May 11, 2021
by Gabriele Maycher, CEO, GEM Dental Experts Inc., BSc, PID, dip DH, RDH.
As seen in Oral Health Hygiene Magazine.
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.
Does a reduced periodontium always indicate periodontitis?
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 predisposing conditions affecting the periodontium. The following criteria will help you distinguish between the two:
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Reduced periodontium due to non-periodontitis criteria:
- loss of periodontal tissue support initiated by non-periodontitis-related causes, like vertical defects due to extractions, piercings, recession due to subgingival restorations, traumatic origin, thin buccal bone plate, iatrogenic conditions, open contacts, etc.
- pocket formation – apical migration of the junctional epithelium that is initiated by the presence of non-periodontitis-related causes.
- disease progression is mediated by not resolving or controlling non-periodontitis- related causes.
Reduced periodontium due to Periodontitis criteria:
- interdental clinical attachment loss (CAL) or radiographic bone loss (RBL) detectable at ≥2 non-adjacent teeth, or buccal or CAL ≥3 mm with pocketing ≥3 mm detectable at ≥2 teeth.
- pocket formation – apical migration of the junctional epithelium initiated by bacterial plaque (biofilms).
- disease progression mediated by host response.
So, 5mm or 6mm pocket depths are not necessarily an 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. It 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. Pocket depths alone is not the determining criteria..
Keep in mind, with up to 65 percent 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.
Are we supposed to stage and grade gingivitis patients?
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. 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 identfied 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.
- Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. J Periodontal.2018;89(Suppl 1):S159-S172. https://doi.org?10.1002/JPER.18-0006
- Chapple ILC, Mealey BL, et al. Periodontal health and gingival diseases and conditions on an intact and a reduced periodontium: Consensus report of workgroup 1 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol. 2018;89(Suppl 1):S74–S84. https://doi.org/10.1002/JPER.17-0719.
- Foundations of Periodontics for the Dental Hygienist, Nield-Gehrig and Willmann, 5th Edition, 2019. Chapter 6: Periodontal Health, Gingival Diseases and Conditions., pg. 102-105.
- Foundations of Periodontics for the Dental Hygienist, Nield-Gehrig and Willmann, 5th Edition, 2019. Chapter 3: Overview of Diseases of the Periodontium, pg. 73, E. What the Research Shows, 1.