Classification of Periodontal Diseases (1)

Question 1

What are the regulations on periodontal treatment in pregnant people? (5)

Answer 1

• Treat periodontitis before patient gets pregnant
• Provide non-surgical treatment in the second trimester
• Avoid ‘traumatic’ procedures during pregnancy (periodontal surgery, full mouth debridement)
• Discuss options with patient
• At a minimum provide supportive periodontal care

Question 2

Why do diseases need to be classified?

Answer 2

• A classification scheme for periodontal and peri-implant diseases and conditions is necessary for clinicians to properly diagnose and treat patients as well as for scientists to investigate etiology, pathologies, natural history and treatment of the disease and conditions

Question 3

What are the 1989 disease classifications for periodontal diseases? (don’t need to learn)

Answer 3

• Rapidly progressing periodontitis/early onset periodontitis/ localised juvenile periodontitis
• Adult periodontitis (>35 years)
• Refractory periodontitis

Question 4

What are the 1999 diseases classifications for periodontal diseases? (don’t need to learn) (8)

Answer 4

• Gingival diseases
• Chronic periodontitis
• Aggressive periodontitis
• Periodontitis as a manifestation of systemic diseases
• Necrotizing periodontal diseases
• Abscesses of the periodontium
• Periodontitis associated with endodontic lesions
• Developmental or acquired deformities and conditions

Question 5

What are the problems with the 1999 classification system?

Answer 5

• Aggressive periodontitis vs chronic periodontitis
• More likely to be genetic
• Often in young patients
• ‘Usually affecting persons under 30 years of age, but patients may be older’
• etc - very woolly - room for interpretation

Question 6

What are the aims of the 2018 disease classifications for periodontal disease? (4)

Answer 6

Capture extent, severity
- amount of periodontal tissue lost

Patient susceptibility
- estimated by historical rate of progression

Current periodontal state
- Pocket depths/bleeding on probing

A system that can be future proofed for update with new biomarker information

Question 7

The term ‘aggressive periodontitis’ was removed. What was it replaced with?

Answer 7

Replaced with a staging and grading system for periodontitis that is based upon bone loss and classifies diseases into:

• 4 stages on severity (I, II, III or IV)
• 3 grades based on disease susceptibility (A, B or C)

Question 8

When staging periodontal disease what are we looking at?

Answer 8

• Use the maximum bone loss at the worst site
• If bitewings are all that’s available - measure from CEJ
• If known to have lost teeth due to perio - can be assigned a stage 4

Question 9

What is a Stage 1?

Answer 9

• Early/mild

Interproximal bone loss at worst site:
- <15% or 2mm

Question 10

What is a stage 2?

Answer 10

Moderate

Interproximal bone loss at worst site:
- Coronal third of root

Question 11

What is a stage 3?

Answer 11

Severe (potential for additional tooth loss)

• Middle third of root

Question 12

What is a stage 4?

Answer 12

• Very severe (potential for loss of dentition)

- Apical third of root

Question 13

What is a grade A?

Answer 13

• Slow progression

% bone loss/age:
- <0.5%

Question 14

What is a grade B?

Answer 14

Moderate progression

% bone loss/age:
- 0.5-1%

Question 15

What is a grade C?

Answer 15

Rapid progression

% bone loss/age:
- >1%

Question 16

How do we work out the grade?

Answer 16

• Find the worst site of bone loss and give it a %
• If in the apical third it if going to be more than 60%
• Also need to know the patients age
• If the % bone loss is less than half their age then progression of periodontitis is slow

Question 17

What does ‘extent’ capture?

Answer 17

• How much bone loss and where

Question 18

What are the 3 classifications of ‘extent’ of periodontal disease?

Answer 18

• Localised
• Generalised
• Molar incisor pattern

Question 19

What is the ‘localised’ extent classification?

Answer 19

<30% of teeth

Question 20

What is the ‘generalised’ extent classification?

Answer 20

More than 30% of teeth

Question 21

What is the ‘molar incisor pattern’ extent classification?

Answer 21

Affects molars and incisors

- Predominantly affects younger patients but can be all ages

Question 22

If periapicals are unavailable what can we use to estimate a measurement of bone pocket depths/bone loss?

Answer 22

• Can use a probe

Question 23

When a patient has had periodontitis why is important that we control bleeding gums?

Answer 23

• IF we don’t there is a high risk of getting periodontitis quite badly again

Question 24

What do we include in the diagnostic pathway of periodontal diseases?

Answer 24

• Identify the type and extent of periodontal disease (if periodontitis then with staging and grading)
• Identification of current health/disease status (PPD and BoP)

Question 25

When would we review sextants if the patient scored a BPE score of 3?

Answer 25

• Can either review this AFTER initial treatment and a 6PPC completed for that sextant only
• OR should be completed BEFORE and AFTER treatment in that sextant

Question 26

What do we need to have to be able to make a periodontal disease diagnosis? (4)

Answer 26

• Medical history
• Dental history
• Oral examination
• Further investigations

Question 27

When looking at the diagnostic pathway, what questions should we ask our self? (6)

Answer 27

• What disease does the patient have?
• How extensive is the disease?
• Is the disease active or controlled?
• How severe is the disease?
• What is the patient’s risk profile?
• What is the rate and risk of disease progression

Question 28

The BPE is of limited value in patients who have already been diagnosed with periodontitis. What should we do?

Answer 28

• If patient has interproximal attachment loss then go straight to 6PPC if can, if can’t then do BPE
• BPE will give some guide to how much more you need to do and what other diagnostic tools you need to use

Question 29

What is the BPE?

Answer 29

• The BPE is a screening tool employed to rapidly guide clinicians to arrive at a provisional diagnosis of periodontal health, gingivitis or periodontitis, irrespective of historical attachment loss and bone loss (irrespective of staging and grading)
• As such the BPE guides the need for further diagnostic measures prior to establishing a definitive periodontal diagnosis and appropriate treatment planning

Question 30

At any given time following therapy a periodontitis patient may represent a case of what 3 states?

Answer 30

• Health in a successfully treated patient (stable)
• Recurrent gingival inflammation (BoP > or equal to 10%) at sites with PPD < or equal to 3mm and no PPD > 4mm (disease remission
• Recurrent periodontitis, bleeding sites > or equal to 4mm or any PPD > or equal to 5mm (unstable)

Question 31

Why is a 4mm threshold critical in people with periodontal disease?

Answer 31

The 4mm threshold is critical as it determines periodontal disease stability at non bleeding sites following successful periodontal therapy. A higher probing depth of 5mm or 6mm in the absence of bleeding may not always represent active disease - in particular soon after periodontal treatment. Therefore, clinicians need to exercise clinical judgements when considering the need or lack of need for additional treatment such as re-instrumentation or surgery for such sites

Question 32

Who is the best dentist?

Answer 32

You. Obviously!