LifeLong Learning

CE Course: The A, B, Cs, and I, II, and IIIs of Periodontitis Staging and Grading By: Fran Soderling, RDH, MA and Jila Torabi, RDH, MPH

Learning Outcomes: Grades A, B, or C estimate the rate and likelihood of progression of the disease ƒ Classify the stages and grades of through direct and indirect evidence of patient risk factors. Periodontal and Peri-Implant Diseases According to the new proposal, the periodontal diseases and conditions are and Conditions. classified into three main and broad categories of periodontal health and gingival 1 ƒ Apply the 2018 proposed diseases, periodontitis, and other conditions affecting the . Peri-implant diseases and conditions include peri-implant health, peri- Classification of implant mucositis, peri-implantitis and peri-implant soft and hard tissue to patient cases. deficiencies. ƒ Defend the value of a classification Three major forms of periodontitis are categorized according to the system that reaches beyond severity microbial etiology and thus are periodontitis, necrotizing Periodontal diseases, of past destruction and includes and Periodontitis as a Manifestation of systemic disease.2 Figure 1. Showcases complexity of the disease and risk for forms of Periodontitis. future disease progression. Periodontal disease diagnosis and Figure 1. Forms of Periodontitis classification has been undergoing modifications and changes for decades. Stage As the body of research and amount of Periodontitis Grade evidence pertaining to periodontal disease pathogenicity, progression and etiology Extent Necrotizing has expanded over years, the experts in the

field have found revision of periodontal Necrotizing Periodontal Necrotizing disease case classification inevitable. The Diseases Periodontitis latest periodontal and peri-implant disease Forms of Necrotizing Periodontitis Stomatitis Genetic disorders diagnosis and classification proposal in 2017, Systemic disorders with a major impact on the loss of AIDS is the result of collaboration, debate, and periodontal tissues by influencing periodontal Inflammatory coalition amongst Periodontists worldwide. inflammation diseases This course will introduce and discuss the Diabetes new classifications of periodontal diseases Periodontitis as a Systemic disorders that Manifestation of influence the pathogenesis and conditions. The new framework of Systemic Disease of periodontal diseases Smoking severity and complexity of periodontitis is Stress Systemic disorders that can result in loss of periodontal described as a system of Staging and Grading. tissues independent of Stage I through Stage IV defines the severity, periodontitis complexity and extent of the disease, while

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Periodontitis Figure 2. Periodontitis classification according to Stage, Periodontitis is described as an Extent and Grade inflammatory disease leading to permanent loss of periodontium due to Stage I: Slight Periodontitis bacterial challenge and the host response. Periodontitis as a complex chronic Stage II: Moderate Periodontitis inflammatory and multifactorial condition Stage has been in need of more detailed and Stage III: Severe Periodontitis with accurate representation of its complexity2. potential tooth loss According to Tonetti, Greenwell and Stage IV: Severe Periodontitis with Kornman the criteria for periodontitis potential loss of dentition includes: ƒ Interdental Clinical Attachment Loss Localized (CAL) detectable at 2 or more non- Periodontitis adjacent teeth. Extent Generalized ƒ Buccal or lingual CAL of 3mm or more with pocketing greater than Molar-Incisor 3mm detectable at 2 or more teeth.2 Distribution

It is important to note the CAL cannot A be due to: Grade B ƒ caused by trauma (e.g. recession caused by oral C piercing) ƒ Cervical carious lesions Periodontitis Staging: ƒ Presence of CAL on distal aspect of a In order to determine stage of periodontitis, the inter-dental clinical rd second molar as a result of 3 molar attachment loss, loss of dentition due to periodontitis, vertical versus extractions or malposition horizontal trend of bone loss, furcation involvement as well as radiographic ƒ Periapical-periodontal bone loss must be determined. combination lesion Stage I periodontitis depicts a patient with slight disease, on which ƒ Vertical root fracture.2 interdental CAL does not exceed 2mm, while stage II represents moderate Periodontitis is classified based on its periodontitis in a patient that has not lost any dentition due to periodontal degree of advancement (stage), its extent disease with interdental CAL 3-4 mm.2 (localized, generalized or molar incisor Stage III and Stage IV periodontitis represent severe cases of period- distribution), and its’ complexity (grade). The ontitis with an interdental CAL of 5 mm or more and are differentiated periodontitis development is categorized in according to the number of teeth lost due to periodontal disease.2 A stages I through IV, while disease complexity patient with stage III periodontitis is at risk of tooth loss or has lost fewer is classified in Grades A, B, or C. Figure than 5 teeth due to periodontitis, presents with grade II or III furcation 2 exhibits classification of periodontitis areas with areas of vertical bone loss.2 A patient suffering from stage IV according to stage, extent and grade. periodontitis has lost 5 or more teeth due to periodontal disease.2 Criteria for periodontitis staging is depicted in Table 1.

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CDHA Journal – Summer 2019 23 LifeLong Learning

Table 1. Periodontitis Staging smoking status, HbA1c levels, changes in radiographic bone *Interdental Tooth RBL Clinical Probing Bone Loss loss or CAL within five years, as STAGE Loss due to Furcation Attachment Depth trend (Radiographic 3 periodontitis well as the age of the patient. Loss Bone Loss) Criteria for periodontitis grading Slight ”PP Horizontal I1-2mm None Class I 15% < Periodontitis 0D[PP loss is exhibited in Table 2. The direct evidence utilized Moderate ”PP Horizontal II PP None Class I 15%-33% Periodontitis Max 5 mm Loss to determine periodontitis grading is changes in radio- Risk of •PP ([WHQGLQJWR tooth loss or Vertical graphic bone loss and/or III •PP PPDQG Class II, III PLGGOHUG of Maximum loss Bone loss more URRWDQGEH\RQG clinical attachment loss within Severe RIWHHWK Periodontitis 5 years’ period. Indirect ([WHQGLQJWR PPDQG Loss of 5 or Vertical IV •PP Class II-III PLGGOHUGRI evidence employed to determine more more teeth Bone loss URRWDQGEH\RQG periodontitis grading are percentages of bone loss as Table 2. Criteria for Periodontitis Grading compared to the age of the patient, as well as periodontal Indirect Direct evidence Disease modifying factors Indirect Evidence Evidence destruction and progression as it relates to the amount of Radiographic Bone % bone loss/ Loss or CAL within 5 Smoking HbA1c %LRÀOP biofilm. The new periodontitis Age years period classification does not recognize None +HDY\ELR¿OP Grade A None < 0.25 Non-Smoker aggressive periodontitis as a 'LDEHWLF Destruction low separate entity. As seen in Table Destruction FLJDUHWWHV +E$F  2, the degree of periodontal Grade B < 2mm 0.25-1.0 proportionate to GD\ 7.0% ELR¿OP destruction, rapid progression

Destruction and early onset may exceed the H[FHHGVELR¿OP • +E$F• amount of biofilm present and, Grade C •PP >1.0 GHSRVLWV FLJDUHWWHVGD\ 7.0% 5DSLGSURJUHVVLRQ therefore, classify the patient (DUO\RQVHW with Grade C periodontitis.4 The modifying risk factors Periodontitis Grading: to be considered in the grading Periodontitis is affected by risk factors such as tobacco use and diabetes. Studies, process are smoking status and however, indicate emerging factors such as obesity, improper nutrition, lack of HbA1c levels. It is important physical activity and certain genetic factors may have potential effect on the health of to note presence or changes of periodontium. modifying factors will affect the Periodontal disease progresses at a different rate for individuals with various risk periodontitis grading status. Table factors. In the past the emphasis of classification has been placed on identifying the 2 displays key factors affecting type of periodontal diseases while the emphasis is now on the factors that contribute periodontitis grading. to periodontitis. The goals of periodontitis grading are to assess all evidence available Age of the patient, as and determine the likelihood of the progression of the disease at a greater rate or as compared to percentage of unresponsive to standard therapy. bone loss, has been proven as Periodontitis grade is classified as Grade A, a slow rate of progression, Grade B a an indirect evidence of disease moderate rate of progression or Grade C exhibiting a rapid rate of progression.3 The progression.4 A 30-year-old with periodontitis Grade determining factors include the amount of biofilm deposit present, 24 CDHA Journal Vol. 37 No. 1 LifeLong Learning

40% bone loss at the site with the greatest destruction is at radiographic bone loss considering the age of the patient. higher risk of progression of periodontitis when compared Table 3 displays Periodontitis Staging and Grading when to a 70-year-old with the same percentage of bone loss. applied to a case study. Figure 3 demonstrates steps in determining percentage of Peri-implantitis and peri-implant mucositis Figure 3. Periodontitis Stage and Grade Case study Implant therapy has become the treatment of choice for edentulous areas. A clear guideline for assessment, diagnosis, and management of peri-implant tissue health and disease has been a long time in the making. The 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions has aimed to create a frame work in which clinicians can classify peri-implant diseases based on clinical signs and symptoms. In order to recognize peri-implant disease, periodontal 1. 2. health around an implant must be defined. As noted by Measure the length of Measure the Cemento- Berglundh et al. implant tissue is considered healthy when the root from the Cemento- Enamel Junction (CEJ) to Enamel Junction (CEJ) to the Alveolar Crest (AC). there are no clinical signs of inflammation, profuse bleeding the Apex. (CEJ-Apex) (CEJ-AC) upon probing, suppuration, edema and erythema.4 It is important to note that probing depths around an implant BL: % of bone loss=(CEJ-AC)÷(CEJ-Apex) x 100 may be greater than a natural tooth due to difference in RBL = % of bone loss/Age = BL÷Age adaptation of gingival tissue around an implant.5 Peri- implant tissue is considered healthy with probing depths Table 3. Periodontitis Stage and Grade Case study ≤ 5mm, with variable levels of bone supporting the implant Age \HDUV Dental History: Periodontitis Stage post initial healing.5 Slight Gender Male /DVWFRPSUHKHQVLYHGHQWDODQG indicators: SHULRGRQWDOH[DPLQDWLRQZDV Furcation class I on bleeding upon probing may Height ¶IW ¿YH\HDUVDJR tooth #19 be present due to trauma ZHUHH[WUDFWHG /RFDOL]HGLQWHUSUR[LPDO Weight OEV \HDUVDJRGXHWRGHFD\ &$/  PP (laceration) of the mucosal wall, B/P PP+J Social History: +RUL]RQWDOWUHQGRIERQH versus an inflammation due to 3DWLHQWOLNHVWRGULQNEHHUVDQLJKW presence of biofilm.5 Chief Complaint “I want white teeth” to relief stress. Stage I Peri-implant mucositis Under Care of 5DGLRJUDSKLFÀQGLQJV Yes is inflammation of gingival Physician )XOOVHWRIUDGLRJUDSKVLQGLFDWHV structure of peri-implant tissue ORFDOL]HGKRUL]RQWDOERQHORVV Periodontitis Grade #29: distance from CEJ to Alveolar Indicators: without any radiographic Ex-Smoker Smoking status : Crest is 4 mm !\HDUVDJR 7\SH,,'0 evidence of bone loss when #29 root length: 12 mm +E$FOHYHO compared to initial healing of Medical History Periodontal Assessment: bone post implant placement. 7\SH,,'LDEHWHV0HOOLWXV '0 DQGK\SHUWHQVLRQ %XFFDODQG/LQJXDO&ODVV, Grade C Peri-Implantitis, is characterized +E$FOHYHO furcation # 19 Current Medications: 1RPRELOLW\ by inflammation of mucosal /LVLQRSULO PJ32T'D\ No recession Localized Periodontitis: tissue around the implant Stage I, Grade C 0HWIRUPLQ PJ32T'D\ZLWKPHDOV 25% of total sites present with LQWHUSUR[LPDO&$/PP associated with bone loss, and ,EXSURIHQ PJDVQHHGHGIRUEDFNSDLQ *HQHUDOL]HGEOHHGLQJRQSURELQJ%23 3ODTXHLQGH[ Continued on Page 26

CDHA Journal – Summer 2019 25 LifeLong Learning

compromised osteointegration. Increased pocket depths The final category of periodontitis as a manifestation of accompanied with radiographic evidence of bone loss post systemic disorders is a result of attachment loss independent initial healing are indication of peri-implantitis.4 of biofilm induced inflammation. Examples Peri-implant hard and soft tissue deficiency, including of this category are neoplastic diseases of the periodontium recessions around the implant or lack of adequate such as oral squamous cell carcinoma and odontogenic keratinized tissue, negatively affects biofilm control by the tumors or other disorders that affect the attachment patient, increasing the chance of peri-implant diseases. apparatus such as systemic sclerosis (scleroderma).3 Periodontitis as a manifestation of Necrotizing Periodontal Diseases. systemic disorders The third category of Periodontitis in the new classifi- According to Jepsen et al., the periodontium can be cation system is necrotizing periodontal diseases (NPD). affected by numerous systemic conditions that can be NPD includes necrotizing gingivitis, necrotizing periodontitis classified into three main categories: and necrotizing stomatitis. Medically comprised patients 1. Systemic conditions that impact the loss of periodontal with severe or moderate chronic condition associated with attachment by influencing periodontal inflammation impaired immune system such as HIV, AIDS, smoking, stress 2. Systemic conditions that influence the pathogenesis of or malnourishments are more at risk of developing NPD.6 periodontal disease and Necrotizing gingivitis (NG) is an acute infection of 3. Systemic conditions that result in the loss of perio- gingival connective tissue due to impaired host immune dontal attachment not related to dental plaque biofilm.3 response. The three criteria necessary to diagnosis NG are gingival pain, bleeding, and necrosis of the interdental An example of systemic disorders that impact the loss papillae. The symptoms may be accompanied by fever, of periodontal attachment by influencing periodontal lymphadenopathy, pseudomembrane, and fetid odor. inflammation are genetic disorders such as Down syndrome, Necrotizing periodontitis (NP) is another form of leukocyte adhesion deficiency syndromes, Papillon-Lefevre necrotizing periodontal disease with the same signs and syndrome, cyclic neutropenia and Chediak-Higashi, to name symptoms of NG however is associated with periodontal a few.3 Diseases affecting the oral mucosa and gingiva (ex. attachment and interdental bone necrosis.7 Epidermolysis bullosa), diseases affecting the connective Necrotizing stomatitis (NS) is a severe inflammatory tissues (ex. Systemic lupus erythematosus), metabolic and condition and presents soft and hard tissue necrosis endocrine disorders (ex. Glycogen storage disease), acquired extending beyond the mucogingival line into buccal mucosa immunodeficiency diseases (ex. HIV infection) and and alveolar bone. Extensive ostitis, leading to formation of inflammatory diseases (ex. inflammatory bowel disease) are sequestrum, is often associated with this form of NPD.6 also included in this category.3 Adopting staging and grading of disease, as it has been The second category of periodontitis as a manifestation utilized in oncology, provides a thorough portrayal of the of systemic disorders include conditions that influence the disease complexity, prognosis, as well as a clear treatment pathogenesis of periodontal disease. Jepsen (2017) states this plan pathway tailored to the patient’s needs. Dental category includes diabetes mellitus, obesity, osteoporosis, hygienists will find adaptation to the new staging and osteoarthritis and rheumatoid arthritis, stress, smoking, grading system is a more effective way of communicating medications and depression.3 Diabetes and smoking, as the advancement and progression of periodontal disease discussed earlier, are highly associated with the pathogenesis with other healthcare professionals and patients. of periodontal disease and are considered as modifying risk factors in the Grading of periodontitis.

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About the Authors References

Fran Soderling, RDH, MA 1. Caton J, Armitage G, Berglundh T, et al. A new classification has served as the Dental Hygiene scheme for periodontal and peri-implant diseases and Academic Administrator at West conditions – Introduction and key changes from the 1999 Coast University in Anaheim, classification. J Periodontol. 2018;89(Suppl 1):S1–S8. https:// California since 2013. She was doi.org/10.1002/JPER.18-0157 Senior Clinic Coordinator and 2. Tonetti MS, Greenwell H, Kornman KS. Staging and grading an Instructor at West Coast of periodontitis: Framework and proposal of a new classification University from 2009 until 2013. and case definition. J eriodontol.P 2018;89(Suppl 1):S159– S172. https://doi.org/10.1002/JPER.18-0006 Before that Fran was an instructor in the dental hygiene department at Cerritos College in 3. Jepsen S, Caton JG, et al. Periodontal manifestations of systemic Norwalk, California for eight years, as well as a part- diseases and developmental and acquired conditions: Consensus report of workgroup 3 of the 2017 World Workshop on the time lecturer in the Department of Professional Studies Classification of eriodontalP and Peri-Implant Diseases and at California State University, Long Beach, California Conditions. J Periodontol. 2018;89(Suppl 1):S237–S248. from 1998 – 2010. She is a member of the American https://doi.org/10.1002/ JPER.17-0733 Dental Hygienist Association, California Dental Hygienist 4. Berglundh T, Armitage G, et al. Peri-implant diseases and Association, Western Society of and Sigma conditions: Consensus report of workgroup 4 of the 2017 Phi Alpha Honor Society. She is a WREB examiner, serving World Workshop on the Classification of Periodontal on the WREB Dental Hygiene Committee. Fran was a and Peri-Implant Diseases and Conditions. J Periodontol. clinical practicing dental hygienist for over 50 years. 2018;89(Suppl 1): S313–S318. https://doi.org/10.1002/ Her education includes a Bachelor of Science in Dental JPER.17-0739 Hygiene from University of Baylor, in Texas, and a Master 5. Renvert S, Persson GR,Pirih FQ, Camargo PM. Peri- Degree in Professional Studies from California State implant health, peri-implant mucositis, and peri- University Long Beach. implantitis: Case definitions and diagnostic considerations.J Periodontol.2018;89(Suppl 1):S304–S312. https://doi. Jila Torabi, RDH, MPH has org/10.1002/JPER.17-0588 been in the field of Dentistry for 6. Papapanou PN, Sanz M, et al. Periodontitis: Consensus the past 16 years. She graduated report of Workgroup 2 of the 2017 World Workshop on the from Cerritos College dental Classification of Periodontal and Peri-Implant Diseases and hygiene program in 2008, and Conditions. J Periodontol. 2018;89(Suppl 1):S173–S182. has worked in private practice https://doi.org/10.1002/JPER.17-0721 ever since. She completed a 7. Gehrig, JS, Shin, DE, Willmann, DE. Foundations of periodon- baccalaureate degree in Dental tics for the dental hygienist. 5th ed. Philadelphia (Penn): Wolters Hygiene Education from Loma Kluwer; 2019. Linda University and Masters in Public Health from West Coast University. She is a full-time faculty member at West Coast University Dental Hygiene Program, at which she directs the Introduction to Periodontology course. She is a member of CDHA, ADHA, Western Society of Periodontology and an active component member of the Long Beach Dental Hygiene Society.

CDHA Journal – Summer 2019 27 2 CE Units (Category I) CDHA Member $25, Non-member $35

Home Study Correspondence Course “The A, B, Cs, and I, II, and IIIs of Periodontitis Staging and Grading ” Circle the correct answer for questions 1-10

1. Which of the following describes the severity or advancement of 6. Determinants for grading levels of periodontitis include: periodontal disease? a. Biofilm, smoking status, and HbA1c levels or diabetes a. Stage I, II and III b. Changes in radiographic bone loss or CAL within 5 years b. Grade A, B and C and age of patient c. Stage I, II, III and IV c. Decayed, missing and filled teeth within the last five years d. Grade A, B, C and D d. Both a and b 2. Three major forms of periodontitis which are classified according 7. Besides clinical attachment loss (CAL) and furcation, what to etiology include Periodontitis (natural teeth and implant) and other factors are considered in staging periodontitis? ______and ______. a. Tooth loss due to periodontitis a. Systemic and caries related diseases b. Radiographic bone loss b. Necrotizing and systemic related diseases c. Probing depth c. Necrotizing and socio economic status related diseases d. All of the above d. Gastrointestinal and systemic related diseases 8. Probing depths around an implant may be greater than a natural 3. The latest periodontal disease and classification is the result of tooth due to adaptation of gingival tissue around an implant. international collaboration amongst periodontists. a. True a. True b. False b. False 9. Clinical attachment loss (CAL) cannot be due to: 4. Which of the following describes the rate and likelihood of a. Vertical root fracture disease progression through patient risk factors? b. Periapical-periodontal combination lesion a. Stage I, II and III c. Third molar extractions b. Grade A, B and C d. All of the above c. Stage I, II, III and IV d. Grade A, B, C and D 10. Which of the following describes the extent of Periodontitis? a. Slight, moderate and/or severe 5. One of the main criteria for Periodontitis is: b. Localized or generalized a. c. Stage I, II, or III b. Plaque/biofilm accumulation d. Grade A, B, or C c. Clinical attachment loss (CAL) d. Age of onset

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