STAGING AND GRADING IN PERIODONTITIS.pptx

SAMANVI BADRI
1ST YEAR POST GRADUATE
DEPARTMENT OF PERIODONTOLOGY
STAGING AND
GRADING IN
PERIODONTITIS

Table of contents
 Introduction
• What is classification?
• Importance of classification?
• Characteristic features of classification
• Need for classification
 Historical aspects of classification
 Classification of periodontal diseases
 Limitations of 1999 classification
 2017 Classification
• Periodontal health, Gingivitis, and gingival conditions

• Periodontitis
NECROTIZING PERIODONTAL DISEASES
PERIODONTITIS AS A MANIFESTATION OF SYSTEMIC DISEASES
STAGING & GRADING
 Clinical Note Template: Six Essential Steps
 Diagnosis statement
 Prognosis
 Periodontitis: clinical decision tree for staging and grading
 Preparing the treatment plan
 Guideline on treatment of Stage I – IV Periodontitis
 Benefits of 2017 classification
 Drawbacks of 2017 classification
 Key points to keep in mind
 Conclusion
 References

WHAT IS A CLASSIFICATION ?
A classification of disease can be defined
as a system of categories to which morbid
entities are assigned according to
established criteria
(ICD vol-2, 2008)
INTRODUCTION

IMPORTANCE OF CLASSIFICATION ?
• Helps the clinician for Diagnosis, prognosis and treatment
planning

CHARACTERISTICS OF A CLASSIFICATION
SYSTEM ?
 It should have a suitable organizing principle matching the nature
of the disease being classified
 Every disease must fall into at-least one of the class
 No disease should fall into more than one class
 Simpler the classification, easier to remember and apply

NEED FOR CLASSIFICATION SYSTEM ?
 Helps to form a foundation to study the etiology, susceptibility
traits, natural history, pathogenesis and treatment of diseases
and conditions in an organized manner
 For diagnosis , prognosis and treatment planning
 Helps us to communicate with other clinicians, researchers,
educators, students, epidemiologists and public health workers
 Assemble similar disease phenotype in more homogenous
syndromes
Critical Evaluation of the 2017 Classification of Periodontaland Peri-implant diseases and Conditions – An Update

HISTORICAL ASPECTS
 GIROLAMO CARDANO (1501-1576) --- 1st person
to differentiate periodontal disease
 FAUCHARD (1723) --- 1st specific term SCURVY OF
THE GUMS

 HUNTER( 1771 ) --- stated that “inflammatory process
in gingiva as an important factor in the dissolution of
alveolar bone”
 JOHN RIGGS (1875) ---
Riggs disease
Father of periodontology
1st practitioner to limit treatment to periodontal diseases

Dominant paradigms in the historical development
of classification system :
PARADIGM - 1
PARADIGM - 2
PARADIGM - 3
To provide maximum assistance in diagnosis and treatment planning, the
classification of periodontal diseases has evolved through three dominant
paradigms:
Clinical features
(1870-1920)
Infectious Etiology
(1970-present)
Pathologic changes
(1920-1970)

CLASSIFICATION OF PERIODONTAL DISEASES
Classification systems should be seen as dynamic and adaptable constructs, open to
modification as our understanding and knowledge evolve.

"The Evolution of
Periodontal
Disease
Classification"
undergone significant changes over time
as our understanding of the disease
process has advanced

LIMITATIONS OF 1999 CLASSIFICATION
• Understanding of periodontal disease is not complete enough to base our classification on etiology.
• The 1999 classification system depends upon assessing the rate of progression spread over multiple
appointments in order to diagnose aggressive periodontitis. It is not possible for patient to repeat
clinical visits just to place him/her under a specific disease entity such as aggressive or chronic
periodontitis.
• Extremely complex and difficult for clinical application
• In spite of rapid advancement in the field of implantology, there is no provision in the classification for the
diseases around implants, leaving a significant void (Armitage, 1999; Devi and Pradeep, 2009)
• All the risk factors are not considered, e.g., smoking and diabetes
Flemingson J. Lazarus et al Periodontal Disease Classification:Controversies, Limitations and the Road Ahead- A Proposed New Classification
Journal of the International Academy of Periodontology 2012 14/4:84- 90.

• widely used for almost 20 years
• During this period, advanced technologies and emerging evidence provided
a better understanding of periodontal and peri-implant diseases, leading to
an update in classification in the 2017 World Workshop.

2017 World Workshop on the Classification of
Periodontal and Peri-implant Diseases and
Conditions
• Co‐sponsored by the American Academy of Periodontology
(AAP) and the European Federation of Periodontology (EFP) to
establish an evidence-based, universally accepted
knowledge framework for a revised, global classification that
can be applied by oral health professionals WORLDWIDE
Jack G. Caton , Gary Armitage , Tord Berglundh, Iain Chapple, Soren Jepsen , Kenneth S. Kornman et al . A new classification scheme for periodontal
and peri implant diseases and conditions – key changes from 1999 classification. J Clin Periodontol2018;45:s1-s8

• Held in Chicago on November 9 to 11, 2017
• Involved 130 experts and review authors
who reviewed the scientific evidence to
update the classification scheme
• Published in 2018 in Journal of periodontology

• "The AAP and EFP jointly formed an organizing committee that commissioned 19
review papers and four consensus reports to address various aspects of
periodontology and implant dentistry."

HIGHLIGHTS OF 2017 CLASSIFICATION

I . PERIODONTAL HEALTH , GINGIVITIS , AND GINGIVAL CONDITIONS –
(Iain chapple, Mealey et al. 2018 …. Trombelli et al. 2018)
1.Periodontal health and gingival health (Lang & Bartold 2018)
a) Clinical gingival health on an intact periodontium
b) Clinical gingival health on a reduced periodontium
i) Stable periodontitis patient
ii) Non-periodontitis patient (Recession, Crown lengthening)
“Bleeding on probing” is the key factor for determining
gingivitis thresholds

 HEALTH --- state of complete physical, mental and
social well-being and not merely the absence of disease
or infirmity (WHO 1948)
 The definition of periodontal health is stated in 2017
classification
 Periodontal health is used to depict the state of
inflammation tissue free from any inflammatory disease
that can cause destruction of periodontal support
Lang, NP, Bartold, PM. Periodontal health. J Periodontol. 2018; 89(Suppl 1): S9–S16.

The periodontal health is divided into 4 levels based on the
state of the periodontium:
(1) Pristine periodontal health
(2) Clinical periodontal health
(3) Periodontal disease stability
(4) Periodontal disease remission/control

Pristine Periodontal Health :
• No bleeding on probing and no anatomical loss of periodontal structures, no
sulcular probing>3 mm, no redness, clinical swelling/edema, or pus.
• Not likely to be observed clinically
Clinical Periodontal Health :
• Characterized by an absence or minimal levels of clinical inﬂammation in a
periodontium with normal support
• Clinical health can be restored following treatment of gingivitis and periodontitis

Determinants of clinical periodontal health
A. Microbiological Determinants of Clinical Periodontal Health :
• Supragingival plaque composition
• Subgingival biofilm composition
B. Host Determinants of Clinical Periodontal Health:
1. Local predisposing factors 2. Systemic modifying factors
• Periodontal pockets Host immune function
• Dental restorations Systemic health
• Root anatomy Genetics
• Tooth position and crowding
C. Environmental Determinants of Clinical Periodontal Health:
Smoking ---- Medications ---- Stress ---- Nutrition

Periodontal disease stability:
state in which periodontitis has been successfully treated through control of local and systemic
factors, resulting in minimal BoP, optimal improvements in PPD and attachment levels, and a
lack of progressive destruction ----- is a reduced periodontium

Periodontal disease remission/control:
• Period in the course of disease during which treatment has resulted in reduction (although not
total resolution) of inflammation and some improvement in PPD and attachment levels, but not
optimal control of local or systemic contributing factors.
• Periodontal disease stability and periodontal disease remission/control are differentiated
based on the ability to control modifying factors and therapeutic response
• Stability is characterized by minimal inﬂammation and optimal therapeutic response, with control
of modiﬁable risk factors; it is a MAJOR TREATMENT GOAL FOR PERIODONTITIS

2.Gingivitis: Dental biofilm induced (Murakami et al 2018)
a) Associated with dental biofilm alone
b) Mediated by systemic or local risk factors
c) Drug influenced gingival enlargement

3.Gingival diseases: Non-dental biofilm induced (Holmstrup
et al 2018)
a) Genetic/developmental disorders
b) Specific infections
c) Inflammatory and immune conditions
d) Reactive processes
e) Neoplasms
f) Endocrine, nutritional & metabolic diseases
g) Traumatic lesions
h) Gingival pigmentation

Patient with gingivitis can revert to a state of health,
but a periodontitis patient remains a periodontitis
patient for life, even following successful therapy,
and requires life‐long supportive care to prevent
recurrence of disease.

II . PERIODONTITIS – (Papapanoau, sanz et al. 2018 … Jepsen, Caton et al. 2018 ….
Tonetti, Greenwell, Kornman et al. 2018)
FORMS OF PERIODONTITIS (BASED ON PATHOPHYSIOLOGY)
1. Necrotizing Periodontal diseases
(Herrera et al. 2018)
a) Nectrotizing gingivitis
b) Necrotizing periodontitis
c) Necrotizing stomatitis

Necrotizing periodontal diseases are characterized by three typical clinical features :
1. Papilla necrosis
2. Bleeding
3. Pain
Papapanou, PN, Sanz, M, et al. Periodontitis: Consensus report of Workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri-
Implant Diseases and Conditions. J Periodontol. 2018; 89(Suppl 1): S173–S182.

Necrotizing gingivitis --- an acute inflammatory process of the gingival tissues
characterized by presence of necrosis/ulcer of the interdental papillae, gingival
bleeding, and pain.
Other signs/symptoms associated with this condition --- halitosis, pseudo-
membranes, regional lymphadenopathy, fever, and sialorrhea (in children).

Necrotizing periodontitis --- an inflammatory process of the periodontium
characterized by presence of necrosis/ulcer of the interdental papillae, gingival
bleeding, halitosis, pain, and RAPID BONE LOSS!!!
Other signs/symptoms associated with this condition --- pseudo-membrane
formation, toothloss, lymphadenopathy, and fever.

Necrotizing stomatitis --- a severe inflammatory condition of the periodontium and
the oral cavity in which soft tissue necrosis extends beyond the gingiva and bone
denudation may occur through the alveolar mucosa, with larger areas of osteitis and
formation of bone sequestrum.
• Occurs in severely systemically compromised patients

2. Periodontitis as a manifestation of systemic disease (Jepsen, Caton et al.
2018) (Albandar et al. 2018)
Classification of these conditions should be based on the primary systemic disease
according to the International Statistical Classification of disease and Related Health
Problems (ICD)
1° Systemic & 2° Periodontal manifestation

Non-necrotizing periodontitis without
rare immune disorders should be
diagnosed as “PERIODONTITIS”

WHAT IS PERIODONTITIS?
Periodontitis is a chronic multifactorial inflammatory disease associated with
dysbiotic plaque biofilms and characterized by progressive destruction of the
tooth-supporting apparatus.

MAIN FEATURES THAT IDENTIFY PERIODONTITIS?
• Loss of periodontal tissue support due to inflammation is the main feature of
periodontitis.
• Clinically, a threshold of interproximal clinical attachment loss (CAL) of ≥2mm
at ≥2 non-adjacent teeth --- is commonly used for diagnosis.
• Buccal or oral CAL at-least 3mm with pocketing ≥ 3mm --- Diagnostic feature
• Radiographic assessments of bone loss confirm interproximal tissue loss.
• Bleeding on probing >10%, probing depths (commonly ≥4mm and ≥6mm)

CAL cannot be ascribed to non-periodontal causes such as:
1) Gingival recession of traumatic origin
2) Dental caries extending in the cervical area of the tooth
3) The presence of CAL on the distal aspect of a second molar
and associated with malposition or extraction of a third molar
4) An endodontic lesion draining through the marginal
periodontium
5) The occurrence of a vertical root fracture.

KEY ELEMENTS IN THE NEW CLASSIFICATION OF
PERIODONTITIS?
• SEVERITY : Degree of periodontal breakdown
• EXTENT : Number and distribution of teeth with detachable breakdown
• COMPLEXITY OF MANAGEMENT :
- Probing depths
- Type of bone loss
- Furcation lesions
- Tooth mobility
- Missing teeth
Tonetti MS, Greenwell H,Kornman KS. Staging and grading of periodontitis:Framework and proposal of a new classification andcase definition.J Periodontol.
2018;89(Suppl 1):S159–S172.

• RATE OF PROGRESSION
• RISK FACTORS : SMOKERS ---- DIABETES
2018;89(Suppl 1):S159–S172.

FRAMEWORK FOR DEVELOPING A
PERIODONTITIS STAGING AND GRADING SYSTEM
The framework of stages and grades was
inspired by a system widely used in
ONCOLOGY, which :
 Individualises the diagnosis and the case
definition of a periodontitis patient and aligns it to
the principles of personalised medicine
2018;89(Suppl 1):S159–S172.

3. Periodontitis (Fine et al. 2018) (Needleman et al. 2018) (Billings et al. 2018)
a) Stages : Based on severity and complexity of management
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 dentition

b) Extent and distribution
Localised (<30% teeth)
Generalised (>30% teeth)
Molar –incisor distribution
c) Grades
Grade A --- Slow rate of progression
Grade B --- Moderate rate of progression
Grade C --- Rapid rate of progression

STAGING :
Goals
 Helps to classify severity and extent of an individual based on currently measurable
extent of destroyed and damaged tissue attributable to periodontitis
 Assess the complexity -- by assessing specific factors that may determine complexity of
controlling current disease and managing long-term function and esthetics of the
patient's dentition
2018;89(Suppl 1):S159–S172.

• Helps to guide treatment strategies based on the stage of
periodontitis.
• Serves to optimize individual patient management.
• It contributes to personalized care or precision medicine.
• This approach enhances the tailored and effective treatment of
periodontitis.
2018;89(Suppl 1):S159–S172.

2018;89(Suppl 1):S159–S172.

STAGE I ---- Initial Periodontitis
• Marks the transition between gingivitis and more advanced periodontitis, characterized by
early attachment loss
• It results from persistent gingival inflammation and biofilm dysbiosis
• Patients are more susceptible to disease onset at a young age
• Early diagnosis in these patients offers opportunities for timely intervention and monitoring.
• Traditional periodontal probing may not be accurate for early diagnosis; alternative methods
like salivary biomarkers and advanced imaging technologies can enhance early detection.
2018;89(Suppl 1):S159–S172.

 Interdental CAL = 1 – 2mm
 RBL = coronal third <15%
 No loss of tooth
 Max. PD = ≤4mm
 Mostly horizontal bone loss
 Describe the extent – Loc.
/Gen. /MI

STAGE II ---- Moderate Periodontitis
• Signifies established periodontal damage
• Diagnosis is based on careful clinical examination.
• Standard treatment principles, including bacterial removal and monitoring, are effective for
many cases.
• Monitoring treatment response is crucial at this stage.
• Case grading help determine if more intensive management is needed for specific patients.
• The focus is on arresting disease progression during this stage.
2018;89(Suppl 1):S159–S172.

 Interdental CAL = 3– 4mm
 RBL = coronal third 15% -
33%
 No loss of tooth
 Max. PD = ≤ 5mm
 Mostly horizontal bone loss
/Gen. /MI

STAGE III ---- Severe periodontitis with potential for
additional tooth loss
• Involves significant damage to the tooth's attachment apparatus
• Without advanced treatment, tooth loss is a risk at this stage
• Characterized by deep periodontal lesions extending to the middle of the root
• Complications may include deep intra-bony defects, furcation involvement,
history of tooth loss, and localized ridge defects
• Despite the risk of tooth loss, masticatory function is typically preserved.
• Treatment focuses on managing periodontitis and doesn't require complex
functional rehabilitation.
2018;89(Suppl 1):S159–S172.

 Interdental CAL =≥ 5mm
 RBL = Extending to the
middle third of the root
and beyond
 Tooth loss due to
periodontitis ≤ 4teeth
 Max. PD = ≥ 6mm
 Vertical bone loss ≥ 3mm
 Furcation = class II/III
 Moderate ridge defect
/Gen. /MI

STAGE IV ---- Severe periodontitis with potential for
loss of dentition
• An advanced stage with considerable damage to tooth support
• Often results in significant tooth loss and loss of masticatory function.
• Deep periodontal lesions that extend to the root apex, a history of multiple
tooth loss, and tooth hypermobility are common characteristics.
• Management frequently involves stabilizing and restoring masticatory
function, addressing secondary occlusal trauma, and dealing with the
consequences of tooth loss, such as bite collapse and drifting.
2018;89(Suppl 1):S159–S172.

 Interdental CAL =≥ 5mm
 RBL = Extending to the
middle third of the root
and beyond
 Tooth loss due to
periodontitis ≥ 5teeth
 Max. PD = ≥ 6mm
 Vertical bone loss ≥ 3mm
 Furcation = class II/III
 Severe ridge defect
 Bite collapse, drifting,
flaring
 <20 remaining teeth
 2° occlusal trauma / G-II
mobility
/Gen. /MI

GRADING :
Goals
 Evaluate the future risk of periodontitis progression and response to standard
treatments to determine the appropriate level of therapy and monitoring.
 Estimate the potential impact of periodontitis on overall health and consider systemic
disease associations, guiding monitoring and collaboration with medical colleagues
when necessary.
Tonetti MS, Greenwell H,Kornman KS. Staging and grading of periodontitis:Framework and proposal of a new classification andcase definition.J Periodontol. 2018;89(Suppl
1):S159–S172.

• Addition of grade (A, B, or C) refines the individual's stage definition
• Grades signify varying rates of periodontal breakdown and control of risk factors
• Relies on:
- the rate of disease progression – recognised risk factors for periodontitis progression –
risk of the individuals case affecting the systemic health of the subject
• Grading is based on direct or indirect evidence of periodontitis progression.
• Direct evidence comes from longitudinal observations ex. X -rays, while indirect
evidence uses age-related bone loss as a reference.
1):S159–S172.

• Clinicians assume a moderate rate of progression (grade B) and consider
risk factors that may modify the grade independently.
• Risk factors --- poorly controlled diabetes/ smoking can shift the grade to
a HIGHER VALUE
1):S159–S172.

GRADE A
 Slow progression
 No bone loss or CAL over five years
 No smoking
 No diabetes
 Heavy biofilm with low levels of tissue destruction.

GRADE B
 Moderate progression
 Less than 2mm bone loss or CAL over five years
 Half pack or less per day smoking
 HbA1c < 7 %
 Biofilm commensurate with destruction.

GRADE C
 Rapid progression
 Greater than 2mm of bone loss or CAL over five years
 Half pack or more per day smoking
 HbA1c 7% or higher
 Tissue destruction exceeds amount of biofilm.

Clinical Note Template:Six EssentialSteps
1) Determine type of periodontal disease : is the bone loss due to periodontitis?
2) Disease extent :
• Localised (up to 30% of teeth)
• Generalised (more than 30% of teeth)
• Molar/incisor pattern.
Das, Neelam. (2021). Critical Analysis of AAP 1999 and 2017 the World Workshop Classification Systems: An Insight. 6. 304-
312. 10.36348/sjodr.2021.v06i07.004.

3) Stage : how severe is the bone loss?
• Stage I (early/mild)
• Stage II (coronal third of root)
• Stage III (mid third of root)
• Stage IV (apical third of root)
4) Grade : how susceptible is my patient?
• Is the maximum amount of bone loss more than
my patient’s age (grade C)
• Is the bone loss less than half the patient’s age
(grade A)?
• Anything else is grade B.
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5) Current disease status :
• Stable = health/successfully treated patient
• Disease remission = recurrent gingival inflammation (BOP ≥10%) --- PPD≤4mm
• Unstable = recurrent periodontitis with bleeding at sites ≥4mm or any PPD ≥5 mm
6) Lifestyle risk factor profile :
• Smoking
• Diabetes
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DIAGNOSIS STATEMENT
EXTENT – PERIODONTITIS – STAGE – GRADE – STABILITY – RISK FACTORS
e.g.: GENERALISED PERIODONTITIS STAGE 3 GRADE B –
CURRENTLY UNSTABLE – SMOKER 15/DAY
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PROGNOSIS
Frequently Asked Questions on the 2018 Classification of Periodontal and Peri-Implant Diseases and Conditions - AAP
• STAGE I PERIODONTITIS (MILD DISEASE)
 PD ≤4 mm
 CAL ≤1-2 mm
 Horizontal bone loss
 Will require non-surgical treatment
 No post-treatment tooth loss is expected
• STAGE II PERIODONTITIS (MODERATE DISEASE)
 PD ≤5 mm
 CAL ≤3-4 mm
 horizontal bone loss
 Will require non-surgical and surgical treatment.
 No post-treatment tooth loss is expected
GOOD PROGNOSIS GOING
INTO MAINTENANCE.

• STAGE III PERIODONTITIS (SEVERE DISEASE)
 PD ≥6 mm, CAL ≥5 mm
 vertical bone loss and/or furcation involvement of Class II or III --- surgical
+ possibly regenerative treatments.
 There is the potential for tooth loss from 0 to 4 teeth.
 The complexity of implant and/or restorative treatment is increased
 The patient may require multi-specialty treatment.
• STAGE IV PERIODONTITIS (VERY SEVERE DISEASE)
 PD ≥6 mm, CAL ≥5 mm
 vertical bone loss and/or furcation involvement of Class II or III.
 The potential for tooth loss of 5 or more teeth
 Advanced surgical treatment and/or regenerative therapy may be
required, including augmentation treatment to facilitate implant therapy.
 Very complex implant and/or restorative treatment may be needed.
 The patient will often require multi-specialty treatment.
FAIR PROGNOSIS GOING INTO
MAINTENANCE
QUESTIONABLE PROGNOSIS
GOING INTO MAINTENANCE

PERIODONTITIS: CLINICAL
DECISION TREE
FOR STAGING AND GRADING
– Guidancefor clinicians

STEP 2 : PATIENT SUSPECTED OF PERIODONTITIS

STEP 3a : PATIENT IS A PERIODONTITIS CASE WHOSE STAGE NEEDS TO BE
ESTABLISHED

STEP 3b: STAGES III AND IV VERSUS I AND II

STEP 3C : STAGES I, II, III, AND IV

STEP 4a : GRADING WHEN THERE ARE NO EXISTING RECORDS

STEP 4b : GRADING WHEN THERE ARE EXISTING RECORD

PREPARING TREATMENTPLAN
MILD TO MODERATE
PERIODONTITIS
STAGES 1 & 2
GRADE A
STANDARD PERIODONTAL
TREATMENT

PREPARING TREATMENTPLAN
SEVERE PERIODONTITIS
STAGES 3 & 4
GRADE B/C
COMPLEX
PERIODONTAL
TREATMENT
COMPLEX
MULTIDISCIPLINARY
TREATMENT

GUIDELINE ON TREATMENT OF STAGE I-III
PERIODONTITIS
• The EFP published the first formal evidence-based guideline, for treating stages I to
III of periodontitis, in July 2020 in the Journal of Clinical Periodontology
• It contains 62 evidence-based recommendations on different therapies
• The guideline is the product of Perio Workshop 2019, the scientific meeting held by
the EFP in November 2019 in La Granja, Spain, where 90 experts from 19 countries
evaluated 15 systematic reviews on different forms of periodontal therapy

• EFP developed S3-level clinical practice guideline for
the treatment of periodontitis – Highest level
Mariano Sanz: 'Guideline will benefit both patients and professionals'

STEP 1: Guiding behaviour change by motivating the patient to undertake successful
removal of supragingival dental biofilm and risk-factor control.
Oral hygiene practices at all steps
IMPLEMENTED IN ALL PERIODONTITIS
PATIENTS

STEP 2: Cause-related therapy, aimed at controlling (reducing/eliminating) the
subgingival biofilm and calculus (subgingival instrumentation).

Step 3 - Treating areas that do not respond adequately to the second step of
therapy, to gain further access to subgingival instrumentation or aiming at
regenerating or resecting lesions that add complexity to the management of
periodontitis (intra-bony and furcation lesions).

MANAGEMENT OF INTRABONY DEFECTS

MANAGEMENT OF FURCATION LESIONS

STEP 4: Supportive periodontal care, aimed at maintaining periodontal stability in all
treated periodontitis patients, combining preventive and therapeutic interventions
defined in the first and second steps of therapy, depending on the gingival and
periodontal status of the patient's dentition

GUIDELINE ON TREATMENT OF STAGE IV
PERIODONTITIS
• The EFP published its second evidence-based guideline, on the multidisciplinary
treatment of stage IV periodontitis, in the Journal of Clinical Periodontology in June
2022
• Included the evaluation of 13 systematic reviews of forms of periodontal therapy
• This guideline is the outcome of Perio Workshop 2021, the scientific meeting held by
the EFP in November 2021 in La Granja, Spain
Herrera, D., Sanz, M., Kebschull, M., Jepsen, S., Sculean, A., Berglundh, T., Papapanou,
P. N., Chapple, I., Tonetti, M. S., & (2022). Treatment of stage IV periodontitis: The EFP
S3 level clinical practice guideline. Journal of Clinical Periodontology, 49(Suppl. 24), 4–71.

Stage IV periodontitis treatment recommendations include:
- Orthodontic tooth movement
- Tooth splinting
- Occlusal adjustment
- Tooth or implant-supported dental prostheses
- Supportive periodontal care
• A thorough diagnosis and case evaluation are crucial before treatment planning
• Necessary inter-disciplinary therapy is required to rehabilitate the compromised
dentition
• Frequent re-evaluations during and after treatment are essential
Herrera, D., Sanz, M., Kebschull, M., Jepsen, S., Sculean, A., Berglundh, T., Papapanou, P. N., Chapple, I., Tonetti, M. S., &
(2022). Treatment of stage IV periodontitis: The EFP S3 level clinical practice guideline. Journal of Clinical Periodontology,
49(Suppl. 24), 4–71.

BENEFITSOF 2017 CLASSIFICATION
 Clear and Non-overlapping Categories: The new classification system
provides a clear and distinct diagnosis for any periodontal condition without
overlapping disease categories.
 Patient Understanding: Patients can better comprehend the root cause of
their periodontal status, leading to improved awareness and compliance.
 Simplified for Dentists: General dentists can easily devise treatment protocols
since there is no overlap among disease categories, making treatment planning
more straightforward.
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 Insurance Assistance: With dental insurance becoming more prevalent, a
transparent and simplified classification system aids in risk profiling for
claim settlements.
 Comprehensive Risk Assessment: The proposed classification includes
previously omitted risk factors associated with periodontitis, enhancing
the overall assessment.
 Incorporation of Peri-implant Conditions: This classification system
accommodates peri-implant conditions, making it comprehensive for
modern dental practices.
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 Efficiency in Diagnosis: Multiple visits to assess disease progression
for a diagnosis are no longer necessary, streamlining the diagnostic
process.
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DRAWBACKS OF 2017 CLASSIFICATION
• The new classification is definitely more extensive than the previous one
• No classification system is perfect as new research will lead to new knowledge and
hence new changes.
• Concerns have been raised about practical application of new classification in day to
day practices because of its complexity

FUTURERESEARCH???
• Developimprovedmethodologies to accurately assess changes in both soft and hard
tissues associated with periodontitis progression over time.
• Identify genetic, microbial, and host responsemarkers that can differentiate between
different periodontitis phenotypesand reflect disease initiation and progression.
• Expand epidemiological databases to include underrepresentedworld regions, using
standardized methodologiesand detailed data collection on patient-related, oral, and
periodontal variables.Open access to data is crucial.
• Integrate multi-dimensional data platforms (clinical, radiographic, -omics) to enable
systemsbiologyapproaches for studying periodontal and peri-implant diseases.
• Establish and utilize databases that support the implementation, validation, and ongoing
refinement of the newly introduced periodontitis classification system.

KEY POINTS TO KEEP IN MIND
 You don’t have to populate every single cell of the grid before arriving at
an assessment of stage and grade
 GRADE can be revised after assessing initial treatment responses,
compliance and risk-factor control
 New classification of periodontitis facilitates precision medicine in dentistry
 Much simpler than what you might think at 1st glance!

CONCLUSION
» Staging and grading of periodontitis offers a valuable framework for
assessing and managing the condition
» Acknowledges the potential systemic impact of periodontitis
» Helps to adapt to incorporate new knowledge through periodic review
by an international task force while staying useful in clinical practice
» Promises to enhance patient care and treatment planning in dentistry.
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.

REFERENCES
 Jack G. Caton , Gary Armitage , Tord Berglundh, Iain Chapple, Soren Jepsen , Kenneth S.
Kornman et al . A new classification scheme for periodontal and peri implant diseases and
conditions – key changes from 1999 classification. J Clin Periodontol2018;45:s1-s8
 Ubele van Der Velden. Purpose and problems of periodontal disease classification. J.
Periodontol2000;39:13-21
 Gary C. Armitage. Development of a classification system for periodontal diseases and
conditions. Ann Periodontol1999;4:1
 Gary C. Armitage.Classifying periodontal diseases – a long standing dilemma. J
Periodontol2000;30:9-23

 Soren Jepsen, jack.G.Caton, Jasim M. Albandar, Nabil F.Bissada, Philippe Bouchard, Pierpaolo
Cortellini et al. Periodontal manifestation of systemic diseases and development and acquired
conditions: consensus report of workshop 3 of the 2017 world workshop on the classification of
periodontal and peri implant diseases and conditions. J Periodontol2017;89:237-248
 Panos N.Papapanou, Mariano Sanz, Nurcan Buduneli, Thomas Dietrich, Magda Feres, Daniel H.
Fine et al. Periodontitis : consensus report of workshop 2 of the 2017 worls workshop on the
classification of periodontal and peri-implant diseases and conditions. J Periodontol2017;89:173-
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 Colin B Wiebe, Edward E. Putnins. The periodontal disease classification system of the american
academy of periodontology – an update. JCDA2000;66:11

 M.R. Milward, ILC Chapple. Classification of periodontal diseases: where were we? Where are
we now? Where are we going?J Periodontol2003;30:37-44
 Maurizio S.Tonetti,Henry Greenwell,Kenneth S. kornman.Staging and grading of periodontitis:
Framework proposal of a new classification and case definition. J Periodontol2018;89:159-172
 Harsh Parikh, Charu Agrawal, Hiral Parikh, Shilpa Duseja. Critical evaluation of 2017
classification of periodontal and peri implant diseases and conditions- An update.Int
J.Dent2020;5(2):104-109
 Das, Neelam. (2021). Critical Analysis of AAP 1999 and 2017 the World Workshop
Classification Systems: An Insight. 6. 304-312. 10.36348/sjodr.2021.v06i07.00

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