9 minute read
Brush up on Perio
We examine the new periodontitis classification system and talk to the experts who are using it
By Margaret Galvin
TO FULLY UNDERSTAND the new Periodontitis Classification System it is worth taking a moment to appreciate it’s history and why an update was needed. The 1999 classification system of periodontitis was based on research that emphasised the individual features of periodontitis, and therefore the differences in phenotype. The research impacted the 1999 classification system, and thus four different periodontitis phenotypes were recognised: 1. Necrotising periodontitis 2.Chronic periodontitis 3.Aggressive periodontitis 4.Periodontitis as a manifestation of systemic diseases
As more research in the field has been carried out it has been found that the original classification system has a few issues that include:
• No clear communication regarding the differences between chronic and aggressive periodontitis
• Difficulty applying the criteria of aggressive periodontitis in everyday clinical practice
• A substantial overlap between the diagnostic categories
• A lack of validity of the criteria for aggressive periodontitis being confirmed by well-designed studies
• A classification system based purely on the severity of the disease failing to capture the complexity of the case
The 2017 World Workshop was held to develop a new classification scheme for periodontal and peri-implant disease and conditions so that clinicians can properly diagnose and treat patients.
The new system allows scientists and researchers to investigate aetiology, pathogenesis, natural history, and treatment.
In accordance with current knowledge, the new classification system recognises three forms of periodontitis: 1. Necrotising periodontitis 2. Periodontitis manifested by systemic diseases 3.Periodontitis (formerly ‘chronic’ and ‘aggressive’, now combined)
The World Workshop also agreed on a classification system based on a ‘staging’ and ‘grading’ framework that is able to be adapted as new evidence emerges.
THE NEW SYSTEM A brief overview
STAGING
The ‘staging’ portion of the classification framework depends on the severity of disease at presentation as well as on the complexity of disease management. It is divided into four categories as follows:
• Stage I – Initial Periodontitis
• Stage II – Moderate Periodontitis
• Stage III – Severe Periodontitis with potential for additional tooth loss
• Stage IV – Severe Periodontitis with potential for loss of the dentition.
The staging category is determined after considering clinical attachment loss; amount and percentage of bone loss; probing depth; presence and extent of angular bony defects; furcation involvement; tooth mobility; and tooth loss due to periodontitis.
GRADING
The ‘grading’ provides supplemental information about biological features of the disease. This includes a historybased analysis of how fast the disease is progressing, assessment of risk for further progression, predicted poor outcomes of treatment, and assessment of the risk that the disease, or its treatment, may negatively affect the general health of the patient. It is divided into three separate grades: >
• Grade A – slow rate of progression
• Grade B – moderate rate of progression
• Grade C – rapid rate of progression
Grading incorporates elements related to periodontitis progression, general health status, and other risk factors such as smoking or level of metabolic control in diabetes. The addition of grading allows the clinician to add individual patient factors into the diagnosis, thus allowing them to comprehensively manage a periodontitis case.
Another benefit of the new classification system is the ability of the diagnosing clinician to factor in the element of ‘complexity.’ Factors such as masticatory dysfunction, bite collapse, drifting, and flaring all contribute to the complexity of a periodontitis case and thus, should be included in the diagnosis to allow for better treatment planning.
IMPLANTS
A new classification system was developed for peri-implant health and a consensus was reached on the following case definitions:
• Peri-Implant Health – characterised by an absence of bleeding on probing and inflammation. It can exist around implants with normal or reduced bone support, however it is not possible to define a range of probing depths
• Peri-Implant Mucositis – characterised by bleeding on probing and visual signs of inflammation. • Peri-Implantitis – characterised by inflammation in the peri-implant mucosa, and subsequent gradual loss of supporting bone
• Peri-Implant Soft and Hard Tissue Deficiencies – The alveolar process/ ridge can be diminished through tooth loss. This can cause hard and soft tissue deficiencies. Medications and systemic diseases can also have an effect on the ridge
At first, the new periodontitis classification system is daunting. There are many factors that were not previously included in the diagnosis of periodontitis. Having said that, a system that includes the elements that affect the disease process makes it easier to diagnose, treatment plan, carry out research, and look at overall population health.
Further reading
Given the complexity of the subject this article can only be a very limited overview of the new periodontitis classification scheme. The information has been gleaned from the following articles so you can perform your own research as required.
Staging and Grading of Periodontitis
Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. J Clin Periodontol. 2018;45(Suppl 20): S149–S161. https://doi. org/10.1111/ jcpe.12945
Periodontital Classification
Caton J, Armitage G, Berglundh T, et al. A new classification scheme for periodontal and peri- implant diseases and conditions – Introduction and key changes from the 1999 classification. J Clin Periodontol. 2018;45(Suppl 20): S1–S8. https://doi.org/10.1111/jcpe.12935 Flowcharts can be downloaded from the British Society of Periodontology website
PDF Reading
Other helpful links include:
• 2017 World Workshop: Periodontal Health PDF – https://dhaa.info/wp-content/uploads/2018/08/Periodontal-Health.pdf
• 2017 World Workshop: Peri-implant Health PDF – https://dhaa.info/wp-content/uploads/2018/08/Peri-Implant-Health.pdf
• 2017 World Workshop: Peri-implant health, peri-implant mucositis, and peri-implantitis – Case definitions and diagnostic considerations PDF – https://dhaa.info/wp-content/uploads/2018/08/Case-Definitions-and-Diagnostics.pdf
• 2017 World Workshop: Dental plaque–induced gingival conditions PDF – https://dhaa.info/wp-content/uploads/2018/08/Case-Definitions-and-Diagnostics.pdf
Tips and tricks
Flowchart: One of the easiest ways to use the new classification framework is as a flowchart (see above). Here is an example that you can download from the British Society of Periodontology
Smartphone App: If you’re someone who likes to reference an app then just enter “Dr Peter Fritz” into the search function of wherever you download your apps, and you’ll find an easy to use tool to assist in your periodontal classifications.
Using the new system Nafeena Feroz: General and Paediatric Dental Clinic
Do you work in a general or specialist practice?
I have worked in a general practice since December 2017 after graduating.
How long have you been using the new periodontal classification?
It was released towards the end of my program and due to the update coinciding with finals, the concept was not heavily emphasised. After graduation the update was used minimally until recently in the last two or three months.
What training did you receive or study did you carry out to educate yourself on the new periodontal classifications?
No official training was provided. I learnt the new classification through the links provided on the American Association of Periodontology (AAP) and the supplemental information that was provided with the new staging and grading of periodontal disease. It took a few days to completely grasp the concept and implementation of the new classification has been difficult due to the time restraints that are present in private general practices.
How did you find the transition from the old classification?
The transition has been challenging, and not only due to the lack of time. The limited understanding and confidence in my knowledge of the parameters of the new classification has also made it tough to properly calculate the right classification. Another issue is the communication with other practitioners who have not updated themselves with the new classification and continue to use the old system. Without a consistent language there are ongoing implications that impact the communication with the patient.
Does the new classification help to provide better diagnosis and treatment?
The updated classification provides a more holistic approach to patient management and for understanding the progression of the disease. Unlike the original, the new classification takes patient factors into consideration that may influence the progression of the disease – directly or indirectly. This makes it easier to analyse if a patient is a high or low risk, and allows for their treatments and review intervals to be planned accordingly for more favorable outcomes. The new classification also breaks the disease down into stages with specific parameters, making it easier to track disease progression or improvement. By having theses stages, clinicians can have a better view of the disease as a whole rather than a blanket descriptor for disease classification.
Do you agree with the new classifications and are there any changes you would like to see in the next update?
Due to the limited use of the new classification I cannot say what I would like to have changed. With more use it will be easier to identify what works and what parts require further modification. Although the new system is more detailed and mildly more complex than original classification, I do agree with the new update and the parameters included.
Using the new system Carol Tran: Specialist practice
Do you work in a general or specialist practice?
I work in specialist practice, where we’ve been using the new classification since it was released at Europerio in July 2018.
What training did you receive or study did you carry out to educate yourself on the new periodontal classifications?
The main training was from the lecture that I attended explaining the new classification, I followed this up with reading the published journal articles, websites and attending additional lectures. In total, I probably put in about 20 hours educating myself on the new classification and reviewing the evidence for it. I also presented a lecture for DHAA Qld members at our annual CPD day in March 2018.
How did you find the transition from the old classification?
While the old classification had its benefits, the new classification is easier to explain to patients. The old classification could be rather subjective. For example, the definition between ‘mild’ and ‘moderate’ required the art of interpretation from the clinician and patient.
Does the new classification help to provide better diagnosis and treatment?
Yes, as it’s grading and staging, it is easier for patients to understand the severity of their disease on a defined scale. It helps patients accept their diagnosis and treatment plans.
Do you agree with the new classifications and are there any changes you would like to see in the next update?
It took me a while to accept the new classifications as it was initially presented as a ‘way to help researchers to report incidences on a population scale’ rather than for day-to-day use in the practice as a clinician. But since adopting the new approach the patients do seem to take the severity and extent of their disease more seriously.
For the next update, I would be keen to see:
1. The grade modifier of ‘smoking < 10 cigarettes/daily = moderate rate, grade B’ to just ‘smoking = rapid rate, grade C’. Smoking is smoking.
2. Remove the ‘tooth loss’ criteria - patients rarely remember how they lost their teeth progressively; especially if it was perio or caries or etc.
3. Emphase in stage IV, patients will probably need to have a pros/ restorative treatment plan due to a collapsing occlusion.
