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    How to navigate the new periodontal classification system

    The new proceedings may appear confusing, but becoming familiar with them will lead to skillful dental hygiene decision-making.

    The proceedings of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions was published in June 2018 and it’s a revision of a 1999 World Workshop Classification. The new proceedings are a bit of a maze to navigate because they contain multiple case definition papers and consensus reports. The papers and consensus reports are a joint effort by the American Academy of Periodontology and the European Federation of Periodontology. The intent of the workshop was to base classification on strongest scientific evidence when available; otherwise, lower levels of evidence and expert opinion were used.1

    Changes in gingivitis/periodontitis classification

    I’m not convinced that many clinicians are familiar with the 1999 periodontal disease classifications, but I remember lecturing on it to my students and writing about it. From 1999- 2017, periodontitis was classified as chronic (localized and generalized), aggressive (localized and generalized), necrotizing and as a manifestation of systemic disease. Gingivitis was differentiated as dental plaque-induced and non-plaque-induced.The newly published classification system (2018) includes characteristics of peri-implant tissues in health and disease that weren’t included in the 1999 classifications.3

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    Three forms of periodontitis have been agreed upon and identified:

    1. Necrotizing periodontitis
    2. Periodontitis as a manifestation of systemic disease
    3. Periodontitis

    Forms of disease previously identified as chronic or aggressive have been removed and are now grouped under the single category “periodontitis.”1 The workshop agreed on a classification framework for periodontitis based on a staging and grading system that can be adapted over time to reflect new scientific evidence.1

    Staging means determining the severity of disease at presentation and the complexity of disease management.

    • Stage 1: Initial periodontitis
    • Stage 2: Moderate periodontitis
    • Stage 3: Severe periodontitis with potential for additional tooth loss
    • Stage 4: Severe periodontitis with potential for loss of dentition

    Extent and distribution of disease should be noted: localized, generalized and molar-incisor distribution. Staging isn’t something that can be determined by recording probing depths only and takes time and critical thinking skills to assess. Several variables need to be carefully evaluated, including clinical attachment loss (CAL), amount and percentage of bone loss, probing depth, presence, and extent of angular bony defects and furcation involvement, tooth mobility and tooth loss due to periodontitis.

    Grading includes three levels:

    •     Grade A: Slow rate of progression
    •     Grade B: Moderate rate of progression
    •     Grade C: Rapid rate of progression

    When grading a patient, general health status and other exposures like smoking or level of metabolic control in diabetes need to be taken into account to allow comprehensive patient management.

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    Periodontal classificationTake, for example, Gena Gentry, age 32, who presents as a new patient. She weighs 230 pounds and was recently diagnosed with Type 2 diabetes, hypertension and hyperlipidemia. In questioning her about her HbA1c, she reports A1c > 9 percent as of last week. In examining her periodontium, her assessment is summarized as: Periodontitis associated with diabetes mellitus, Stage II, Grade C. In staging Gena, CAL, radiographic bone loss and probing depths were taken into consideration. Grading severity was based on smoking, obesity and HbA1c.4 In order to stage and grade your patient, you’ll need a copy of the staging and grading framework. You can print it out for free at www.perio.org. (Click on 2017 World Workshop Proceedings, click again on the Journal of Periodontology Proceedings, and then scroll down until you find the document by Tonetti, Greenwell and Kornman titled “Staging and Grading of Periodontitis.”) Read the document, laminate it and share it with your professional colleagues.

    In 1999, gingivitis was referred to as gingival diseases and categorized as dental plaque-induced gingival diseases or non-plaque-induced gingival diseases. The newly published classification system differentiates between plaque-induced gingivitis and non-plaque-induced gingival diseases. Management of gingival inflammation is a key risk factor for the onset of periodontitis, and plaque-induced gingivitis results from supra- and subgingival plaque/biofilm accumulation modified by many factors, including systemic diseases/disorders like diabetes and oral factors such as restorative margins, xerostomia, drug-induced gingival enlargement, and tooth and root anatomy. 

    Non-plaque-induced gingival diseases are less often diagnosed but should be reviewed periodically. Lichen planus, traumatic lesions and necrotizing stomatitis are some common presentations. Non-plaque-induced gingival diseases can be reviewed at www.perio.org with free access to 2017 World Workshop documents pertaining to gingival diseases and gingivitis.

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