Classified Information by Drs. Diego Velasquez and Bryan J. Frantz

Categories: Periodontics;
Dentaltown Magazine

What the recent periodontal and peri-implant disease classifications mean for you and your patients

by Drs. Diego Velasquez and Bryan J. Frantz

In 2015, leaders from the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) agreed that they needed to revisit the existing periodontal disease classifications. At the time, the most up-to-date set of classifications had been published in 1999, and a growing body of literature necessitated the inclusion of advancements that were emerging, if not altogether nonexistent, in the late 1990s.

The AAP and EFP held the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions last November, after two years of planning, and more than 100 experts from Europe, Asia, Australia and the Americas gathered in Chicago to develop an evidence-based update to the 1999 classifications. Participants, who were separated into four topical work groups, conducted literature reviews, established case definitions and deliberated diagnostic considerations to account for what the specialty has learned about periodontitis and implant-related conditions in the past 20 years.

The new classifications and their highlights—particularly a new staging and grading system that echoes what is used in oncology—will likely influence various facets of dentistry, including hygiene, education and general clinical practice. Central to this update, of course, is the improvement of patient care.

For restorative practitioners, understanding the new classifications will be key to evaluating patient needs, whether periodontally or with regard to implants. By working together, periodontists and dentists can provide guidance and support to patients who require conventional therapy or more rigorous maintenance.

Here are developments from the updated disease classifications to consider now:

Periodontal health, gingivitis and gingival conditions
The update: The workshop agreed that bleeding on probing should be the primary parameter by which thresholds are set for gingivitis. It defined periodontal health and gingival inflammation in a reduced periodontium after completion of successful treatment of a patient with periodontitis based on bleeding on probing and depth of the residual sulcus/pocket. It was accepted that a patient with gingivitis can revert to a state of health, but a periodontitis patient remains a periodontitis patient for life.

What this means for patient care: Patients successfully treated for periodontal disease need comprehensive maintenance and surveillance. A lifelong support program, executed in tandem by a periodontist and restorative dentist, can prevent recurrence of disease.

New classification of periodontitis
The update: Periodontal diseases are now defined as one of three distinct forms:

• periodontitis (formerly aggressive and chronic),
• necrotizing periodontitis,
• or periodontitis as a manifestation of systemic conditions.

A newly developed, multidimensional staging and grading framework indicates the severity of the disease and the complexity of its treatment (staging), and also incorporates within the diagnosis a systematic assignment of supplemental information about biological features of the patient (grading). This new system mirrors medical models that facilitate development of comprehensive therapy that addresses a patient’s specific needs.

What this means for patient care: Staging and grading allows for personalized patient care, outlined by a systematic approach for treatment planning and monitoring therapy response. Four categories determine the severity of the disease, ranging from Stage I (least severe) to Stage IV (most severe). These are qualified by three levels of grading that consider overall health status and risk factors, such as smoking and metabolic control of diabetes. Grading indicates the risk of disease progression: low risk (Grade A), moderate risk (Grade B) or high risk (Grade C). Disease assessment will not be limited to a recognition of previous damage. With the staging and grading approach, clinicians will be able to identify elements that contribute to disease progression and can potentially magnify the complexity of care in managing periodontal disease.

Systemic diseases associated with loss of periodontal supporting tissues
The update: The updated classification also categorizes conditions that affect periodontal health because of primary systemic disease. One example is Papillon Lefèvre syndrome, which generally results in an early presentation of severe periodontitis.

Common systemic diseases, such as diabetes mellitus, can modify the course of periodontal diseases. Although these modifiers of periodontitis may influence the disease’s occurrence, severity, progression and response to treatment, current evidence does not support a unique pathophysiology in patients with diabetes and periodontitis.

What this means for patient care: Classifying systemic conditions that affect the periodontium can help facilitate diagnosis and multidisciplinary care as needed.

Periodontal developmental and acquired deformities and conditions
The update: Gingival recession based on interproximal loss of clinical attachment is included within the latest classification, and it incorporates the identification of the gingival phenotype (this term is introduced in lieu of periodontal biotype) as well as the assessment of the exposed root and cementoenamel junction.

What this means for patient care: Assessing recession severity, dimension of the gingiva (gingival phenotype), presence or absence of caries and noncarious cervical lesions, aesthetic concerns of the patient, and presence or absence of dentin hypersensitivity will help clinicians formulate an accurate diagnosis and tailor a therapeutic approach that may require interdisciplinary care (e.g., restorative treatment or orthodontic therapy). These therapies may be used in conjunction with surgical periodontal treatment to address the various conditions associated with gingival recession.

A new classification for peri-implant disease and conditions
The update: For the first time, categorizations for peri-implant disease and conditions are included within the updated classification. The update also defines peri-implant health as the absence of visual signs of inflammation and bleeding on probing. The workshop acknowledged that it is not possible to define a range of probing depths compatible with peri-implant health. Peri-implant mucositis is described as a condition strongly associated with plaque where bleeding on probing and visual signs of inflammation are present. This condition is assumed to precede peri-implantitis.

Peri-implantitis is defined as a plaque-associated pathologic condition characterized by inflammation in the peri-implant mucosa in combination with progressive loss of supportive bone. In the absence of treatment, peri-implantitis progresses in a nonlinear and accelerating pattern.

Acknowledgment of hard- and soft-tissue deficiencies associated with healing patterns after tooth loss, extraction trauma, endodontic pathology, injury and others are included within this section of the classification.

What this means for patient care: Just like natural teeth, dental implants are susceptible to inflammation-driven complications that can worsen without proper supervision and care. Periodic assessment of dental implants provides an opportunity to identify and treat implant-related conditions. Clinicians should establish a radiographic and clinical baseline immediately after completion of the prosthetic phase of implant therapy.

Author Bio
Author Diego Velasquez, DDS, MSD, works in private practice in Fenton, Michigan, and is an adjunct clinical assistant professor at the School of Dentistry of the University of Michigan. Velasquez, a diplomate of the American Board of Periodontology, is a member of the peer review panel of the Journal of Periodontology and Clinical Advances in Periodontics and a consultant for the International Journal of Periodontics and Restorative Dentistry. He has published articles about topics related to prosthodontics, periodontics and dental implants, and has lectured internationally. He is past president of the Midwest Society of Periodontology and current vice president of the Michigan Periodontal Association.
Author Bryan J. Frantz, DDS, MS, is a board-certified periodontist in Scranton, Pennsylvania, and vice president of the American Academy of Periodontology. Frantz is also a clinical associate professor at Commonwealth Medical College’s Department of Surgery, Eastman Institute of Oral Health, and at Temple University’s Kornberg School of Dentistry (where he earned his Doctor of Dental Medicine degree). In addition to more than 25 years in practice, he has served as president of the AAP Foundation and president and board chairman of the Scranton District Dental Society.

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