staging and grading

Question 1

1999 Classification for Periodontal Diseases and Conditions

stages 1-8

Answer 1

I. Gingival diseases
II. Chronic Periodontitis
III. Aggressive Periodontitis
IV. Periodontitis as a manifestation of Systemic Diseases
V. Necrotizing Periodontal Diseases
VI. Abscesses of the Periodontium
VII.Periodontitis Associated with Endodontic Lesions
VIII.Developmental or Acquired Deformities and Conditions.

Question 2

Periodontitis: Armitage 1999
*Severity of disease based upon?
*Slight:
*Moderate:
*Severe:

Answer 2

*Severity of disease based upon Clinical Attachment Level (Gold Standard)
*Slight: 1‐2 mm
*Moderate: 3‐4 mm
*Severe: ≥ 5mm

Question 3

why change from the 1999 CAL levels

Answer 3

*Few practitioners use clinical attachment level (CAL) routinely
*AAP formed a Task Force in 2015 to identify alternative criteria including
*Radiographic Bone Loss (RBL)
*Probing Depth (PD)
However, a 6 mm probing depth with 20% bone loss is significantly different that 6 mm with 75% bone loss

Question 4

2015 Task Force vs. 2017 Workshop

probing diagnostic? workshop recomendations

Answer 4

*Probing depth not considered diagnostic:
*Inflammation has effect on penetration of probe into tissue
*Inflammation (swelling) may move gingival margin coronally (pseudopocket)

*Workshop Recommendations:
*Use Interproximal Attachment Loss (2 or more non‐adjacent teeth)
*Use probing depth as a ‘complexity’ factor (difficulty of treatment)

Question 5

2017 Classification of Periodontal and Peri‐implant
Diseases and Conditions

Answer 5

*New classification based on strongest current evidence.
*Clarifies ‐Contemporizes

*Adaptive System‐3 dimensional:
*Severity/Extent (number of teeth affected rather than sites)
*Prognosis (affects no teeth, up to 4 teeth, 5 or more teeth)
*Progression (Grading)

Question 6

2017 AAP Classification Rationale for change is to:

Answer 6

*Recognize and monitor systemic influences INFLOWING to Periodontal Disease such as Smoking and Diabetes
*Control Inflammatory and Microbial influences from Periodontal Disease OUTFLOWING to systemic targets to decrease the co‐morbid effect of the periodontal disease

Question 7

2017 Classification of Periodontal and Peri‐implant
Diseases and Conditions

Answer 7

Question 8

Periodontal Diseases And Conditions

Answer 8

Question 9

NHANES 2009‐2014 study results
*% periodontitis
*% severe
*% non‐severe
*Prevalence of non‐severe and total increased with age:
*Greatest in what demographics?
*Prevalence of total disease highest in those who did not?
*Centers for Disease Control and Prevention conclusion?

Answer 9

*10,683 dentate subjects 30 years or older
*42% periodontitis
*7.8% severe
*34.4% non‐severe
*Prevalence of non‐severe and total increased with age
*Greatest amongst men (50.2%), Mexican Americans (59.7%), adults below 100% of Federal poverty level (60.4%), current smokers (62.4%) and self reported diabetes (59.9%)
*Prevalence of total disease highest in those who did not use dental floss or visit dentist regularly
*Centers for Disease Control and Prevention‐approximately 47% of adults >30 years old have periodontitis and this is the primary cause of tooth loss in adults.
SRM

Question 10

intial case review components

Answer 10

FM probing
FMX: diagnostic quality
missing teeth present? why are they missing?

Question 11

Goal of New System
Staging and Grading

Answer 11

*Easy to use
*Should promote better communication (?) with:
*Patient
*Referring dentists, hygienists
*Other health care professionals
*Identify response to treatment

Question 12

AAP 2017 Classification

Answer 12

Staging and Grading
*Every patient categorized based on the worst periodontal site and specific factors that may impact long term management
*Staging is divided into:
*Severity
*Complexity
*Extent and distribution

Question 13

STAGING

Answer 13

*“Staging” (1‐4) based upon severity of disease and complexity of case management

Question 14

staging considerations

Answer 14

*Clinical attachment loss (CAL)‐using worst site
*Amount and % of bone loss
*Probing depth
*Presence/extent of ridge defects and furcation involvement
*Tooth mobility
*Tooth loss (due to periodontitis if known)

Question 15

Criteria for Defining Periodontitis

Answer 15

*Interdental Clinical Attachment Loss at 2 or more non‐adjacent teeth

OR

*Buccal or Oral Clinical Attachment Loss ≥ 3 mm
*with pocketing >3mm on 2 or more teeth

Question 16

Severity based on CAL

stages

Answer 16

Question 17

Caution with CAL, ensure what when it is found? examples?

Answer 17

*Ensure the problem cannot be attributed to non‐periodontal causes such as:
*Gingival recession due to trauma (toothbrush trauma/toothpaste abrasion)
*Dental caries extending to or below the gingival margin
*Defect on distal of 2nd molars caused by malposition or extraction of a 3rd molar
*Endodontic lesion draining through marginal periodontium (deep probing depth)
*Vertical root fracture (usually isolated deep probing depth)

Question 18

Complexity of staging, what is evaluated?

Answer 18

*Takes into account overall probing depths
*Evaluates radiographic bone loss, horizontal and vertical
*Evaluates furcation involvements, number of missing teeth, function

Question 19

Prognosis of tooth loss based upon Staging

Answer 19

Stage I or II: No tooth loss likely
Stage III: Risk of tooth loss (up to 4)
Stage IV: Risk of loss of arch or dentition (>5
teeth)
***Remember tooth loss MUST be due to Periodontitis

Question 20

Complexity factors
(difficulty of successful treatment) stage 1

Answer 20

*Max probing depth ≤ 4 mm
*Mostly horizontal bone loss

Question 21

Complexity factors (difficulty of successful treatment) stage 2
PD
BL

Answer 21

*Max probing depth ≤ 5 mm
*Mostly horizontal bone loss

Question 22

Complexity factors
(difficulty of successful treatment) stage 3
PD
VBL
F
ridge

Answer 22

In addition to Stage IIcomplexity
Probing depths ≥ 6mm
*Vertical bone loss ≥ 3mm
*Class II or III Furcation Involvements
*Moderate ridge defects

Question 23

Complexity factors (difficulty of successful treatment) stage 4

Answer 23

In addition to Stage III complexity Need for complex rehabilitationdue to
*Masticatory dysfunction
*Secondary Occlusal Trauma (≥ 2 mobility)
*Bite collapse, drifting, flaring
*<10 opposing pairs remaining teeth (<20 teeth total)
*Severe ridge defects

Question 24

Stage 1
CAL
BL
tooth loss?
PD

Answer 24

*1–2 mm clinical attachment loss (CAL), less than 15% bone loss (BL) around root, no tooth loss due to periodontal disease, probing depth (PD) 4 mm or less, mostly horizontal BL

Question 25

Stage 2
CAL
BL
tooth loss?
PD

Answer 25

*Stage II (moderate)
3–4 mm CAL, 15%–33% BL, no tooth loss due to periodontal disease, PD 5 mm or less, mostly horizontal BL

Question 26

Stage 3
CAL
BL
tooth loss?
PD

Answer 26

*Stage III (severe with potential for additional tooth loss)
5 mm or more CAL, BL beyond 33%, tooth loss of four teeth or less (due to periodontal disease), with complex issues such as PD 6 mm or more, vertical BL 3 mm or more, Class II–III furcations, and/or moderate ridge defects

Question 27

Stage 4

Answer 27

*Stage IV (severe with potential for loss of dentition)
Encompasses all of Stage III with additional features that will require the need for complex rehabilitation due to masticatory dysfunction, secondary occlusal
trauma, severe ridge defects, bite collapse, pathologic migration of teeth, less than 20 remaining teeth (10 opposing pairs)

Question 28

Tooth Loss due to Periodontitis (if known) staging

Answer 28

*No tooth loss = Stage I or II
≤ 4 teeth = Stage III
≥5 teeth = Stage IV
*Trump cards
*if lost ANY teeth due to periodontitis, then automatically Stage III or IV

Question 29

Furcation Involvement

Answer 29

Trump card
*Furcation involvement of Grade 2 or 3 automatically puts patient into Periodontitis Stage 3 or 4 (Severe or Very Severe)

Question 30

EXTENT AND DISTRIBUTION
(Added to Stage as a Descriptor)

Answer 30

Concept is to know percentage of teeth affected by periodontitis of ANY Stage
*1. Localized—Bone Loss involves less than 30% of teeth in mouth
*2. Generalized—Bone Loss involves more than 30% of teeth in mouth
*3. Molar‐incisor—BL is found around molar (usually first) and anterior incisors

Question 31

Molar/Incisor pattern

Answer 31

generally applies to ‘old’ classifications of:
*Localized Aggressive Periodontitis which was known before that as
*Localized Juvenile PeriodontitisNow Stage III Grade C

Question 32

GRADING
Considers biological features:

Answer 32

*RATE of disease progression
*Risk for further advancement
*Potential threats to general health (including smoking, diabetes)
*Response to standard therapy

Question 33

grades

Answer 33

*A: Low risk of progression
*B: Moderate risk of progression
*C: High risk of progression
*Initially assume Grade B then seek specific evidence to shift to Grade A or C

Question 34

Grading‐Primary Criteria
direct evidence

Answer 34

historical radiographic bone loss or clinical attachment loss (progression of either)

Question 35

Grading‐Primary Criteria
2. Indirect Evidence

Answer 35

*% bone loss/patient age
*Case Phenotype (Soft tissue thickness, bone thickness)
*Heavy plaque accumulation but minimal destruction vs. minimal plaque but major destruction

Question 36

grading with bone loss

Answer 36

*No loss over 5 years (Grade A)
*< 2mm loss over 5 years (Grade B)
*> 2mm over 5 years (Grade C)

Question 37

Calculation for bone loss percentage ÷ Age

Answer 37

Question 38

Grading
Modifiers (RISK factors)

Answer 38

Smoking and Diabetes
Grade A: Slow rate: Nonsmoker, nondiabetic

Grade B: Moderate rate: < 10 cigarettes/day
Diabetic with HbA1c <7%

Grade C: Rapid rate: ≥ 10 cigarettes/day, Diabetic with HbA1c ≥ 7%