|Year : 2021 | Volume
| Issue : 3 | Page : 152-160
Clinical decision-making in the treatment of periodontitis with new classification system of periodontal diseases
Deepak Sharma1, Shalu Chandna Bathla2, Pravesh Kumar Jhingta1, Ankit Mahajan1
1 Department of Periodontology, H. P. Government Dental College and Hospital, Shimla, Himachal Pradesh, India
2 Department of Periodontology and Oral Implantology, M. M. College of Dental Sciences and Research, Ambala, Haryana, India
|Date of Submission||29-Jan-2021|
|Date of Decision||04-Jun-2021|
|Date of Acceptance||05-Jul-2021|
|Date of Web Publication||17-Sep-2021|
Dr. Deepak Sharma
Department of Periodontology, H. P. Government Dental College and Hospital, Shimla - 171 001, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Clinical application of the new classification of periodontal diseases requires knowledge of case definitions, parameters, and criteria of different categories and subcategories to arrive at final diagnosis. Correct implementation of the new classification of periodontitis is possible by understanding of the basic rules and guidelines, clarification of complex issues, and use of evidence-based dental practices. Step-wise sequence should be adopted to diagnose a patient with periodontitis. The authors, based on the current scientific evidence and clinical experience, have described specific decision-making algorithms of the diagnostic process and treatment plans of various subcategories of periodontitis.
Keywords: Classification, clinical decision, periodontal, periodontitis
|How to cite this article:|
Sharma D, Bathla SC, Jhingta PK, Mahajan A. Clinical decision-making in the treatment of periodontitis with new classification system of periodontal diseases. SRM J Res Dent Sci 2021;12:152-60
|How to cite this URL:|
Sharma D, Bathla SC, Jhingta PK, Mahajan A. Clinical decision-making in the treatment of periodontitis with new classification system of periodontal diseases. SRM J Res Dent Sci [serial online] 2021 [cited 2022 Dec 5];12:152-60. Available from: https://www.srmjrds.in/text.asp?2021/12/3/152/326213
| Introduction|| |
World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions was organized in 2017 by the American Academy of Periodontology (AAP) and the European Federation of Periodontology. After analysis of the evidence from population studies, basic science, clinical and translational research, and studies on oral systemic link put forward a new classification scheme for periodontal and peri-implant diseases and conditions with transformative changes from 1999 classification system.
The workshop in light of recent knowledge on pathophysiology agreed that three forms of periodontitis can be identified: necrotizing periodontitis, periodontitis as a manifestation of systemic disease, and a new single category of periodontitis. Additional features include categories of periodontal health and gingival inflammation for patients with reduced periodontium due to periodontitis. Removal of aggressive periodontitis as a separate entity is decided considering it as a variation along the spectrum of periodontitis disease process.
The new classification system is capable of assessing past, present, and future of the periodontal disease. It incorporates the reflection of amount of periodontal tissue loss with severity and also reflects historical rate of diseases progression. It also includes current periodontal status of a patient with probing pocket depth (PPD) and bleeding on probing (BOP) and assessment of patient's risk profile. A scope for future advances in clinical or biological knowledge as biomarkers is also reserved in the present scheme making it a “live system.” The relationship of systemic health and periodontitis has been highlighted in the system as well. It has become global standard procedure for diagnosing periodontal diseases and must be practiced by students, academicians, and clinicians alike.
| Clinical Application of New Classification System|| |
In the context of clinical care, a patient is a “periodontitis case” if it fulfills the following case definition.
- Interdental Clinical Attachment Loss (CAL) is detectable at ≥2 nonadjacent teeth or
- Buccal or oral CAL ≥3 mm with pocketing ≥3 mm is detectable at ≥2 teeth. Exclude the CAL that is associated with nonperiodontal conditions such as recession due to mechanical trauma, cervical dental caries, vertical root fracture, and endodontic lesion draining in the marginal gingiva.
Development of novel two-vector system of periodontitis staging and grading is in direction to inculcate precision medicine and enables a clinician to give individualized diagnosis and tailor made treatment plan, adopting a multidimensional treatment approach. Stage provides clinicians with knowledge of severity of the disease by assessing CAL and radiographic bone loss (RBL) and periodontal tooth loss. In addition, it reflects anticipated complexity of treatment required to eradicate/reduce the current level of infection and inflammation and to restore masticatory function. Staging involves four categories, i.e. stages I, II, III, and IV.
- Stage I: Initial periodontitis with early stages of attachment loss
- Stage II: Moderate periodontitis
- Stage III: Severe periodontitis with potential for additional tooth loss with significant damage to the attachment apparatus
- Stage IV: Severe periodontitis with potential for loss of dentition with significant damage to periodontal support, leading to tooth loss and loss of masticatory function.
Grade describes additional biological dimensions of the disease including the observed or inferred progression rate, the risk for further deterioration due to environmental exposures such as smoking and comorbidities such as diabetes, and the risk that the disease or its treatment may affect the particular patient's general health status. Grading includes three levels, i.e. Grade A – slow rate of disease progression, Grade B – moderate rate, Grade C – high rate of disease progression. The primary criteria for staging are either direct or indirect evidence of progression. Whenever available, direct evidence of longitudinal disease progression with CAL and RBL is used; in its absence, indirect estimation is made using bone loss as a function of age at the most affected tooth or case presentation (RBL expressed as percentage of root length divided by the age of the subject, RBL/age). Clinicians should initially assume Grade B disease and seek specific evidence to shift toward Grade A or C, if available. Once grade is established based on the evidence of progression, it can be modified based on the presence of risk factors. The immune dysregulation related to genetic difference or dysbiosis may express as higher grading scores and encourage clinicians for periodontal risk assessment and personalized periodontal treatment plan.
Grading can be done as follows:
- Grade A. Direct estimation: No progressive CAL or RBL over 5 years. Indirect estimation: Severe RBL% is less than half the patients' age in years, e.g. <25% in 50 years. Normoglycemic and nonsmoker patient.
- Grade C. Direct estimation: ≥2 mm progressive CAL or RBL over 5 years. Indirect estimation: Severe RBL% is more than the patients' age in years, e.g. more than 50% in 50 years. Smoking ≥10 cigarettes/day and HbA1C ≥7%.
- Grade B. When two extremes of spectrum, i.e. Grade A and Grade C, are ruled out, Grade B can be assessed with direct estimation: <2 mm progressive CAL or RBL over 5 years. Indirect estimation: Severe RBL% is in-between Grade A and C value, e.g. <50% but more than 25% in 50 years. Smoking <10 cigarettes/day and HbA1C <7%.
Key points in application of staging and grading are: 
- Clinical attachment loss (CAL) is important and is the hallmark of periodontitis. CAL and RBL initially predict periodontitis staging
- Stage can deteriorate and shift upward, depending on the addition of complexity factors, and it cannot be lowered after treatment even with improvement in PPD and BOP or other parameters. Shift of Grade, on the other hand, is possible in either direction, after assessment of parameters over follow-up maintenance period.
The complexity factors that determine Stage must be evaluated collectively to arrive at final diagnosis as its patient oriented. The present classification system considers multiple factors as described above for diagnosing the periodontitis as compared to previous classification systems. The system bridges high level of evidence-based research with translational research and clinicians' experience and expertise.
Although new classification system relies on clinical attachment loss and RBL as two main parameters in assessing periodontitis, they can have individual, gender, racial, geographical, and other variations. Systematic review conducted by Needleman et al. concluded that the mean CAL loss and tooth loss are 0.1 mm and 0.2 tooth annually which may increase to 6 times CAL loss in periodontitis patients. CAL loss was also observed to be higher in the population of developing economies compared to developed ones by three times. There is substantial heterogeneity in the definition of what constituted a progressing site, and hence, regional difference may impact grading categorization and reduces classification system specificity. Study conducted by Billings et al. in populations of two geographic locations in the USA and Germany found periodontitis severity may vary in different populations and in different age groups. It concluded that empirical evidence-driven definitions of CAL thresholds signifying disproportionate severity of periodontitis by age and regions are feasible. A meta-analysis in different regions in 30 Indian states also found different prevalence of periodontitis categories which also differenced in regions (more in urban population), age groups (more in 65 years and older), and gender (more in males).
| Decision-Making Steps for Diagnosis of Periodontitis|| |
After careful dental, periodontal, and radiographic examination, history, and risk factor evaluation, a diagnosis is finalized and periodontal therapy is planned. [Table 1] shows features of different classes of periodontitis as per new classification system.
With available radiographs, perform assessment of marginal bone loss (RBL) in two nonadjacent teeth due to periodontitis excluding nonperiodontitis causes: Consider periodontitis case.
Proceed for comprehensive dental and medical history evaluation and clinical dental, gingival, and periodontal examination and consider full mouth radiographs and categories as in Step 3.
If radiographs are of inadequate quality or unavailable, examine interdental CAL and buccal CAL to fulfill periodontitis case definition criteria: Consider periodontitis case.
Proceed for comprehensive dental and medical history evaluation and clinical dental, gingival, and periodontal examination and consider full mouth radiographs and categorize as in Step 3.
Examine periodontal pocket depth and BOP at six sites per tooth. Diagnose it as:
- Clinical gingival health on reduced periodontitis in stable periodontitis patient: PPD <4 mm and BOP <10%
- Gingival inflammation reduced periodontitis in treated periodontitis patient: PPD <3 mm and BOP >10%
- Periodontitis: PPD >4 mm and BOP >10%.
Establish staging which is severity and complexity of disease management. Based on CAL and RBL, when clinician finds more than 33% of RBL and 5 mm or more CAL in most affected site and periodontal tooth loss, it calls for complex and severe Stages III and IV, whereas <33% RBL and 5 mm CAL and no periodontal tooth loss are initial or moderate periodontitis. Classify extent and severity on the bases of 30% teeth involvement and incisor molar involvement and add to stage as descriptor.
Establish grading, risk of progression, and risk factor profile. On bases of previous radiographic record analysis of 5-year longitudinal disease progression (direct evidence), and if radiographic assessment is not done, apply indirect evidence of percentage of root length bone loss divided by the age of the subject criteria and case phenotype. Clinicians should initially assume Grade B disease and seek specific evidence to shift toward Grade A or C, if available. Once grade is established based on the evidence of progression, it can be modified based on the presence of risk factors as smoking and metabolic control of diabetes.
Additional diagnostic aids required.
| Treatment Planning|| |
Previously treated patient for periodontitis.,,,,
Examine periodontal pocket depth and BOP at six sites per tooth. Diagnose it as:
- Clinical gingival health on reduced periodontitis in stable periodontitis patient: PPD <4 mm and BOP <10%. Consider updating dental and medical history and clinical dental, gingival and periodontal examination
- Gingival inflammation on reduced periodontitis in treated periodontitis patient: PPD <3 mm and BOP >10%. Consider updating dental and medical history and clinical dental, gingival and periodontal examination and risk factors reassessment
- Periodontitis: PPD >3 mm and BOP >10%. Proceed for comprehensive dental and medical history evaluation and clinical dental, gingival, and periodontal examination and consider full mouth radiographs and categorize as in Step 4 of previous protocol.
| Guidelines For Periodontal Disease Treatment as per New Classification System|| |
The aim of the periodontal therapy is to arrest and stabilize the disease while maintaining function and esthetics. Goals in line with this include decreasing bacterial deposits and resolving periodontal pocketing, bleeding, and mobility. The initial phase or phase I of periodontal therapy include tailored oral hygiene instructions, and associative preventive advice like smoking cessation, an attempt to aid the patient to control any systemic modifiers like diabetes mellitus, local and systemic pharmacotherapy, correction of any local plaque retentive factors like overhanging restorations margins and nonsurgical periodontal therapy. Patient should be made aware of risk factors and importance of compliance in the management of periodontitis. Reassessment at 4–8 weeks, postphase I, is performed which should include updating of medical and dental history and assessment of patient compliance, oral hygiene, plaque and gingival inflammation scores, BOP, PPDs, clinical attachment levels, mobility, keratinized gingiva, phenotype, and other factors.
Incidence of disease progression is greater in sites with deeper periodontal pockets. These sites tend to respond more favorably when surgical therapy is provided., Thus, it is important to alert patients with severe periodontitis about the possibility of a second phase of surgical treatment, which could include open flap debridement and regenerative surgery. As periodontitis patients are more susceptible to disease relapse and recurrence, a strict periodontal supportive therapy is needed which is a continuous process along with etiologic, surgical, and rehabilitation phase.,,, Decision-making chart for treatment planning for various classes of periodontitis as per new classification system is shown in detail in [Table 2].
|Table 2: Decision-making chart for treatment planning for various classes of periodontitis as per new classification system|
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Limitation of new classification system
- The listed periodontal examination procedure is complicated, time-consuming, and exhaustive, with overlapping diagnostic features, and hence pose difficulty in general clinical practice or with nonperiodontal specialists
- CAL measurement is prone to interexaminer variations, different tissue conditions, use of nonstandardized probes, and different probe dimensions. Hence, diagnosis based on CAL measurement can have reliability, reproducibility, generalizability, and validity issues
- Another assessment method of measuring RBL is also associated with inherent limitations, vis-a-vis nonstandardized radiographic parameters, obstruction from anatomic landmarks, inadequate assessment of facial and palatal or lingual marginal bone levels, and disadvantage of radiographs in identifying initial periodontitis as substantial bone loss is required to occur to appear on radiographs
- As only one tooth with severe or greatest CAL or bone loss is the measurable unit for entire periodontium, it makes the classification system prone to subjective errors.
- Direct evidence to categorize grading which critically assesses future risk of periodontitis and response to periodontal treatment is not practical approach in most clinical situations where treatment records are inadequate or unavailable
- Effects of traumatic occlusal forces on initiation and progression of periodontitis solely or as additional factor along with plaque are poorly understood and need further longitudinal studies
- Unique etiological, microbial, pathophysiological, genomics, metagenomics, demographic, and clinical characteristics of localized aggressive periodontitis do not justify its noninclusion as separate category and may need more research on this subject
- Patient-centered staging classification ignores the asynchronous multiple burst aspect of the periodontal diseases, whereas treatment focuses also on local etiological factors, anatomic factors, diseases recurrences, residual pockets, etc., and hence lack acceptance of classification system as therapeutic guide.
| Future Directions|| |
- A more simple, clinician-friendly, and objective algorithm-based approach should be considered for periodontal diseases diagnosis
- The examination protocol needs simplification as its exhaustive for general dental practitioners, nonperiodontal specialist, and graduate students
- Standardized methods of periodontal probing, radiographic examination, and instrumentation should be adopted globally
- Education and training in periodontal probing methods and CAL measurement will go a long way to have uniform diagnosis
- The traumatic occlusal forces playing a role in periodontal pathogenesis has occupied a major part for the past decades and more evidence-based research in this area should be conducted to further ascertain its role in periodontitis as complexity factors in categorizing periodontitis staging
- Epidemiological studies and randomized controlled trials on different races and regions will give more information on various aspects of periodontal disease such as initiation, progression, severity, risk profiles, and disease trajectory and also on response to different treatment approaches which will enable practice of precision medicine
- Genomic, metagenomic, epigenomic, immunological, and behavioral aspects of periodontal diseases should be included in future which will have impact of periodontal treatment
- Inclusion of systemic conditions other than diabetes in patient's risk profile which have shown to affect periodontal health and disease
- The role of classification system in periodontal treatment planning as standard therapeutic guide needs to be established and developed further.
| Conclusion|| |
The new classification system is the new standard of periodontal and peri-implant disease diagnosis and periodontal treatment practiced by all dental professionals around the world. It has several key changes compared to 1999 periodontal disease AAP classification system. Although this system is framed on evidence-based scientific knowledge, it may appear little complex to understand and practice initially. The authors have attempted to frame a quick aid algorithm to diagnose the periodontitis case. The treatment plan algorithm for the classes of periodontitis based on the current knowledge and scientific evidence has also been put forwarded for easy understanding and clinical implementation by periodontists and general practitioners alike.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]