February 19, 2021
by Gabriele Maycher, CEO, GEM Dental Experts Inc., BSc, PID, dip DH, RDH
Still confused about the 2018 AAP Periodontal classification. Never fear! The next few monthly columns will review some of the most important updates made to the industry’s global periodontal guidelines to help hygiene teams achieve the highest level of care. Once we have exhausted this topic we will move onto other questions about the process of care. If you have any specific questions you would like answers to, please let me know.
Q: Are we supposed to stage and grade gingivitis patients?
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A: No; you only stage and grade periodontitis patients. The format of staging and grading to classify periodontitis was a concept adopted from oncology to help dental professionals determine severity, complexity of treatment, disease progression, and the systemic effects of periodontitis. Periodontitis is a disease that once a patient has is it, he or she has it for life. We can’t reverse it or cure it; we can only manage it. It’s no less serious than atherosclerosis, Crohns disease, or rheumatoid arthritis. Gingivitis, on the other hand, is a disease process we can reverse and cure. So, let’s review how and why staging and grading helps us treat and manage periodontitis.
Staging. The process involves assessing both the severity of disease and complexity of treatment. When determining severity, consider how much attachment loss exists: Slight (Stage 1), moderate (Stage II), severe (Stage III), or advanced (Stage IV). Is there any tooth loss due to periodontitis? If so, severity may increase to Stage III or Stage IV. What is the chance the patient will lose his or her entire dentition because of periodontitis? If it’s possible, then you’re likely at Stage IV.
Complexity of treatment to re-establish health is the second important piece in staging. Severity of such factors as pocket depths, furcations, vertical bone loss, ridge defects, and degree of mobility may increase the patient’s stage and thus the complexity in treatment to re-establish health. For instance, if Class II or III furcations, vertical bone loss greater than or equal to 3mm and or mobility greater than or equal to 2mm exists perhaps both nonsurgical periodontal therapy and surgical periodontal therapy are needed.
Grading. This process exists to help us identify and monitor disease progression in the face of important direct and indirect evidence, plus grade modifiers/risk factors. To assess how quickly a patient’s periodontitis is progressing, use the following guidelines:
- Grade A (slow progression). These patients have periodontitis but progression moves at a glacial speed. They are the lucky ones.
- Grade B (moderate progression). The new global classification wants us to “assume” that most patients fall into this category unless direct evidence, which compares previous FMS with new FMS, or indirect evidence of disease outcomes, which compares how much periodontal destruction exists vs. biofilms, prove otherwise. Eighty percent of patients formally identified with Chronic Periodontitis in the 1999 AAP Classification will be Grade B.
- Grade C (rapid progression). Thirteen percent of patients formally identified with Aggressive Periodontitis in the 1999 AAP Classification will be in Grade C. Chances are there is a grade modifier/risk factor present, like smoking and/or diabetes, or the patient’s age vs. the amount of destruction exceeds expectation (i.e., %bone loss ÷ age).
Finally, it’s important to understand which grade modifiers/risk factors will impact your patient’s disease progression and grading the most. Consider, for example, the quantity and regularity of smoking or the severity of diabetes. How will those grade modifiers/risk factors affect an individual patient systemically? Will these grade modifiers/risk factors expediate the progression of the patient’s current periodontitis status? If so, how are you going to manage this clinically? Staging and grading offer vital information that will help you design a treatment plan for both short-term and long-term management of periodontitis.