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Periodontal Diseases: What to Do When the Answer Isn't Clear

 

Stats from the CDC show that 47.2% of adults 30 and older suffer from periodontal disease. And since periodontal disease worsens with age, a whopping 70.1% of adults 65 and older have periodontal disease.


Although periodontal diseases are common, care providers often have to play a guessing game when it comes to determining the stage and severity of any given case.


With this issue in mind, in 2017, the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) updated the system that classifies the stage and grade of periodontal diseases. The previous classification of periodontal disease was published in 1999.


The AAP and EFP set out to evolve the system through an evidence-based approach that detailed the advancements made in understanding periodontitis and implant-related conditions.


There's no doubt that the revised classification is valuable. It’s a massive step in the right direction.


However, despite these positive changes, it remains difficult to determine the stage and grade of many periodontal diseases.


In Brief Review: What is Staging? What is Grading?


Staging a periodontal disease involves classifying the severity and extent of the patient’s condition. The process includes assessing measurable amounts of tissue that’s been damaged or destroyed by periodontitis. It also examines specific factors that might help with case management over the long term.


At first, clinical attachment loss (CAL) should be used to assess the stage, but it’s not always available. In which case, radiographic bone loss (RBL) is the next most reliable option.


Note that tooth loss caused by periodontitis changes the staging process. Also, when there are one or more complexity factors, the stage could reach a higher level.


Grading is the process in which you rate the periodontitis’s progression in a patient and how it’s responding to therapies and treatments. Moreover, grading deals with the effects that periodontitis can have on overall health.


Initially, the care provider should give a grade of B disease. They’ll then determine whether other factors exist to change the status to an A or C.


 

What Are the Three Stages Used in Staging and Grading?


Stage 1: Initial Case Overview


This stage includes screening with full mouth-probing depths and radiographs of the whole mouth. You’ll also need to look for missing teeth.


Generally, you’ll find that Stage III or Stage II can be applied to moderate periodontitis. Alternatively, Stage III and Stage IV are appropriate for severe to very severe periodontitis.


Stage 2: Establishing the Stage


Stage I and II periodontitis require that you confirm CAL and rule out causes outside of periodontitis (e.g., cavities, root fractures).


From there, you must determine the maximum CAL or RBL, then confirm potential RBL patterns.


When dealing with Stage III and IV periodontitis, you need to adhere to the above methods. But you also must assess tooth loss due to periodontitis and evaluate complexity factors.


Stage 3: Establishing the Grade


You need to divide the RBL (percentage of root-length multiplied by 100) by age. Then you must assess whether the patient has related risk factors such as smoking or diabetes.


Patient responses to scaling, root planing, and plaque control should be measured while the expected rate of bone loss is assessed.


Conduct a thorough risk assessment and keep medical/systemic inflammatory considerations in mind.

 

But Wait...The Ground Rules for Assessing Grade of Periodontal Diseases Have Changed


There are new rules for how you should assess the grade of a patient’s periodontitis, as highlighted below.


First and foremost, you’ll define your grade primarily on the observed or inferred rate of periodontitis progression. Heavily weigh the presence (or lack thereof) of control or risk factors that could impact treatment outcomes and further disease progression.


After therapy, the grade can be dropped to a lower level, provided the patient’s risk profile improves enough. Note that these improvements should be sustainable.


Using a B-grade is your go-to when you’re unsure, as it suggests a moderate rate of progression. Afterward, you can make the necessary changes to the grade when the risk profile and its elements make themselves more evident.

 

Dealing with the Abstract Nature of Periodontitis


Unfortunately, in the world of periodontics, you can’t punch a bunch of numbers in a calculator or type a Google search and get the black-and-white answer you seek.


No, the “right” answer is more abstract when it comes to periodontal disease, existing within an endless number of shades of grey.


Fortunately, the updated Classification of Periodontal and Peri-Implant Diseases and Conditions provides some clarity on the issue.


Correctly using this upgraded system whenever it’s appropriate will improve your judgement as a periodontist. This way, you can ensure your patients receive the best available care. That notion will hold true even when their current condition is confusing, and you don’t have immediate answers.

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