April 22, 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: Does a reduced periodontium always indicate periodontitis?
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A: Not necessarily. First, the clinician needs to ensure that he or she can distinguish between a periodontium that is reduced because of disease due to biofilms or conditions affecting the periodontium like ortho forces, extractions, or open contacts. The following criteria will help you distinguish between the two:
Reduced periodontium due to Periodontitis criteria includes:
- loss of periodontal tissue support (interdental at >2 non-adjacent teeth), including clinical attachment loss (CAL) and radiographic bone loss (RBL).
- pocket formation—apical migration of the junctional
epithelium initiated by bacterial plaque (biofilms)
- presence of gingival bleeding—pocket epithelial ulceration.
- disease progression mediated by host response.
Reduced periodontium due to non-periodontitis criteria includes:
- loss of periodontal tissue support initiated by conditions affecting the periodontium like vertical defects due to extractions, piercings, subgingival fillings, open contacts, ortho forces, thin buccal bone plate, thin periodontal phenotype, iatrogenic conditions, and so on. The literature also refers to these conditions affecting the periodontium as predisposing factors and I like to refer to them as acquired or development deformities and conditions (ADC’s), just to have a short acronym to use in identifying them.
- a reduced periodontium due to non-periodontitis can be localized or generalized.
- pocket formation – apical migration of the junctional epithelium that is initiated by the presence of predisposing factors rather than by bacterial plaque.
- disease progression is mediated by not resolving or controlling the predisposing factors.
So, in conclusion, 5mm or 6mm pocket depths are not necessarily and indicator of periodontitis, they could be pseudo pockets, just as 4mm pocket depths in the anterior region or molar area of a patient 13 years of age, is not an indicator of just gingivitis. Could be a Grade C periodontitis patient, formally known as aggressive periodontitis. The determining factor if a reduced periodontium is due to periodontitis is if the apical migration of the junctional epithelium is due to or initiated by plaque biofilms or by conditions affecting the periodontium/predisposing factors/ADCs. The only way to determine this clinically is with a comprehensive medical dental history, odontogram, and the appropriate type and number of radiographs to screen for these different types of periodontium’s. Notice I didn’t include periodontal assessment because of the reasons mentioned above.
Finally, keep in mind, with 65% of your patients having periodontitis they will probably have a reduced periodontium due to a combination of periodontitis plus conditions affecting the periodontium from years of dental work and or acquired or developmental deformities or conditions. This is when clinical judgement comes into play.