October 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: When updating a patient’s medical history, what specific questions do I need to ask?

A: If you’re using the 2018 AAP Periodontal Classification, I recommend asking the following five questions. The first three help ensure patient safety and perhaps a need for treatment modifications. The last two questions will ensure your patients’ grade descriptors are accurate based on their current medical history status.

  1. Have you had any recent hospitable visits (illnesses, surgeries, joint replacements)?
  2. Do you have any new allergies?
  3. Are you taking any new medication including over-the-counter medications, vitamins, or supplements?
  4. Have you recently started using tobacco products and or cannabis? Or for current users: Have you recently changed the amount of tobacco and/or cannabis that you use?

Smoking has a profound effect on gingival tissue i.e., inducing microvascular vasoconstriction and fibrosis, masking clinical signs of gingivitis, bleeding on probing despite significant underlying pathological inflammatory cell infiltrate. This creates an impaired healing response, higher prevalence, severity, and progression of periodontitis requiring treatment and maintenance modifications.  Aside from this, if your Grade B patient reports that she is now smoking >10 cigarettes per day, her grade would change to C. And conversely, she would regress from a C to Grade B if she reports smoking <10 cigarettes per day.

  1. Have you recently had your sugar levels checked (HbA1c)? Or for diabetics: Have you recently had any changes to your HbA1c levels?

Diabetes mellitus (DM) is considered a global epidemic. World Health Organization data show a four-fold increase in diabetes prevalence from 1980 to 2014, and in many diabetic patients DM is undiagnosed.2 Therefore, it is important to ask when the last time your patient has had their HbA1c checked, especially if they have periodontitis.

DM is also associated with a higher prevalence and severity of periodontitis due to hyperinflammatory response to the bacterial challenge, which may give rise to a range of changes in the host, including neutrophil defects, hyperinflammatory responsive monocytes, increased release of proinflammatory cytokines, oxidative stress reactions, and impaired healing responses,2 all of which will affect treatment and maintenance.

 If patients have DM, then a change in their HbA1c may affect their assigned grade descriptor. If a Grade B patient reports an increased HbA1c (>7.0%), then his/her grade would change to Grade C, and vise versa (see Table Periodontitis: Grading).


  1. 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;45(Suppl 20):S68-S77. https://doi.org/10.1111/jcpe12940
  2. 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. https://doi.org/10.1002/JPER.16-0480
  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. https://doi.org/10.1002/JPER.18-0006

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