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Technically Speaking: Tips for Implementing the 2018 AAP Periodontal Classification (Part 13)

February 25, 2022
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: What is the easiest way to determine if a reduced periodontium is due to non-periodontitis causes vs. periodontitis causes?

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A: The first clue is your client’s age.  But before I explain further, let’s review the definitions of these two periodontium types.

  • Reduced periodontium due to non-periodontitis causes (non-periodontitis causes also known in the literature as acquired and developmental conditions or pre-disposing factors). Examples include recession due to cervical restorations or trauma, alveolar bone loss due to ortho forces, crown lengthening, vertical bone loss due to open contacts and/or extractions (distal aspect of the second molar due to extraction or malposition of third molar or the distal aspect of any tooth where vertical bone loss may exist), an endodontic lesion draining through the marginal periodontium, the occurrence of a vertical root fracture, etc.1
  • Reduced periodontium due to periodontitis. Loss of the periodontal attachment (alveolar bone loss or detectable clinical attachment loss [CAL]) due to microbially associated, host-mediated inflammation, initiating an inflammatory response.1

So how does knowing the client’s age help you determine if the radiographic findings of a reduced periodontium is due to non-periodontitis causes or periodontitis? The statistics tell us that periodontitis is much more common in clients 30 years and older. In fact, only 13% of individuals under the age of 30 have periodontitis. If you encounter one of these rare cases, chances are the client has a history of tobacco use, uncontrolled diabetes, or some other systemic condition that may be identified through self-reporting on his or her medical dental health history. In the under-30 age range, most cases of a reduced periodontium will be due to a non-periodontitis cause(s) in which you will find evidence in self-reporting or the client’s assessments.

On the flip side, more than 47% of clients 30 years and older have periodontitis (slight – 8.7%; moderate – 30%; advanced to severe – 8.5%). The probability of a client in this age range having a reduced periodontium due to periodontitis is relatively high—almost 50%. There is also a high probability that some non-periodontitis causes may exist, and you should be able to identify those contributing factors in your assessments. It’s safe to assume that the older your patients get, the greater the odds of periodontitis. It’s reported that 65% of the North American population 65 years and older has periodontitis. And in this age range, you will almost always find a reduced periodontium due to periodontitis and non-periodontitis causes in combination. 2,3,4

Finding the Evidence

So how do we get to a definitive diagnosis? These are the steps I expect my practices to follow to identify the mechanisms behind a reduced periodontium:

Medical history. Does your patient report using tobacco products? If so, starting at what age? Do they have uncontrolled diabetes? Does a systemic condition exist that may predispose them to periodontitis?

Dental health history. This is where a client will self-report non-periodontitis causative factors. Be sure to ask such questions as:

  1. Have your teeth changed in the last five years, become shorter, thinner, worn, or darker?
  2. Are your teeth crowding or developing spaces?
  3. Are there areas in your mouth where food gets trapped?
  4. Do you bite your nails or hold foreign objects with your teeth? (i.e., pens, pencils, nails)?
  5. Do you wear or have you worn a night appliance/guard or sports guard?
  6. Have you had orthodontic treatment? If yes, when?
  7. Do you have implants or dentures?
  8. Have you had extractions? When and why?
  9. Have you had any root canals?
  10. Do you clench or grind during the day or been told you do so at night?

Radiographs findings. Radiographs will establish a) if a reduced periodontium exists and b) if the reduced periodontium correlates to non-periodontitis causes like clenching and grinding, bruxism (widened periodontal ligament, mobility), short clinical root to crown length (mobility), short root trunk relationship (furcation involvement), root resorption (ortho forces), defective and iatrogenic restorative dental work, fractured roots, and pulpal pathology c) if the reduced periodontium is due to periodontitis as evidenced by deep, old subgingival calculus, osseous defects, etc.

Periodontal assessments. Do periodontal or pseudo pockets exist? Is there attachment loss as evidenced by CAL, mobility, recession, or marginal attached gingiva caused by biofilms and the host-mediated response?

Hard tissue (odontogram) assessment. Record iatrogenic restorative, missing, impacted, and extracted teeth; super and over eruption; root canal treated teeth and implants; wear facets; attrition; open contacts; tooth rotations and malalignment, which all contribute to a non-periodontitis breakdown. Do these hard tissue findings correlate with the problem areas you identified during the periodontal assessments? They may. If you are unable to see the connection during the client’s initial examination, it may become evident at post care, when another comparison is made.

The assessment evidence should assist in identifying why the periodontium is reduced. But right from “hello,” you should already have a pretty good idea—based on your client’s age—if you will find radiographic evidence of a reduced periodontium due to periodontitis, non-periodontitis causes, or a combination.

References:

  1. 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
  2. Lang NP, Bartold PM. Periodontal health. J Periodontol. 2018;89(Suppl 1): S9–S16. https://doi.org/10.1002/JPER.16-0517
  3. Eke PI, Dye BA, Wei L, Thornton-Evans GO, Genco RJ; CDC Periodontal Disease Surveillance workgroup: James Beck GDRP. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dent Res. 2012;91 (10):914-920.
  4. Holtfreter B, Schwahn C, Biffar R, Kocher T. Epidemiology of periodontal diseases in the Study of Health in Pomerania. J Clin Periodontol. 2009;36:114–123. [PubMed] [Google Scholar][Ref list].

About the Author

A passionate educator with 30+ years of clinical and business experience, Gabriele has revolutionized the way practices optimize client outcomes, growth, and revenue through her consultancy company, GEM Dental Experts Inc. A former practice owner, published author, dental hygiene program director, quality assurance program assessor, and entrepreneur of the year, Gabriele shares her innovative views on dental hygiene through her work as a public speaker, consultant, educator, and business coach for forward-thinking dental practices.  Gabriele can be reached at gem@gemdentalexperts.com or visit www.gemdentalexperts.com.


RELATED ARTICLE: Technically Speaking: Tips for Implementing the 2018 AAP Periodontal Classification (Part 12)


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