2017 classification of periodontal and periimplant diseases

Based on journals released by AAP and workshop conducted in Chicago from 9-11 Nov,2017...

1. 2017 CLASSIFICATION OF PERIODONTAL & PERI-IMPLANT DISEASES Presented by Bibina George

2. CONTENTS Introduction 1999 classification Limitations 2017 classification Features Staging of Periodontal disease Grading of Periodontal disease Mucogingival deformities/conditions Peri implant Conclusion

3. 1999 AAP CLASSIFICATION

4. 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. 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.

5. In spite of rapid advancement in the field of implantology, there is no provision in the present 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 (Armitage, 1999 ) Jack G. Caton 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;45:45( Suppl 20);S1–S8.

6. The workshop reorganized broad spectrum of non‐plaque induced gingival diseases and conditions based on primary etiology

7. Periodontal Health and Gingival Health (Lang NP, Bartold PM)

8. Dental plaque induced gingival conditions REVISED CLASSIFICATION 1 ) description of the extent and severity of the gingival inflammation , 2 ) description of the extent and severity of gingival enlargements , 3 ) a reduction in gingival disease taxonomy , and 4 ) discussion of whether mild localized gingivitis should be considered a disease or variant of health .

9. Non-plaque induced gingival diseases

10. FEATURES OF 2017 CLASSIFICATION Staging levels indicate the severity of the disease and the complexity of disease management and is determined after considering several variables including clinical attachment loss, 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 structure considers supplemental biologic characteristics of the patient in estimating the rate and likelihood of periodontitis progression.

11. The four categories of periodontitis staging are determined by a number of variables and range from the least severe Stage I to most severe Stage IV. The three levels of periodontitis grading—which consider a patient’s overall health status and risk factors such as smoking and metabolic control of diabetes—indicate low risk of progression (Grade A), moderate risk of progression (Grade B), and high risk of progression (Grade C).

12. Necrotizing Periodontal Diseases (Herrera D et al)

13. Excessive occlusal forces NEW BIOLOGIC WIDTH - SUPRACRESTAL ATTACHED TISSUES

14. Systemic diseases/conditions affecting periodontal attachment apparatus

15. Periodontal Abscess ( Herrera D et al)

16. Endo- perio Lesions (Herrera D et al)

17. Mucogingival conditions and deformities ( Cortellini & Bissada ) Periodontal” “Biotype”/ “ Morphotype ” / “Phenotype The distinction among different biotypes is based upon anatomic characteristics of components of the masticatory complex, including: 1) Gingival biotype, which includes in its definition gingival thickness (GT) and keratinized tissue width (KTW); 2) Bone morphotype (BM); and 3) Tooth dimension.

18. A recent systematic review using the parameters reported previously, classified the “biotypes” in three categories: Thin scalloped biotype in which there is a greater association with slender triangular crown, subtle cervical convexity, interproximal contacts close to the incisal edge and a narrow zone of KT, clear thin delicate gingiva, and a relatively thin alveolar bone. • Thick flat biotype showing more square‐shaped tooth crowns, pronounced cervical convexity, large interproximal contact located more apically, a broad zone of KT, thick, fibrotic gingiva, and a comparatively thick alveolar bone. • Thick scalloped biotype showing a thick fibrotic gingiva, slender teeth, narrow zone of KT, and a pronounced gingival scalloping.

19. Gingival thickness, is assessed by: Transgingival probing Ultrasonic measurement. Probe visibility Gingiva was defined as thin (≤1.0 mm) or thick (>1 mm) upon the observation of the periodontal probe visible through the gingiva. A color‐coded probe was proposed to identify four gingival biotypes (thin, medium, thick and very thick).

20. Keratinized tissue width(KTW) Thin biotype - 2.75 mm to 5.44mm Thick biotype - 5.09 mm to 6.65 mm Gingival thickness(GT) Thin biotype – 0.63mm Thick biotype - 1.79 mm. Bone morphotype Thin biotype – 0.343mm Thick biotype - .754 mm.

21. Recession Type 1 (RT1): Gingival recession with no loss of interproximal attachment. Interproximal CEJ is clinically not detectable at both mesial and distal aspects of the tooth. Recession Type 2 (RT2): Gingival recession associated with loss of interproximal attachment. The amount of interproximal attachment loss (measured from the interproximal CEJ to the depth of the interproximal sulcus/pocket) is less than or equal to the buccal attachment loss (measured from the buccal CEJ to the apical end of the buccal sulcus/pocket ).

22. Recession Type 3 (RT3 ): Gingival recession associated with loss of interproximal attachment. The amount of interproximal attachment loss (measured from the interproximal CEJ to the apical end of the sulcus/pocket) is greater than the buccal attachment loss (measured from the buccal CEJ to the apical end of the buccal sulcus/pocket). Cairo F, Nieri M, Cincinelli S, Mervelt J, Pagliaro U. The interproximal clinical attachment level to classify gingival recessions and predict root coverage outcomes: an explorative and reliability study. J Clin Periodontol . 2011;38:661–666.

23. Impact of Orthodontics in GR According to Kim DM et al, the direction of the tooth movement and the buccolingual thickness of the gingiva may play important roles in soft tissue alteration during orthodontic treatment. Higher probability of recession during tooth movement in areas with <2 mm of gingiva. Gingival augmentation can be indicated before the initiation of orthodontic treatment in areas with <2 mm. These conclusions are mainly based on historic clinical observations and recommendations (low level of evidence).

24. Peri‐implant health: Was defined both clinically and histologically. Clinically, characterized by: an absence of visual signs of inflammation and bleeding on probing. Peri‐implant health can exist around implants with normal or reduced bone support. It is not possible to define a range of probing depths compatible with peri‐implant health.

25. Peri‐implant mucositis : Characterized by bleeding on probing and visual signs of inflammation. While there is strong evidence that peri‐implant mucositis is caused by plaque, there is very limited evidence for non‐plaque induced peri‐implant mucositis. It can be reversed with measures aimed at eliminating the plaque.

26. Peri‐implantitis: Peri‐implant mucositis is assumed to precede peri‐implantitis. Peri‐implantitis is associated with poor plaque control and with patients with a history of severe periodontitis. Onset: May occur early following implant placement as indicated by radiographic data. Peri‐implantitis, in the absence of treatment, seems to progress in a non‐linear and accelerating pattern.

27. Hard and soft tissue implant site deficiencies Normal healing following tooth loss leads to diminished dimensions of the alveolar process/ridge that result in both hard and soft tissue deficiencies . Larger ridge deficiencies can occur at sites associated with severe loss of periodontal support, extraction trauma, endodontic infections, root fractures, thin buccal bone plates, poor tooth position, injury and pneumatization of the maxillary sinuses . Other factors: medications and systemic diseases reducing the amount of naturally formed bone, tooth agenesis, and pressure from prostheses.

28. References Classification and diagnosis of aggressive periodontitis.Daniel H. Fine. J Clin Periodontol . 2018;45( Suppl 20):S95–S111. Mucogingival conditions in the natural dentition: Narrative review, case definitions, and diagnostic considerations.Pierpaolo Cortellini . J Clin Periodontol . 2018;45( Suppl 20):S190–S198. Periodontal health and gingival diseases and conditions on an intact and a reduced periodontium: Consensus report of workgroup 1 of the 2017 World Workshop on the Classification of Periodontal and Peri ‐Implant Diseases and Conditions .Iain L.C. Chapple . J Clin Periodontol . 2018;45( Suppl 20):S68–S77. 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 Clin Periodontol . 2018;45( Suppl 20):S162–S170.

29. 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. Cortellini P, Bissada NF. Mucogingival conditions in the natural dentition: Narrative review, case definitions, and diagnostic considerations. J Clin Periodontol . 2018;45( Suppl 20):S199–S206. Berglundh T, Armitage G, et al. Peri ‐implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri ‐Implant Diseases and Conditions. J Clin Periodontol . 2018;45( Suppl 20):S286–S291. Araujo MG, Lindhe J. Peri ‐implant health. J Clin Periodontol . 2018; 45( Suppl 20):S36–S36.