Staging and Grading of Periodontitis

Application of the 2018 classification of periodontitis. Decision-making algorithms for clinical practice and education

1. Staging and Grading of Periodontitis: Decision making algorithms for clinical practice and education Seminar Presented by- Shashikiran s 17/04/2020

2. A new classification of Periodontitis 2

3. Clinical definition of periodontitis Periodontitis is characterized by microbially ‐associated, host‐me‐ diated inflammation that results in loss of periodontal attachment . (2017 WORLD WORKSHOP ) This is detected as clinical attachment loss (CAL) by circumferential assessment of the erupted dentition with a standardized periodontal probe with reference to the cemento ‐enamel junction (CEJ ). 3 Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. Journal of periodontology. 2018 Jun;89:S159-72.

4. Case definition of periodontitis A patient is a periodontitis case in the context of clinical care if: Interdental CAL is detectable at ≥2 non‐adjacent teeth, or Buccal or oral CAL ≥3 mm with pocketing >3 mm is detectable at ≥2 teeth (2017 WORLD WORKSHOP) 4 Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. Journal of periodontology. 2018 Jun;89:S159-72.

5. and the observed CAL cannot be ascribed to non‐periodontal causes such as: gingival recession of traumatic origin; dental caries extending in the cervical area of the tooth the presence of CAL on the distal aspect of a second molar and associated with malposition or extraction of a third molar an endodontic lesion draining through the marginal periodontium; and the occurrence of a vertical root fracture. 5 Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. Journal of periodontology. 2018 Jun;89:S159-72.

6. Forms of Periodontitis Based on pathophysiology, three clearly different forms of periodontitis have been identified : Necrotizing periodontitis Periodontitis as a direct manifestation of systemic diseases Periodontitis (2017 WORLD WORKSHOP) 6 Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. Journal of periodontology. 2018 Jun;89:S159-72.

7. Staging and Grading of Periodontitis Staging relies on the standard dimensions of severity and extent of periodontitis at presentation but introduces the dimension of complexity of managing the individual patient Grading relies on three sets of parameters: rate of periodontitis progression ; recognized risk factors for periodontitis progression; and risk of an individual's case affecting the systemic health of the subject 7 Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. Journal of periodontology. 2018 Jun;89:S159-72.

8. Goals of Staging and Grading 8 Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. Journal of periodontology. 2018 Jun;89:S159-72.

9. 9 Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. Journal of periodontology. 2018 Jun;89:S159-72.

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14. In summary, a periodontitis diagnosis for an individual patient should encompass three dimensions: Definition of a periodontitis case based on detectable CAL loss at two non‐adjacent teeth Identification of the form of periodontitis: necrotizing periodonti ‐ tis, periodontitis as a manifestation of systemic disease or periodontitis Description of the presentation and aggressiveness of the disease by stage and grade 14 Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. Journal of periodontology. 2018 Jun;89:S159-72.

15. Clinical Decision Algorithms Tonetti MS, Sanz M. Implementation of the new classification of periodontal diseases: Decision‐making algorithms for clinical practice and education. Journal of clinical periodontology. 2019 Apr;46(4):398-405.

16. STEP 1 : New Patient 16

17. STEP 2 : Suspect Periodontitis Diagnosis 17

18. STEP 3 A : Patient is a Periodontitis Case that needs to be staged 18

19. STEP 3 B : Staging III and IV versus I and II 19

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21. STEP 4 A : Grading when there are existing previous records 21

22. STEP 4B : Grading in the absence of previous record s 22

23. Conclusion The proposed staging and grading of periodontitis provides an individual patient assessment that classifies patients by two dimensions beyond severity and extent of disease that identify patients as to complexity of managing the case and risk of the case exhibiting more progression and/or responding less predictably to standard periodontal therapy. The proposed risk stratification is based on well‐validated risk factors including smoking, uncontrolled Type II diabetes, clinical evidence of progression or disease diagnosis at an early age, and severity of bone loss relative to patient age 23

24. The proposed staging and grading is designed to avoid the paradox of improvement of disease severity observed after loss/ extraction of the more compromised teeth. This is achieved by incorporating , whenever available, knowledge about periodontitis being the predominant reason for loss of one or more teeth Finally, one of the strong benefits of the staging and grading of periodontitis is that it is designed to accommodate regular review by an ad hoc international task force to ensure that the framework incorporates relevant new knowledge within an already functioning clinical application. 24

25. References Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. Journal of periodontology. 2018 Jun;89:S159-72. Tonetti MS, Sanz M. Implementation of the new classification of periodontal diseases: Decision‐making algorithms for clinical practice and education. Journal of clinical periodontology. 2019 Apr;46(4):398-405 . Caton JG, Armitage G, Berglundh T, Chapple IL, Jepsen S, Kornman KS, Mealey BL, Papapanou PN, Sanz M, Tonetti MS. A new classification scheme for periodontal and peri ‐implant diseases and conditions–Introduction and key changes from the 1999 classification. Journal of periodontology. 2018 Jun;89:S1-8. 25

26. QnA Other classifications after AAP 1999 classification? UBELE VAN DER VELDEN, 2005 classification This classification was based on four dimensions, i.e. extent, severity, age, and clinical characteristics. 26

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28. 2. Vishnu Mittal et al 2013 classification Plaque induced periodontal destruction Plaque induced periodontal destruction influenced by systemic disease/condition/environmental factor. Periodontal destruction as a manifestation of systemic disease. Necrotizing periodontal disease. 28

29. 29 Severity of the periodontal disease can be divided into mild (bone loss less than 1/3 rd  of the root surface), moderate (bone loss more than 1/3 rd  and less than 2/3 rd  of the root surface), severe (bone loss more than 2/3 rd  of the root surface). Extent of the disease can be incidental (1 tooth affected), localized (2-7 teeth affected), generalized (More than 7 teeth affected)

30. QnA European workshop 1993 classification? The 1993 classification proposed a simple classification distinguishing between 1. Early onset periodontitis, 2 . Adult periodontitis, 3 . Necrotizing periodontitis. However , there was a need to use additional secondary descriptors for defining the clinical situation. These include: Distribution within the dentition, rate of progression, response to treatment, relation to systemic diseases, microbiological, ethnic group characteristics, and other factors. 30

31. QnA Intrest behind introduction of new classification? The 1999 workshop did not clearly communicate differences between chronic and aggressive periodontitis. While the consensus report of the aggressive periodontitis working group articulated major and minor criteria required for the aggressive periodontitis diagnosis as well as specific definitions to identify patterns of distribution of lesions within the dentition (localized molar incisor versus generalized , see Lang et al. 1999 for detailed discussion), the difficulty in applying the stipulated criteria in the everyday clinical practice and the substantial overlap between the diagnostic categories provided a barrier to clinicians in the application of the classification system 31 Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. Journal of periodontology. 2018 Jun;89:S159-72.

32. Furthermore, the validity of many of the criteria for aggressive periodontitis has not been confirmed in adequately designed studies . Over the past 2 decades clinicians, educators, researchers and epidemiologists have voiced concern about their ability to correctly differentiate between aggressive and chronic periodontitis cases , and these difficulties have been a major rationale for a new classification workshop 32 Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. Journal of periodontology. 2018 Jun;89:S159-72.

33. QnA Why based on TNM classification? A case definition system needs to be a dynamic process that will require revisions over time in much the same way the tumor , node, metastasis (TNM) staging system for cancer has been shaped over many decades. It needs to be : Simple enough to be clinically applicable but not simplistic: additional knowledge has distinguished dimensions of periodontitis , such as complexity of managing the case to provide the best level of care Standardized to be able to support effective communication among all stakeholders Accessible to a wide range of people in training and understood by members of the oral health care team around the world 33 Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. Journal of periodontology. 2018 Jun;89:S159-72.

34. Thank you! Stay safe!