Perio 13 - Classification of Periodontal Diseases Part 2 (Dr. Valverde)

Supracrestal tissue attachment (SCTA)

Biologic width is now more commonly known as __________

Periodontitis (with staging and grading)

What is the correct way to refer to chronic periodontitis and aggressive periodontitis?

Molar/Incisor Pattern (MIP)

What is a specific extent and distribution descriptor for aggressive periodontitis?

Cairo Classification (RT1, RT2, & RT3)

The Miller Classification for gingival recession has been replaced by what?

Clinical health

How would you classify this patient's periodontal status?

BOP: No/minimal

Normal gingival sulcus depth? > Yes

Normal bone heights? > Yes

Modifying factors: Controlled

Predisposing factors: Controlled

Gingivitis

How would you classify this patient's periodontal status?

BOP: Yes

Normal gingival sulcus depth? > Yes

Normal bone heights? > Yes

Modifying factors: May be present

Predisposing factors: May be present

Periodontal disease stability

How would you classify this patient's periodontal status?

BOP: No/minimal

Normal gingival sulcus depth? > No

Normal bone heights? > No

Modifying factors: Controlled

Predisposing factors: Controlled

Periodontal disease remission/control

How would you classify this patient's periodontal status?

BOP: Significantly reduced

Normal gingival sulcus depth? > No

Normal bone heights? > No

Modifying factors: Not fully controlled

Predisposing factors: Not fully controlled

Clinical health

How would you classify this patient's periodontal status?

Gingivitis

How would you classify this patient's periodontal status?

Periodontitis

How would you classify this patient's periodontal status?

- Gingivitis is reversible

- Periodontitis is irreversible

Are gingivitis and periodontitis reversible?

True, if well-controlled

T/F: You can have a patient with stable periodontitis

- Erythema

- Bleeding

- Supperation (most severe)

Rank the severity of inflammation from least to most severe:

- Erythema

- Supperation

- Bleeding

Periodontal diseases have a range of interconnected conditions, symptoms, or severity levels that share underlying similarities or causes, often manifesting in different forms and degrees across individuals

Which of the following best explains the concept shown in the slide?

Gingivitis

_________ is treatable and can be reversed to periodontal health

Periodontitis

____________ cannot be reversed but rather managed or 'stabilized', meaning that the attachment loss remains, but the inflammation can be controlled

- Multi-dimension staging and grading

- New framework (Periodontitis, Necrotizing periodontitis, and Periodontitis as manifestation of systemic disease)

- Underscores similarities to progressive medical conditions that can manifest and modify based on patient characteristics and risk

What were some key changes to periodontitis classifications in 2018?

Interdental clinical attachment loss (CAL) detectable at ≥ 2 non-adjacent teeth (!!!!)

What is the definition of periodontitis?

1) Gingival recession of traumatic origin

2) Dental caries extending in the cervical area of the tooth

3) The presence of CAL on the distal aspect of a second molar and associated with malposition or extraction of a third molar

4) An endodontic lesion draining through the marginal periodontium

5) The occurrence of a vertical root fracture

Periodontitis is defined as interdental clinical attachment loss (CAL) detectable at ≥ 2 non-adjacent teeth and the observed CAL cannot be ascribed to non-periodontal causes such as... (5)

Periodontitis

How would you classify this patient's periodontal status?

- Inflammation (BOP >10%)

- Interproximal attachment loss in at least 2 non-adjacent teeth

No

Does this patient have periodontitis?

Yes

Does this patient have periodontitis?

Probing Depth (PD) - Free Gingival Margin (FGM)

In periodontal charting, how do you measure the attachment loss (ATTACH)?

Stage

Define the following:

Defines the severity of the disease

Grade

Define the following:

Defines the progression rate of the disease

Only one stage and grade per patient (i.e. patient-based)

How many stages and grades per patient?

Step 1: Initial case overview to assess disease

What step is this in the three steps to staging and grading a patient?

Screen:

- Full mouth probing depths

- Full mouth radiographs

- Missing teeth

- Rule out non-periodontitis causes of CAL (e.g., cervical restorations or caries, root fractures, CAL due to traumatic causes)

- Mild to moderate periodontitis will be either Stage I or Stage II

- Severe periodontitis will be either Stage III or Stage IV

Step 2: Establish stage

What step is this in the three steps to staging and grading a patient?

For mild to moderate periodontitis (Stage I or Stage II):

- Determine maximum CAL or radiographic bone loss (RBL)

- Confirm RBL patterns

For moderate to severe periodontitis (Stage III or Stage IV):

- Determine maximum CAL or RBL

- Confirm RBL patterns

- Assess tooth loss due to periodontitis

- Evaluate case complexity factors (e.g., severe CAL frequency, surgical challenges)

Step 3: Establish grade

What step is this in the three steps to staging and grading a patient?

- Assess progression rate of periodontitis

- - Based on existing data

- Based on calculated RBL (% of root length x 100) divided by age

- Assess risk factors (e.g., smoking, diabetes, other)

- Account for medical and systemic inflammatory considerations

Stage

What has the following characteristics:

- Severity of the disease at the most affected area (Expressed through attachment loss and bone loss)

- Tooth loss that has occurred as a result of periodontitis

- Anticipated complexity of treatment required

The most severe area of periodontitis

- But expand the description with additional information: E.g., a patient with localized Stage III periodontitis may have areas of dentition with mild/moderate severity of CAL, which should be noted in the narrative of the case description

What is the stage based on?

False - one stage per person (Stage is patient-based, not tooth-based)

T/F: You can assign multiple stages to one person

1. Interdental clinical attachment loss (CAL) at site of greatest loss

2. Radiographic bone loss (RBL)

3. Tooth loss due to periodontitis

What are three parameters that are considered in establishing the severity of periodontitis?

- Interdental CAL: 1-2 mm

- RBL: coronal third (<15%)

- No tooth loss

What is the interdental CAL (at the site of greatest loss), Radiographic bone loss (RBL), and tooth loss status for stage I periodontitis?

- Interdental CAL: 3-4 mm

- RBL: coronal third (15%-33%)

- No tooth loss

What is the interdental CAL (at the site of greatest loss), Radiographic bone loss (RBL), and tooth loss status for stage II periodontitis?

- Interdental CAL: ≥5mm

- RBL: Extending to middle third of tooth and beyond

- ≤4 teeth

What is the interdental CAL (at the site of greatest loss), Radiographic bone loss (RBL), and tooth loss status for stage III periodontitis?

- Interdental CAL: ≥5mm

- RBL: Extending to middle third of tooth and beyond

- ≥5 teeth

What is the interdental CAL (at the site of greatest loss), Radiographic bone loss (RBL) and tooth loss status for stage IV periodontitis?

Stage III

A patient presents with interdental CAL of 6 mm and loss of 3 teeth due to periodontitis. What is the most appropriate stage?

Complexity

All of the following parameters are consideration in establishing the _________ of periodontitis:

1. Probing depths

2. Type of bone loss

3. Furcation involvement

4. Ridge defects

5. Masticatory dysfunction

6. Occlusal trauma

7. Bite collapse, drifting, flaring

Stage I

What stage of periodontitis has the following complexities:

- Max. probing depth ≤4 mm

- Mostly horizontal bone loss

Stage II

What stage of periodontitis has the following complexities:

- Max. probing depth ≤5 mm

- Mostly horizontal bone loss

Stage III

What stage of periodontitis has the following complexities?

In addition to previous stage complexity:

- Probing depths ≥6 mm

- Vertical bone loss ≥3 mm

- Furcation involvement Class Il or Ill

- Moderate ridge defects

Stage IV

What stage of periodontitis has the following complexities?

In addition to previous stage complexity:

- Need for complex rehabilitation due to:

- - Masticatory dysfunction

- - Secondary occlusal trauma (tooth mobility degree ≥2)

- - Severe ridge defects

- - Bite collapse, drifting, flaring

- < 20 remaining teeth (10 opposing pairs)

Extent

_______ describes the percent of teeth affected at the severity level that defines the stage.

1. Localized (<30% of teeth involved)

2. Generalized (>30% of teeth involved)

3. Molar-incisor pattern of distribution (formerly localized juvenile periodontitis)

For each stage, what three ways can you describe extent?

Localized

When <30% of teeth involved how do you describe the extent?

Generalized

When >30% of teeth involved how do you describe the extent?

Stages I and II

What two stages of patients have the following characteristics?

- Show periodontitis of mild to moderate severity

- Have not lost any teeth due to disease

Stages III and IV

What two stages of patients have the following characteristics?

- More complex cases

- Require more advanced periodontal treatment

- Extent of tooth loss requires extensive rehabilitation in Stage IV cases

Stages III and IV

What stage periodontists patients would you refer to PG perio or specialist?

Grading

__________ allows the clinician to incorporate individual patient factors into the diagnosis, which are crucial to comprehensive case management.

Grade

What describes the following:

- Observed/inferred progression rate

- Risk for further deterioration due to environmental exposures (e.g., smoking) and co-morbidities (e.g., diabetes)

- Risk that disease or treatment may adversely affect general health

1. Not all individuals are equally susceptible to periodontitis.

2. Periodontitis progression and severity is a function of multifactorial influences on a patient's response to the microbial challenge. Multiple factors often interact to influence clinical phenotypes.

3. Some periodontitis cases require more intensive control of the microbial biofilm and inflammation than achieved using current principles of care.

Grading is based on what three fundamental principles?

Staging

Define the following:

Classifies the severity and extent of a patient's disease based on the measurable amount of destroyed and/or damaged tissue as a result of periodontitis and to assess the specific factors that may attribute to the complexity of long-term case management

Grading

Define the following:

Aims to indicate the rate of periodontitis progression, responsiveness to standard therapy, and potential impact on systemic health

Grade A (slow rate)

What grade of periodontitis shows no loss over 5 years in the radiographic bone loss or CAL?

Grade B (moderate rate)

What grade of periodontitis shows <2 mm over 5 years in the radiographic bone loss or CAL?

Grade C (rapid rate)

What grade of periodontitis shows ≥2 mm over 5 years in the radiographic bone loss or CAL?

<0.25

What is the % bone loss/age for grade a periodontitis?

0.25-1.0

What is the % bone loss/age for grade b periodontitis?

≥1.0

What is the % bone loss/age for grade c periodontitis?

Grade A (slow rate)

What grade of periodontitis has the following case phenotype?

- Heavy biofilm deposits with low levels of destruction

Grade B (moderate rate)

What grade of periodontitis has the following case phenotype?

- Destruction commensurate with biofilm deposits

Grade C (rapid rate)

What grade of periodontitis has the following case phenotype?

- Destruction exceeds expectations given biofllm deposits; specific clinical patterns suggestive of periods of rapid progression and/or early onset disease

Radiographic bone loss or CAL over 5 years

What is considered direct evidence of progression in grading periodontitis?

- % of bone loss/age

- Case phenotype: biofilm deposits or level of destruction

What is considered indirect evidence of progression in grading periodontitis?

0.22 → Grade A

A 45-year-old patient presents with 10% bone loss. The % bone loss/age ratio is what?

0.56 → Grade B

A 45-year-old patient presents with 25% bone loss. The % bone loss/age ratio is what?

1.11 → Grade C

A 45-year-old patient presents with 50% bone loss. The % bone loss/age ratio is what?

1.67 → Grade C

A 45-year-old patient presents with 75% bone loss. The % bone loss/age ratio is what?

Grade A (slow rate)

What grade of periodontitis do non-smokers fall under?

Grade B (moderate rate)

What grade of periodontitis do individuals who smoke <10 cigarettes/day fall under?

Grade C (rapid rate)

What grade of periodontitis do individuals who smoke ≥10 cigarettes/day fall under?

Grade A (slow rate)

What grade of periodontitis is the following?

Normoglycemic/ no diagnosis of diabetes

Grade B (moderate rate)

What grade of periodontitis is the following?

HbA1c <7.0% in patients with diabetes

Grade C (rapid rate)

What grade of periodontitis is the following?

HbA1c ≥7.0% in patients with diabetes

Grade C

If an individual has a %bone loss/age of 0.25 but they are a heavy smoker, what would you grade them?

localized periodontitis, stage 1

Case study: What stage is this patient with 2mm interproximal attachment loss?

Grade A

Case study: What grade is this patient?

- No new RBL compared to 5 years prior

- No DMII

- No smoking

localized periodontitis stage III

Case study: What stage is this patient?

30 year old patient with 9mm interproximal attachment loss isolated to central incisor and first molar

Grade C

Case study: What grade is this patient?

- 50% bone loss

- 30 year old

- 50/30 = 1.6

True

T/F: Stage III Grade C replaces old "localized aggressive periodontitis"

generalized periodontitis, stage IV

Case study: What stage is this patient?

- 95 year old patient with 12 remaining teeth and more than 30% of teeth with 10mm interproximal attachment loss

B

What grade is this patient?

- 95 year old with 80% bone loss

- 80/95 - 0.8

Grade C

If a 95 year old comes in with 80% bone loss and a HbA1C >7%, what is their grade?

Grade C

If a 95 year old comes in with 80% bone loss and is a heavy smoker, what is their grade?

Grade C

What grade is this patient?

- 65 year old with 80% bone loss

- 80/65 = 1.2

Necrotizing periodontal disease

What condition has the following clinical keys?

- Impaired immunity

- Malnutrition

- Stress

- Necrosed/sloughing tissues

- Smell

- Acute onset + painful

Necrotizing periodontal disease

What condition has the following intraoral signs and symptoms?

- Punched-out craterlike depressions at the crest of interdental papillae

- Gray pseudomembranous slough

- Linear erythema

- Hemorrhagic tendency

- Fetid odor, increased salivation

- Extreme sensitivity to touch

- Radiating gnawing pain

- Metallic foul taste

- Pasty saliva

Necrotizing periodontal disease

ID the condition:

Mucogingival conditions

The following is pertinent information to assess what type of conditions?

- Periodontal phenotype (thick/thin)

- Tooth position (B/L, rotated, etc)

- Aberrant frenum

- Vestibular Depth

- Lip Line

- Gingival Pigmentation

- Gingival Excess

- Gingival tissue (probe show through test)

<1mm

According to the probe show-through test, gingival tissue is considered thin if it is <_____mm

>1mm

According to the probe show-through test, gingival tissue is considered thick if it is >_____mm

Mucogingival deformities and conditions around teeth

All of the following fall under what category of conditions?

- Gingival phenotype

- Gingival/soft tissue recession

- Lack of gingiva

- Decreased vestibular depth

- Aberrant frenum/muscle position

- Gingival excess

- Abnormal color

- Condition of the exposed root surface

Lack of attached gingiva

What is a key sign of mucogingival conditions?

Roll test - place probe against mucosa and roll upwards—will fold along mucogingival junction

What is the name of this test that you can do to assess for a mucogingival condition?

c) BOP >10%

What is the bleeding on probing (BOP) threshold for diagnosing gingivitis?

a) BOP > 20%

b) BOP < 15%

c) BOP >10%

d) BOP < 5%

b ) Lack of keratinized tissue

Which of the following is considered a mucogingival deformity?

a) Peri-implant mucositis

b) Lack of keratinized tissue

c) Periodontal abscess

d) Necrotizing periodontal disease

c) Degree of bone loss/attachment

Which of the following is a diagnostic criteria for periodontitis?

a) Periodontal pocket depth

b) Lack of keratinized tissue

c) Degree of bone loss/attachment

d) Suppuration around implants