December 19, 2023
by Gabriele Maycher, CEO, GEM Dental Experts Inc. BSc, PID, dip DH, RDH

Are flawed processes keeping your team from experiencing better efficiency, healthier clients, happier employees, and continued practice growth?

The Challenge:

I often find myself in disagreement with my fellow hygienists regarding the stage determination for our periodontitis clients. From my perspective, they may be overestimating the severity of the condition based on their assessments.


To ensure accurate stage determination for periodontitis clients, it is essential to revisit and thoroughly understand the 2018 AAP Periodontal Classification guidelines. While the classification provides a standardized framework, its successful implementation relies on careful clinical judgment and attention to specific considerations.

Here are some essential factors to keep in mind when determining a client’s stage:

Periodontitis threshold. Step one is to establish if the reduced periodontium is due to periodontitis or non-periodontitis causes (NPC). Look for interdental clinical attachment loss (CAL) at two or more non-adjacent teeth. Be cautious with adjacent areas or single affected areas, as they might be impacted by such NPC as occlusal trauma, open contacts, etc. Ensure that the attachment loss is genuinely due to periodontitis before determining the stage.

Individual assessment. Each client’s case is unique, and a comprehensive assessment is crucial for an accurate diagnosis. Pay close attention to various clinical parameters, including CAL, radiographic bone loss (RBL), tooth loss, and complexity factors.

CAL vs. RBL. The initial stage should be determined using CAL. If CAL is unavailable, consider using radiographic bone loss. Both criteria should not be attributed to NPC. RBL may be preferred for its objectivity and alignment with the team’s assessment. Be aware that CAL determination can be challenging and might lead to overestimation.

Tooth loss. Tooth loss or anticipated extractions attributed to periodontitis can modify the stage, even without complexity factors. If a client is missing one or more teeth due to periodontitis, this automatically shifts him or her to a higher stage. Rule out tooth loss due to NPC (such as tooth fractures).

Complexity factors: Ensure accurate assessments.

They play a crucial role in determining the stage of periodontitis. These factors, such as ≥6mm pocket depths (PDs), furcation involvement (II or III), or vertical bone loss ≥3mm, can elevate a client to a higher stage (III or IV), irrespective of CAL or RBL.

To accurately assess ≥6mm PDs, it is crucial to verify that they meet the definition of a true periodontal pocket, with apical migration of the junctional epithelium (JE) caused by periodontitis, rather than NPC contributing to the migration of the JE or a pseudo pocket resulting from inflammation. Early assessments should consider these factors. Pocket depth readings typically include inflammation so don’t solely rely on PD readings to advance a client to stage III. This will lead to more precise post-care stage predictions since regressing a stage is only allowed if vertical bone loss ≥3mm and furcation involvement (Class II & III) are surgically regenerated.

It only takes one complexity factor to shift the diagnosis to a higher stage. Be cautious, though, not to overestimate the severity of periodontitis based on isolated findings attributable to NPC. Consider the cumulative evidence and ensure that all clinical indicators align to support the stage determination.

Stage III vs. IV: What’s the client’s risk?

The critical factor that distinguishes stage III from stage IV in periodontitis is the level of risk the client faces concerning the potential loss of his or her entire dentition. Stage III primarily involves complexity factors, but the decision to shift to stage IV should hinge on whether the client is at risk of losing all of his or her teeth without complex rehabilitation. This criterion should be the guiding principle in determining between these two stages.

Stage Distribution

Statistically, most clients will fall into stage II or III. A small percentage (around 11%) may be stage IV. If a disproportionate number of clients are categorized as stage IV, it might signal overestimation.

It is crucial to approach the staging process with critical thinking, a comprehensive understanding of the new global classification, and clinical experience. Avoiding overestimation requires a thorough examination of the available evidence and a careful assessment of each client’s unique condition.

By following these guidelines and staying up to date with the latest research, you can confidently determine the appropriate stage for your periodontitis clients and provide them with the most accurate treatment and care. If you find yourself differing in opinion with colleagues, engage in open communication and professional discussions. Sharing knowledge and experiences can lead to better clinical decision-making and foster a collaborative approach to client care.

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