December 23, 2022
by Gabriele Maycher, CEO, GEM Dental Experts Inc. BSc, PID, dip DH, RDH
Q: Our hygiene team gathers for monthly chart audit meetings to align on patient treatment, but we are debating the correct diagnosis of our last case. Perhaps you can help us settle the debate.
A: Great to hear you have monthly chart audit meetings. They are a great way to align and learn. So, let’s hear more about this case?
“We are debating whether the correct dental hygiene diagnosis (DHD) for a patient was periodontitis Stage II or III. I thought based on the clinical assessments it was obvious that the patient was Stage III. The site of greatest loss was 38%, measured at the distal of #1.6. We had a furcation involvement Class II as well, and >3mm vertical bone loss (VBL) in this area. We all agreed that the radiographic interpretation was generalized slight to moderate horizontal bone loss (HBL) and VBL between 1.6 and 1.7, furcation involvement #1.6 Class II. Doesn’t this indicate Stage III?”
Yes, based on the 2018 AAP Periodontal Classification, once you have determined that a patient has periodontitis (two or more non-adjacent interproximal sites, with breakdown of the periodontium due to biofilms), this is in fact a classic example of complexity factors that puts this patient into the Stage III category. See Periodontitis: Staging. However, to be sure, we need to first ask the question: Is the bone loss between 1.6 and 1.7 due to biofilms or some other contributing factor, such as an acquired or developmental condition (ADC)? For example, if the vertical defect and furcation involvement is created by super-eruption, an open contact, defective restoration, or a combination, this would not be a site to measure as “the site of greatest loss” when determining the patient’s stage. If your radiographic interpretation had indicated several areas of VBL, I would agree that the stage should be III, but with only one area being so profoundly affected, it makes me suspect that an ADC may exist in this area. If this is the case, I would probably lean toward staging this patient as stage II. Go back with discerning and critical eyes and re-assess this area to determine the true nature of the VBL and furcation involvement. If you determine it is due to an ADC, then don’t use this site to determine the stage.
I always advise hygienists to have a comprehensive odontogram where open contacts, attrition, malalignment, super eruption, missing teeth, iatrogenic restoration, etc., are documented. Then once the periodontal assessments are completed, superimpose the perio-chart with the odontogram to determine areas affected by an ADC. This will assist you in determining the true nature of the reduced periodontium in those areas: biofilms, ADC(s), or a combination? It will also assist you in selecting the appropriate site to measure the greatest loss. This is an important step in determining an accurate DHD, which will inform an effective treatment plan in achieving optimal tissue response. Nonsurgical periodontal therapy alone won’t give you optimal tissue response if an ADC exists in the area. Both the disease and the ADC(s) will need to be treatment planned and addressed. Hope this helps!