The New Periodontal Classification

Payvand Menhadji
Mar 28, 2019
4 min read

Updated: Apr 1, 2019

The New Classification is here! Many have asked me to write a post about this topic so I hope this sheds some light on it.

Background

The AAP and EFP (American and European Perio societies) came together in 2017 to come up with a new classification system. It has been developed to accommodate the many advances in knowledge and research as it has been almost 2 decades since the last classification (Armitage 1999). It is also important to remember that this is a live system that will continue to be updated regularly.

However, the British Society of Periodontology (BSP) felt the system developed by the international societies was largely unsuitable for use in general practice and aimed more at

specialists and researchers. The difference is that the worldwide system bases their classification on interproximal attachment levels, which we do not really use. We tend to measure pockets in the UK. The gold standard is argued to be attachment levels but under the NHS we are simply not funded for this and therefore it is unrealistic. The BSP version is much more user friendly and suitable for general practice and is mainly based on radiographic bone loss. Therefore if you read some papers online be sure to read the main BDJ paper which is done by the BSP as otherwise it can get quite confusing.

https://www.nature.com/articles/sj.bdj.2019.3?fbclid=IwAR35aekxShgWUIHH2xQ1LA6EP3YvoHSPrV67UKmJHCoGE9_SSkmILFheoLI

What's different?

Few key changes include:

Periodontal health is defined
Peri Implant Diseases and conditions defined
No more aggressive or chronic classifications
Classification - Type of periodontal disease, staging and grading
Staging and Grading based on the oncology model.
Current disease status (Based on BoP and PPD)
Patient Risk Factor Profile - modifiable risk factors!

Dr Reena Wadia breaks down the classification into 6 simple steps:

Determine the TYPE of Periodontal disease
Disease EXTENT
STAGING - Severity of the problem
GRADING- Susceptibility of my patient?
Current Disease STATUS
RISK FACTOR Profile

Ok if you're still following I'm going to break it down even more for you...

1) Determine the TYPE of Periodontal disease:

Assess the patient, are they a perio patient?
Detailed MH, DH, oral exam and further investigations allows differentiations between the different types of periodontal disease. e.g. gingivitis, necrotizing periodontal disease, non-plaque indued gingivitis.
You must recognise alveolar bone loss or attachment loss due to other causes other than periodontitis.... e.g. surgical crown lengthening, orthodontic treatment, perio-endo lesions etc.

2) Disease EXTENT:

LOCALISED – up to 30% of teeth*
GENERALISED- more than 30% of teeth*
MOLAR/INCISOR PATTERN- for periodontitis only, (rare!)

*teeth now, used to be sites.

Once a patient is now diagnosed with periodontitis- staging and grading must be performed. This is based on bone loss from radiographs.

3) STAGING:

SEVERITY of the disease- associated with complexity of patient management.
Based on % bone loss in relation to root length.
The bone loss is taken as the WORST value at any site in the mouth – due to periodontitis.
Early stage periodontitis- radiographs may be limited to bitewings in posterior regions and no radiographs of anterior sextants.

Therefore, if you can see crestal bone on a bitewing- likely to be stage 1 or 2.

If you can not see the crestal bone, a periapical is needed and it is likely to be stage 3 or 4.

If one tooth is around 80% bone loss but the rest is 30% you must go with the worst value.

So to speed things up just remember:

4 stages
Divide the root into thirds.
Roughly - If crestal bone is on bitewings stage – 1 and 2. If not you need a periapical and likely to be stage 3 or 4.

Patients cannot regress to a lower stage of periodontitis due to treatment.

4) GRADING:

Patients SUSCEPTIBILITY to periodontitis.
Predictor of future disease experience in absence of treatment.
Ratio of percentage of bone loss/age.

This reflects the average rate of disease progression over time.

Think of patients age- how susceptible is my patient? E.g. 80 year old with 20% bone loss is not susceptible.

GRADE A – maximum amount of bone loss % is less than half of patients age in years.

GRADE C – maximum amount of bone loss % is more than patients age in years.

GRADE B – otherwise (in the middle)

5) Current Disease STATUS:

Stage and grade are a reflection of historical disease experience, therefore it is important in patients who have received periodontal therapy in the past. A successfully treated periodontitis patient remains a periodontitis patient for life because the disease may progress at any time if periodontal maintenance is sub-optimal and risk factors are not well controlled.

Following therapy a periodontitis patient may represent a case of:

STABLE = Health/Successfully treated patient
DISEASE REMISSION = Recurrent gingival inflammation (BoP ≥ 10%) at sites with PPD ≤ 3mm and no bop on sites >4mm.
UNSTABLE = Recurrent periodontitis with bleeding sites ≥4mm or any PPD ≥5mm.

The 4mm threshold is critical as it determines periodontal disease stability at non-bleeding sites following periodontal therapy.

6) RISK FACTOR Profile:

Documented as part of diagnostic statement. Focus on those that can be measured and that have good evidence base. E.g:

Current smoker > 10 cigarettes per day.
Sub-optimally controlled diabetes.

Remember risk factors are characteristics associated with the increased rate of subsequently occurring disease. They increase the rate of the disease but is not a cause.

Medical History: Diabetes, immunodeficiency, obesity, pregnancy and medications.
Family History: Genetics
Social History: Smoking, Stress
Dental History: Diet

STEPS Summary: