May 11, 2021
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. Please feel free to send in your questions!
Does a reduced periodontium always indicate periodontitis?
Not necessarily. First, the clinician needs to ensure that he or she can distinguish between a periodontium that is reduced because of disease due to biofilms or predisposing conditions affecting the periodontium. The following criteria will help you distinguish between the two:
Reduced periodontium due to non-periodontitis criteria:
Reduced periodontium due to Periodontitis criteria:
So, 5mm or 6mm pocket depths are not necessarily an indicator of periodontitis, they could be pseudo pockets, just as 4mm pocket depths in the anterior region or molar area of a patient 13 years of age, is not an indicator of just gingivitis. It could be a Grade C periodontitis patient, formally known as aggressive periodontitis. The determining factor if a reduced periodontium is due to periodontitis is if the apical migration of the junctional epithelium is due to or initiated by plaque biofilms or by conditions affecting the periodontium/predisposing factors/ADCs. The only way to determine this clinically is with a comprehensive medical dental history, odontogram, and the appropriate type and number of radiographs to screen for these different types of periodontium’s. Pocket depths alone is not the determining criteria..
Keep in mind, with up to 65 percent of your patients having periodontitis they will probably have a reduced periodontium due to a combination of periodontitis plus conditions affecting the periodontium from years of dental work and/or acquired or developmental deformities or conditions. This is when clinical judgement comes into play.
Are we supposed to stage and grade gingivitis patients?
No; you only stage and grade periodontitis patients. The format of staging and grading to classify periodontitis was a concept adopted from oncology to help dental professionals determine severity, complexity of treatment, disease progression, and the systemic effects of periodontitis. Periodontitis is a disease that once a patient has is it, he or she has it for life. We can’t reverse it or cure it; we can only manage it. Gingivitis, on the other hand, is a disease process we can reverse and cure. So, let’s review how and why staging and grading helps us treat and manage periodontitis.
Staging – The process involves assessing both the severity of disease and complexity of treatment. When determining severity, consider how much attachment loss exists: Slight (Stage 1), moderate (Stage II), severe (Stage III), or advanced (Stage IV). Is there any tooth loss due to periodontitis? If so, severity may increase to Stage III or Stage IV. What is the chance the patient will lose his or her entire dentition because of periodontitis? If it’s possible, then you’re likely at Stage IV.
Complexity of treatment to re-establish health is the second important piece in staging. Severity of such factors as pocket depths, furcations, vertical bone loss, ridge defects, and degree of mobility may increase the patient’s stage and thus the complexity in treatment to re-establish health. For instance, if Class II or III furcations, vertical bone loss greater than or equal to 3mm and or mobility greater than or equal to 2mm exists perhaps both nonsurgical periodontal therapy and surgical periodontal therapy are needed.
Grading – This process exists to help us identify and monitor disease progression in the face of important direct and indirect evidence, plus grade modifiers/risk factors. To assess how quickly a patient’s periodontitis is progressing, use the following guidelines:
Finally, it’s important to understand which grade modifiers/risk factors will impact your patient’s disease progression and grading the most. Consider, for example, the quantity and regularity of smoking or the severity of diabetes. How will those grade modifiers/risk factors affect an individual patient systemically? Will these grade modifiers/risk factors expediate the progression of the patient’s current periodontitis status? If so, how are you going to manage this clinically? Staging and grading offer vital information that will help you design a treatment plan for both short-term and long-term management of periodontitis.
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, entrepreneur of the year, and thought leader for Crest and Oral B, 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 firstname.lastname@example.org or visit www.gemdentalexperts.com.