor in the faculty of odontology at the
University of Oslo (Norway). He is chair of the EFP workshop committee, a member
of the EFP executive committee, and president of the Osteology Foundation.

Maurizio Tonetti is clinical professor of periodontology at the Faculty of Dentistry

of Hong Kong University and executive director of the European Research
Group on Periodontology (ERGOPerio). He is the editor-in-chief of the Journal
of Clinical Periodontology and a member of the EFP executive committee.

Periodontitis: clinical decision tree for staging and grading Guidance for clinicians 9
New Classification of periodontal and peri-implant diseases and conditions

The New Classification is the product of the World Workshop on the Classification of
Periodontal and Peri-implant Diseases and Conditions, held in Chicago in November
2017. The World Workshop was organised jointly by the American Academy of
Periodontology (AAP) and the European Federation of Periodontology (EFP) to create
a consensus knowledge base for a new classification to be promoted globally. The
New Classification updates the previous classification made in 1999. The research
papers and consensus reports of the World Workshop were published simultaneously
in June 2018 in the EFP’s Journal of Clinical Periodontology and the AAP’s Journal of
Periodontology. The new classification was presented formally by the two organisations
at the EuroPerio9 congress in Amsterdam in June 2018.

European
Federation of
Periodontology

About the EFP

The European Federation of Periodontology (EFP) is an umbrella organisation of 35

national scientific societies devoted to promoting research, education, and awareness
of periodontal science and practice. It represents more than 14,000 periodontists and
gum-health professionals in Europe alone. In addition to 31 European members,
the EFP has recently welcomed four international associate members from Asia, the
Middle East, and Latin America.

www.efp.org
www.efp.org/newclassification

European Federation of Periodontology

Avenida Doctor Arce, 14. Office 38
28002 Madrid
Spain