March 13, 2023
by Gabriele Maycher, CEO, GEM Dental Experts Inc. BSc, PID, dip DH, RDH

  1. Q: How do I stage and grade Necrotizing Periodontal Disease (NPD) and Periodontitis as a Manifestation of Systemic Diseases (PMSD)?

    A: NPD and PMSD fall under the classification of “Periodontitis” in the new 2018 America Academy of Periodontology (AAP) global classification. (See Table 1.) However, the guidelines don’t recommend staging and grading these types of periodontitis based on their characteristics. Let’s take a closer look at the three classifications of periodontitis in this category:

    Table 1: Classification of Periodontal and Peri-Implant Diseases and Conditions 20181


    Necrotizing periodontal diseases are strongly associated with impairment of the host immune system. The client may be chronically or severely compromised from AIDS, malnourishment, extreme living conditions, or severe infection, which may constitute a serious or even life-threatening condition. We also see NPD in temporarily or moderately compromised clients (such as smokers or psycho-socially stressed individuals).2

    Rather than staging and grading NPD, clinicians should categorize the condition based on the following case phenotypes or disease outcomes.

    • Necrotizing gingivitis (NG): an acute inflammatory process of the gingival tissues only.
    • Necrotizing periodontitis (NP): an inflammatory process of the periodontium with the potential for rapid bone loss.

    The presence of necrosis or ulcers of the interdental papillae, gingival bleeding, and pain characterizes both NG and NP. Other signs and symptoms may include halitosis, pseudo membranes, regional lymphadenopathy, fever, and sialorrhea (in children).2

    • Necrotizing stomatitis (NS): a severe inflammatory condition of the periodontium and the oral cavity in which soft tissue necrosis extends beyond the gingiva. Bone denudation may occur through the alveolar mucosa. It typically occurs in severely systemically compromised clients.2

    Atypical cases have also been reported in which necrotizing stomatitis may develop without the prior appearance of necrotizing gingivitis/periodontitis lesions.2


    This condition is due to rare systemic disorders, such as Papillon-Lefevre syndrome, Down syndrome, Leukocyte adhesion deficiency syndromes, etc., resulting in the early presentation (primary dentition) of severe periodontitis.3

    Since it is a systemic disease that severely impairs the host, the primary diagnosis of periodontitis should reflect the disease causing the impairment (i.e., “periodontitis as a manifestation of systemic disease due to Papillon-Lefevre syndrome”). So again, rather than staging and grading PMSD, clinicians should further delineate the condition based on the causative disease condition.


    Most clinical cases of periodontitis do not have the local characteristics of NPD or the systemic characteristics of a rare immune disorder as in the case of PMSD and will be diagnosed simply as periodontitis. We stage and grade these cases to further break down the diagnosis of periodontitis and determine the severity of disease presentation, the complexity of disease management, the extent of the disease, the rate of progression, response to therapy, and potential impact on systemic health.

    So, even though NPD and PMSD are classified as a type of periodontitis in the 2018 AAP periodontal classification, we only stage and grade Periodontitis in this category.


    1. Caton J, Armitage G, Berglundh T, et al. A new classification scheme for periodontal and peri-implant diseases and conditions – Introduction and key changes from the 1999 classification. J Periodontol. 2018;89(Suppl 1):S1–S8.
    2. 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. J Periodontol. 2018;89(Suppl 1):S173–S182.
    3. Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. J Periodontol. 2018;89(Suppl 1):S159– S172.
    4. Albandar JM, Susin C, Hughes FJ. Manifestations of systemic diseases and conditions that affect the periodontal attachment apparatus: Case definitions and diagnostic considerations. J Periodontol. 2018;89(Suppl 1):S183–S203.
    5. Herrera D, Retamal-Valdes B, Alonso B, Feres M. Acute periodontal lesions (periodontal abscesses and necrotizing periodontal diseases) and endo-periodontal lesions. J Periodontol. 2018;89(Suppl 1):S85–S102.

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