Scientific journal of the Period I, Year V, n.º 15 Sociedad Española de Periodoncia Editor: Ion Zabalegui 2019 / 15 International Edition periodonciaclínica NEW CLASSIFICATION OF PERIODONTAL AND PERI-IMPLANT DISEASES Guest editors: Mariano Sanz y Panos N. Papapanou ADVERTISING Presentation

ANTONIO BUJALDÓN, PRESIDENT OF SEPA 2019-2022

THIS IS THE FIRST EDITORIAL of Periodoncia Clínica of the Before ending this editorial, it is essential to dedicate some SEPA presidential mandate for 2019-2022. It is a huge honour lines of recognition and thanks to the active and committed SEPA to start with a monographic issue on the New Classification members involved with Periodoncia Clínica over the four years that of Periodontal and Peri-implant Diseases, fruit of the work of have passed since the creation of this informative publication, which the World Workshop held in 2017 by the American Academy has consolidated a style and friendly way of strengthening and of Periodontology (AAP) and the European Federation of facilitating professional access to knowledge, under the values of Periodontology (EFP), to which SEPA is proud to belong as one of its rigour, innovation, and excellence that are the hallmarks of SEPA. most dynamic members. Ion Zabalegui, editor of Periodoncia Clínica, together with The rejoicing increases by having the brilliant collaboration as associate editors Laurence Adriaens, Andrés Pascual, and Jorge guest editors of Panos N. Papapanou and Mariano Sanz, the latter Serrano, deserve a display of immense gratitude from all SEPA of which – as chair of the European Workshop in Periodontology members, the Spanish dental community, and the international – has led the work and consensus of this new classification, which periodontal community for having allowed us to enjoy these 15 will allow all oral-health professionals to have clear criteria, based editions of Periodoncia Clínica, together with the immeasurable on evidence and the latest knowledge, when focusing both on work of the national and international editorial committees, the treatment and on the diagnosis and prevention of periodontal and guest editors of each issue, and the huge number of authors who peri-implant diseases. The classification also provides for the first have provided their reviews and clinical cases in a disinterested way time a definition of how to understand and identify periodontal to fulfil SEPA’s aims and mission. health. Thus, this issue number 15 has sought to give shape to the To all the collaborators involved in this project – which was summaries of each of the Workshop’s working groups written by born in February 2015 – much thanks. Similarly, it is also right the EFP – through Iain Chapple, Mariano Sanz, Maurizio Tonetti, to recognize the work of the technical teams that have made it Søren Jepsen, and Tord Berglundh – and translated into Spanish by possible for SEPA to publish its own publication. And, of course, SEPA. a special thanks too to the Platinum and Gold strategic partners The visual style and the focus applied to the clinical cases, who, thanks to their commitment and alliance with a scientific which has made Periodoncia Clinica a benchmark for professionals non-profit-making organization, have encouraged the fulfilment of in periodontology and other related dental disciplines and SEPA’s mission in the service of the development of periodontology therapies, is also reflected in the excellent cases in which the and health promotion. SEPA: periodontology and oral health for outstanding current editor of Periodoncia Clínica, Ion Zabalegui, everyone. and his successor from the next issue, Ignacio Sanz Martín, have participated, accompanying talented young periodontists who are able to reflect on the application of specific cases according to the new classification. Both Ana Marcos and María Rioboo, together with other young clinicians of recognised prestige such as Marta Escribano, enrich this magazine with cases of a brilliant execution and clarity when better understanding the practical application of the new classification.

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Management Board Editorial committee Editorial committee Scientific magazine of the SEPA 2019-2022: Clinical Periodontics: Clinical Periodontics: Spanish Society of Periodontology

President: Editor: National Editorial Committee: Edited by: Antonio Bujaldón Luis Antonio Aguirre Sociedad Española de Periodoncia Vice-president: Rodrigo Andrés y Osteointegración José Nart Olalla Argibay Editorial management of the project: Secretary: Eva Berroeta Javier García Fernando Blanco-Moreno Paula Matesanz Design and Art Direction: Cristina Carral Board members: Ion Zabalegui Juan Aís Neus Carrió Olalla Argibay Associate editors: Ana Echeverría Editorial co-ordination, layout, Andrés Pascual Ruth Estefanía and printing: Ignacio Sanz Sánchez Francisco José Enrile elestudio.com Francisco Vijande Sebastián Fabreges Translation: Member, Periodoncia Clínica: Gerardo Gómez Moreno Paul Edward Davies Andrés Pascual Óscar González Advertising: Board of Trustees, SEPA Jorge Serrano Federico Hernández-Alfaro [email protected] Foundation of Periodontology Berta Legido € and Dental Implants: Andrés López Price Spain: 180 President: Francesc Matas SEPA members receive a free copy of Antonio Bujaldón Francisco Mesa Clinical Periodontics Rafael Naranjo Vice-president: Andrés Pascual Subscription (annual: three issues): €390 Juan Puchades José Nart Cancellation of the subscription must Isabel Ramos be communicated at least two months Secretary General: Vicente Ríos before its scheduled renewal. Paula Matesanz Silvia Roldán Trustees: Vanessa Ruiz Prices of the printed magazine: Olalla Argibay Laurence Adriaens Juan Rumeu SEPA members: included in the Óscar González Ignacio Sanz Sánchez membership fee Adrián Guerrero Fabio Vignoletti Non-members of SEPA: € 390 David Herrera Institutions: € 390 Rafael Naranjo International Editorial Students: Free online Andrés Pascual Committee: Ignacio Sanz Martín access Ignacio Sanz Sánchez Gil Alcoforado. Portugal For customers in Spain, prices include Mónica Vicario Sofía Aroca. Francia Guest editors n.º 15 VAT and postage costs. Francisco Vijande Raúl Caffesse. EEUU. New classification of Ion Zabalegui Leandro Chambrone. Brasil For deliveries outside of Spain, postage periodontal and peri-implant Honorary Trustees: Moshe Goldstein. Israel costs are not included. diseases: Juan Blanco Phoebus Madianos. Grecia Raúl Caffesse Maurizio Tonetti. Italia Legal Deposit: M-4615-2015 José Javier Echeverría Otto Zuhr. Suiza ISSN 2386-9623 Niklaus Lang Jan Lindhe Blas Noguerol © Copyright SEPA. This publication Mariano Sanz Mariano Panos N. may not be reproduced or transmitted, Maurizio Tonetti Sanz Papapanou in whole or part, by any electronic or Nuria Vallcorba mechanical means, nor by photocopy, Writers: Editor Periodoncia Clínica: recording, or any other system of Tord Berglundh Ion Zabalegui information reproduction without Iain Chapple authorization in writing by the Editor Cuida tus Encías: Marta Escribano Regina Izquierdo copyright owner. The editor assumes Søren Jepsen no responsibility for unsolicited Management Structure: Ana Marcos Terán manuscripts. All opinions belong to their María Rioboo Executive Director: authors. Javier García Ignacio Sanz Martín Mariano Sanz Coordinator of Operations and Innovation: Maurizio Tonetti Jaume Pros Ion Zabalegui Administration: Marta Alcayde Training and Projects: Eva Castro Eugenia Huerta Lorena Ortiz Flor Laciar Communication: Miguel López Paco Romero Member services: Mario Rueda 4 Editorial

ION ZABALEGUI, EDITOR OF PERIODONCIA CLÍNICA

AT THE END OF 2017, the European Federation of Convinced of the benefit that this new classification implies for Periodontology (EFP), the American Academy of Periodontology our patients, at Periodoncia Clínica we decided to a bring this new (AAP), and representatives of the remaining worldwide classification to all Spanish-speaking colleagues, counting on two associations of periodontology met in Chicago with the aim of of its creators and leading exponents of European and American reaching a consensus on a new classification of periodontal and periodontology: Prof. Mariano Sanz and Prof. Panos Papapanou, peri-implant diseases that allows our field to advance towards who invite us to understand why the classification was necessary precision and individualized dentistry through the unification of and the advantages of its application. diagnosis, prevention, and treatment of these diseases. In addition, in line with this magazine’s purpose of linking This new classification defines three new clinical entities: i) science with the day-to-day practice of the dental clinic, the next periodontal health, ii) reduced periodontium in health, and iii) issue of Periodoncia Clínica (No. 16) will address the clinical gingival inflammation in a patient treated for periodontitis. In the application of these new concepts and thereby address the clinical same way, it recognises three periodontal diagnoses: i) necrotizing concern that has been generated. Through explicative cases, it periodontal diseases, ii) periodontitis, and iii) periodontitis as a will try to link the concepts derived from the consensus with the manifestation of systemic diseases. The other important feature challenges that clinicians face in their daily practice. of this classification is the introduction of the concepts of staging, We hope it can help you. which allows the description of the severity and complexity of managing the case, and grading, which allows informing about the risk of disease progression and the patient’s risk profile. Putting this initiative into practice implies the introduction of new concepts and represents a significant change from the previous classification. Despite the manifest benefits of this new classification – the result of a wide consensus among the leading academics in our field – its use in daily practice is a challenge for clinicians.

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6 NEW CLASSIFICATION OF PERIODONTAL Periodoncia Clínica AND PERI-IMPLANT DISEASES

review articles 9

Periodontal health and gingivitis 10 Iain Chapple Periodontitis 18 Mariano Sanz, Maurizio Tonetti

Periodontitis: clinical decision tree for 26 staging and grading Mariano Sanz, Maurizio Tonetti

Systemic and other periodontal 36 conditions Søren Jepsen

Peri-implant health, peri-implant mucositis, 44 and peri-implantitis Tord Berglundh

index Clinical cases 51

Clinical case 1. Generalized gingivitis 53 Ana Marcos Terán, María Rioboo, Ignacio Sanz Martín, Ion Zabalegui Clinical case 2. Generalized periodontitis. Stage I. 61 Grade B María Rioboo, Ignacio Sanz Martín, Ana Marcos Terán, Ion Zabalegui, Marta Escribano Clinical case 3. Generalized periodontitis. Stage III. 75 Grade B Ana Marcos Terán, María Rioboo, Ignacio Sanz Martín, Ion Zabalegui

Clinical case 4. Periodontitis. Stage III. Grade C 89 Ignacio Sanz Martín, Ana Marcos Terán, Ion Zabalegui, María Rioboo

Clinical case 5. Generalized periodontitis. Stage IV. 107 Grade C Ana Marcos Terán, María Rioboo, Ignacio Sanz Martín, Ion Zabalegui

scientific articles of 119 interest to businesses

conclusions 130

New classification of periodontal 130 and peri-implant diseases 7 Mariano Sanz, Panos N. Papapanou Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases’

periodonciaclínica

8 NEW CLASSIFICATION OF PERIODONTAL AND PERI-IMPLANT DISEASES

Periodontal health and gingivitis review Iain Chapple Periodontitis Mariano Sanz, Maurizio Tonetti articles Periodontitis: clinical decision tree for staging and grading Mariano Sanz, Maurizio Tonetti Systemic and other periodontal conditions Søren Jepsen Peri-implant health, peri-implant mucositis, and peri-implantitis Tord Berglundh

New Classification of periodontal and peri-implant diseases

New Classification of periodontal and peri-implant diseases and conditions The New Classification is the product of the World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions, held in Chicago in November 2017. The World Workshop was organised jointly by the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) to create a consensus knowledge base for a new classification to be promoted globally. The New Classification updates the previous classification made in 1999. The research papers and consensus reports of the World Workshop were published simultaneously in June 2018 in the EFP’s Journal of Clinical Periodontology and the AAP’s Journal of Periodontology. The new classification was presented formally by the two organisations at the EuroPerio9 congress in Amsterdam in June 2018.

9 Review article New Classification of periodontal and peri-implant diseases

PERIODONTAL HEALTH AND GINGIVITIS.

IAIN CHAPPLE.

Iain Chapple. Professor of periodontology and head of the School of Dentistry at the GUIDANCE FOR CLINICIANS University of Birmingham (UK). He is a former scientific editor of the British Dental Journal, • The 1999 classification system was the first to recognise the need to classify gingival former associate editor of the Journal of diseases and conditions, but there were many flaws in its approach. Periodontal Research, and currently associate editor of the Journal of Clinical Periodontology. • It did not define “health” and the description of gingivitis was unnecessarily complex. He has written eight textbooks and more than • The New Classification from the 2017 World Workshop provides a clear definition of 20 book chapters. At the European Federation periodontal health, both histologically and clinically. of Periodontology (EFP), Prof Chapple was • It also simplifies the definition of gingivitis into two categories: gingivitis induced by treasurer (2007-2013), co-organiser of Perio plaque biofilm and gingival diseases not induced by plaque biofilm. Workshops, chair of the scientific advisory • Clinical gingival health is defined both on an intact and a reduced periodontium, while committee and editor of JCP Digest (2014- 2016), and secretary general (2016-2019). In health/stability is defined for a successfully treated periodontitis patient. 2012 he was awarded the Tomes medal of the Royal College of Surgeons of England and in 2018 won the IADR Distinguished Scientist Award in Periodontal Research.

Correspondence to:

Iain Chapple

Iain Chapple 10 Iain Chapple Periodontal health and gingivitis Review article

INTRODUCTION

HUMAN PERIODONTAL DISEASES encompass a wide spectrum of conditions. Some of these are related to plaque biofilm while others arise independently of biofilm accumulation and may either be modified by the biofilm or be uninfluenced by it. The 1999 classification system was the first to recognise a need to classify gingival diseases. But it had many flaws. Included in its classification of gingival conditions are some oddities, such as “diabetes mellitus-associated gingivitis” and “ascorbic acid- deficiency gingivitis” which are misleading (“ascorbic acid-deficiency gingivitis”, for example, does not exist – it is really “scurvy” or gingival ulceration caused by ascorbate deficiency). There was no attempt in this system to define “health”, which is clearly a critical factor when trying to establish case definitions for disease. And the description of gingivitis was unnecessarily complex, as it embedded both predisposing and modifying factors in the diagnosis. It was in the context of these limitations of the 1999 classification that working group 1 of the 2017 World Workshop decided to create a clear definition of periodontal health, both histologically and clinically. It also adopted a reductionist methodology to enable the definition of gingivitis according to only two principal categories: (1) gingivitis induced by the dental-plaque biofilm and (2) gingival diseases not induced by the plaque biofilm. DEFINING PERIODONTAL HEALTH

A CRITICAL FACTOR in defining health was the recognition that periodontal health can exist at a site level and at a whole-mouth level, and on an intact or a reduced periodontium. An intact periodontium is one without clinical attachment loss (CAL) or bone loss, whereas a reduced periodontium may arise in two separate situations: either in a non-periodontitis patient (e.g. patients with some forms of gingival recession or following crown-lengthening surgery) or in a patient with a history of periodontitis. Therefore, case definitions of health and gingivitis were established for all three scenarios, as described below. Another fundamental decision concerns the concept of “pristine” versus “clinical” health. Given that in medicine normality is defined by 95% of the population fitting that definition, and that 95% of adults have one or more bleeding points in their mouths, then “health” needs to accept some localised sites of mild inflammation. It was evident from the literature that histological changes in the gingival microvasculature arise almost immediately following tooth eruption and that an inflammatory infiltrate is evident as part of normal immune surveillance. So too are subtle clinical signs of inflammation at isolated sites as part of “clinical health”. Pristine health can therefore be considered exceptional and largely limited to textbooks (<5% of the population).

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Figure 1. Pristine periodontal health, a very rare condition.

A case of clinical gingival health was defined, in the case of both an intact and a reduced periodontium in a non-periodontitis patient, as less than 10% sites of bleeding on probing and probing depths ≤3mm. The intact periodontium had no attachment loss, whereas the reduced periodontium did have evident attachment loss. In the reduced periodontium in a successfully treated periodontitis patient, the definition of health allowed probing depths of up to 4mm (embracing the concept of the “closed pocket”). But there must be no bleeding on probing (BoP) at any 4mm site, as this would represent the likelihood of recurrent periodontitis and indicate a need for remedial intervention.

12 Iain Chapple Periodontal health and gingivitis Review article

DEFINING GINGIVITIS

DEFINING PLAQUE-INDUCED GINGIVITIS on a reduced periodontium was the most challenging concept on which to achieve consensus. This is because it is recognised that the consequences of periodontitis are irreversible and that a patient who develops periodontitis remains at high risk of recurrent periodontitis. This risk remains regardless of whether a patient: • is currently healthy as the result of successful treatment; Figure 2. • has individual sites of gingival inflammation defined by BoP at shallow sites (≤3mm); Clinical gingival health, <10% localised sites of • has 4mm non-bleeding “closed pockets”. bleeding. It was therefore agreed that, once periodontitis has been diagnosed, a patient remains a periodontitis patient for life, whose status at any given moment following successful therapy can be categorised in one of three ways: • Controlled: healthy/stable; • Remission: gingival inflammation; • Uncontrolled: recurrent periodontitis/unstable.

Gingivitis versus “gingival inflammation”: In the context of the periodontitis patient, the term “gingival inflammation” is used rather than “gingivitis”. Although these two terms mean the same thing from a technical point of view, it was decided that one could not have a patient who was defined as a “case” of periodontitis as well as a “case” of gingivitis. Nonetheless, a periodontitis patient may Figure 3. have sites of gingival inflammation at probing depths of ≤3mm following treatment, but Gingival health/stability on a reduced such patients may not need root-surface debridement for recurrent periodontitis, but periodontium in a periodontitis patient. rather oral-hygiene reinforcement and plaque removal to manage the localised gingival inflammation.

Variations in definition for research and clinical care: A further complication arose from trying to balance two competing needs: for epidemiological studies to capture periodontitis prevalence and for clinical management protocols to avoid over-treatment in successfully managed periodontitis patients. The threshold for defining health on a reduced periodontium in a treated periodontitis patient was set at ≤3mm for epidemiological surveys, where it is important to capture all cases of periodontitis, but at ≤4mm (but with no BoP) for clinical care, where over-treatment of non-bleeding 4mm pockets is to be avoided.

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Figure 4. Predisposing factors (local risk factors), e.g. plaque retention factors.

Gingivitis and risk factors: Gingivitis was simply categorised as gingivitis on an intact or a reduced periodontium. The predisposing factors (local risk factors) that lead to increased plaque accumulation were defined as: • plaque-retention factors (e.g. ledges on restorations or sub-gingival crown margins); • oral dryness. Modifying factors (systemic risk factors) that alter the immune-inflammatory response to plaque were also defined: • smoking; • hyperglycaemia (in patients with diabetes); • low antioxidant micronutrient intake (e.g. Vitamin C); • Drugs, especially immune-modulating drugs; • Elevated levels of sex steroids; • Haematological disorders (e.g. neutropenia). Gingivitis induced by the dental-plaque biofilm is broken down into three categories: • Associated with dental biofilm alone; • Mediated by systemic or local risk factors; • Drug-influenced gingival enlargement.

Figure 5. Drug influenced gingival enlargement. 14 Iain Chapple Periodontal health and gingivitis Review article

Non-biofilm-induced gingival conditions and lesions were stratified into eight groups differentiating them from non-plaque-induced periodontal conditions: a. Genetic/developmental disorders; b. Specific infections; c. Inflammatory and immune conditions; d. Reactive processes; e. Neoplasms; f. Endocrine, nutritional, and metabolic diseases; g. Traumatic lesions; h. Gingival pigmentation. NEED FOR STANDARD PROBE

WORKING GROUP 1 also recognised that there was a need to develop an ISO-standard, constant-force periodontal probe, as probing depths vary with probing pressure: without this, case definitions based on probing differences of just 1mm are futile.

Classification of periodontal health and gingival diseases/conditions

1. Periodontal health and gingival 2. Gingivitis – induced by dental 3. Gingival diseases – not induced health biofilm* by dental biofilm

a. Clinical gingival health on an intact a. Associated with dental biofilm alone; a. Genetic/developmental disorders; periodontium; b. Mediated by systemic or local risk b. Specific infections; b. Clinical gingival health on a reduced factors; c. Inflammatory and immune conditions; periodontium: c. Drug-influenced gingival enlargement. d. Reactive processes; i. Stable periodontitis patient; e. Neoplasms; ii. Non-periodontitis patient. f. Endocrine, nutritional, and metabolic diseases; g. Traumatic lesions; h. Gingival pigmentation.

* Predisposing factors (local risk factors)

1. Plaque-retention factors 2. Oral dryness. (e.g. sub-gingival crown margins, orthodontic appliances);

* Modifying factors (systemic risk factors)

1. Smoking; 2. Hyperglycaemia (in people with diabetes); 3. Low antioxidant micronutrient intake (e.g. Vitamin C); 4. Drugs – especially immune-modulating drugs; 5. Sex steroids – elevated levels; 6. Haematological disorders (e.g. neutropenia).

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Health and dental-biofilm-induced gingivitis on an intact and a reduced periodontium: from classification to diagnosis

Patient classification/categorisation

Patient Periodontitis with Gingivitis patient periodontal patient stage & grade health

Periodontal therapy

Diagnosis: Diagnosis: Diagnosis: Diagnosis: Diagnosis: Diagnosis: periodontal case of gingivitis periodontitis periodontitis periodontitis health patient - patient - patient - controlled remission uncontrolled (case (case with (unstable case of current some gingival of recurrent health) inflammation) periodontitis)

FURTHER READING

Kornman KS, Tonetti MS (eds). (2018) Proceedings S, Plemons J, Romito GA, Shapira L, Tatakis DN, Lang MP, Bartold PM. (2018) Periodontal health. Journal of the World Workshop on the Classification of Teughels W, Trombelli L, Walter C, Wimmer G, of Periodontology 89 Suppl 1, S9-S16. Periodontal and Periimplant Diseases and Conditions, Xenoudi P, Yoshie H. (2018) Periodontal health Murakami S, Mealey BL, Mariotti A, Chapple ILC. (2018) Journal of Clinical Periodontology 45 Special Issue. and gingival diseases and conditions on an intact Dental plaque-induced gingival conditions. Journal and a reduced periodontium: Consensus report of of Periodontology 89 Suppl 1, S17-S27. Proceedings include: workgroup 1 of the 2017 World Workshop on the Chapple ILC, Hamburger J. (2004) Periodontal medicine: Classification of Periodontal and Peri-Implant Diseases Trombelli L, Farina R, Silva CO, Tatakis DN. (2018) Plaque- A window on the body. Londres: Quintessence. and Conditions. Journal of Clinical Periodontology 45 induced gingivitis: Case definition and diagnostic Suppl 20, S68-S77. considerations. Journal of Clinical Periodontology 45 Chapple ILC, Mealey BL, Van Dyke TE, Bartold PM, Suppl 20, S44-S67. Dommisch H, Eickholz P, Geisinger ML, Genco RJ, Holmstrup P, Plemons L, Meyle J. (2018) Non-plaque- Glogauer M, Goldstein M, Griffin TJ, Holmstrup P, induced gingival diseases. Journal of Clinical Johnson GK, Kapila Y, Lang NP, Meyle J, Murakami Periodontology 45 Suppl 20, S28-S43. 16 ADVERTISING

17 Review article New Classification of periodontal and peri-implant diseases

PERIODONTITIS.

MARIANO SANZ, MAURIZIO TONETTI.

Mariano Sanz. Professor and chair of periodontology at the University Complutense GUIDANCE FOR CLINICIANS of Madrid and a professor in the faculty of odontology at the University of Oslo (Norway). • Attempts to classify periodontitis have struggled to decide if there are different He is chair of the EFP workshop committee, a diseases or variations of a single disease. member of the EFP executive committee, and president of the Osteology Foundation. • There is no evidence to support differentiating “chronic” and “aggressive” periodontitis. • Three forms of periodontitis have been identified: (1) periodontitis, (2) necrotising Maurizio Tonetti. Clinical professor of periodontitis, (3) periodontitis as a direct manifestation of systemic diseases. periodontology at the Faculty of Dentistry of Hong Kong University and executive • A classification system must include complexity and risk factors as well as disease director of the European Research Group severity. on Periodontology (ERGOPerio). He is the • Individual cases of periodontitis should be characterised according to the stage and editor-in-chief of the Journal of Clinical grade of the disease. Periodontology and a member of the EFP executive committee. INTRODUCTION: CLASSIFYING PERIODONTITIS

PREVIOUS ATTEMPTS TO CLASSIFY PERIODONTITIS have revolved around the question of whether phenotypically different case presentations represent different diseases or variations of a single disease. The internationally accepted classification of periodontitis, published in 1999, provided a workable framework that has been used extensively in both clinical practice and scientific investigation. But this system suffers from significant shortcomings, including Correspondence to: substantial overlap, the lack of a clear pathobiology-based distinctions between categories, Mariano Sanz diagnostic imprecision, and difficulties in implementation.

Mariano Sanz Maurizio Tonetti 18 Mariano Sanz and Periodontitis Review article Maurizio Tonetti

The New Classification from the 2017 World Workshop on Periodontal and Peri- implant Disease and Conditions (“the World Workshop”) reviewed the scientific evidence and reached four main conclusions: 1. There is no evidence of a specific pathophysiology that enables the differentiation of cases as “aggressive” or “chronic” periodontitis or provides guidance for different kinds of intervention. 2. There is little consistent evidence that aggressive and chronic periodontitis are different diseases. But there is evidence that multiple factors, and the interactions between them, influence clinically observable disease outcomes (phenotypes) at the individual level. 3. On a population basis, the average (mean) rates of periodontitis progression are consistent across all observed populations in the world. However, there is evidence that specific segments of the population exhibit different levels of disease progression. 4. A classification system based only on disease severity fails to capture important dimensions of an individual’s disease, including complexity (which influences approaches to therapy) and risk factors (which influence disease outcomes). Based on these findings, a new periodontitis classification scheme has been adopted. The forms of the disease previously described as “chronic” and “aggressive” are now described under the single category of “periodontitis”. Three forms of periodontitis have been identified: 1. Periodontitis; 2. Necrotising periodontitis; 3. Periodontitis as a direct manifestation of systemic diseases. A multidimensional system of stages and grades has been devised to further describe the different manifestations of periodontitis in individual cases. Stages describe the severity and the extent of the disease, grades describe the likely rate of progression. CLINICAL DEFINITION OF PERIODONTITIS

PERIODONTITIS IS A CHRONIC MULTIFACTORIAL INFLAMMATORY DISEASE associated with dysbiotic plaque biofilms and characterised by the progressive destruction of the tooth-supporting apparatus. Periodontitis is characterised by inflammation that results in the loss of periodontal attachment. While the formation of bacterial biofilm initiates gingival inflammation, the disease of periodontitis is characterised by three factors: • The loss of periodontal-tissue support, manifested through clinical attachment loss (CAL) and radiographically assessed alveolar bone loss; • The presence of periodontal pocketing; • Gingival bleeding. Current evidence supports multifactorial disease influences – including smoking – on multiple immunoinflammatory responses. This makes dysbiotic microbiome changes more likely for some patients than for others and may well influence the severity of disease for such individuals.

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A periodontitis classification system should include three components: • Identification of a patient as a periodontitis case; • Identification of the specific type of periodontitis; • Description of the clinical presentation and other elements that affect clinical management, prognosis, and potentially broader influences on both oral and systemic health. In the context of clinical care, a periodontitis case is defined when loss of periodontal- tissue support through inflammation is the primary feature. Clinical attachment loss (CAL) is calculated by a circumferential assessment of the erupted dentition with a standardised periodontal probe with reference to the cemento-enamel junction (CEJ). A patient is a periodontitis case when: • Interdental CAL is detectable at ≥2 non-adjacent teeth, or • Buccal/oral CAL of ≥3mm with pocketing of >3mm is detectable at ≥2 teeth, and • The observed CAL cannot be ascribed to non-periodontal causes such as: 1. Gingival recession of traumatic origin; 2 Dental caries extending in the cervical area of the tooth; 3. The presence of CAL on the distal aspect of a second molar and associated with malposition or extraction of a third molar; 4. An endodontic lesion draining through the marginal periodontium; 5. The occurrence of a vertical root fracture.

Measuring CAL Given the measurement error of CAL with a standard periodontal probe, a degree of misclassification of the initial stage of periodontitis is inevitable and this affects diagnostic accuracy. It is recognized that “detectable” interdental attachment loss may represent different magnitudes of CAL according to the skill of the operator (e.g. specialist or general practitioner) and local conditions that may facilitate or impair detection of the CEJ (most notably, the position of the gingival margin in relation to the CEJ, the presence of calculus, and restorative margins).

Bleeding on probing Clinically meaningful descriptions of periodontitis should include the proportion of sites that bleed on probing, and the number and proportion of teeth with probing depth above certain thresholds (commonly ≥4mm and ≥6mm). It should be noted that periodontal inflammation – generally measured as bleeding on probing (BOP) – is an important clinical parameter in relation to the assessment of periodontitis treatment outcomes and the residual disease risk after treatment. However, BOP itself does not change the initial case definition as defined by CAL or change the classification of the severity of periodontitis.

Severity of disease The degree of periodontal breakdown present at diagnosis describes the severity of the disease, which is measured by the degree of attachment loss or periodontal bone loss. Severity must incorporate the tooth loss attributable to periodontitis. Another dimension of disease severity is the complexity of treatment. Factors such as probing depths, type of bone loss (vertical and/or horizontal), furcation involvement, tooth mobility, number of missing teeth, bite collapse, and increased treatment complexity need to be incorporated into the diagnostic classification. Similarly, the extent of the disease – defined by the number and the distribution of teeth with detectable periodontal breakdown – should also be incorporated in the classification.

20 Mariano Sanz and Periodontitis Review article Maurizio Tonetti

FORMS OF PERIODONTITIS

BASED ON PATHOPHYSIOLOGY, three clearly different forms of periodontitis have been identified: 1. Periodontitis; 2. Necrotising periodontitis; 3. Periodontitis as a direct manifestation of systemic diseases. Differential diagnosis to establish which form of the disease is present is based on patient history, the specific signs and symptoms of necrotising periodontitis, and the presence or absence of an systemic disease that definitively alters the immune response of the host. Necrotising periodontitis is characterised by a history of pain, the presence of ulceration of the gingival margin, and/or fibrin deposits at sites with characteristically decapitated gingival papillae and, in some cases, exposure of the marginal alveolar bone.

severity of complexity Staging disease at of disease = presentation + management

information on biological rate of risk Grading = features + progression + assessment of disease

With periodontitis as a direct manifestation of systemic disease, the recommendation is that the clinician should follow the classification of the primary disease according to the International Statistical Classification of Diseases and Related Health Problems (ICD) codes.

21 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

STAGING AND GRADING

AN INDIVIDUAL CASE OF PERIODONTITIS should be further characterised using a simple matrix of four steps (see: Periodontitis: clinical decision tree for staging and grading, part of this toolkit) that describes the stage and grade of the disease. There are four stages and three grades. Staging relies on the standard dimensions of the severity and extent of periodontitis at presentation but adds the complexity of managing the individual patient. The information derived from assessing the stage of periodontitis should be supplemented by information on the inherent biological grade of the disease. This relies on three sets of parameters: 1. The rate of periodontitis progression; 2. Recognised risk factors for periodontitis progression; 3. The risk of an individual’s case affecting their systemic health. Within this classification framework, staging is largely dependent upon the severity of disease at presentation and on the complexity of disease management, while grading provides supplemental information about biological features of the disease. These features include a history-based analysis of the rate of periodontitis progression, assessment of the risk for further progression, analysis of possible poor outcomes of treatment, and assessment of the risk that the disease or its treatment may negatively affect the patient’s general health.

Staging There are two dimensions in the process of assessing the stage of periodontitis in a patient: severity and complexity.

Severity The primary goal is to classify the severity and extent of destroyed and damaged tissue caused by periodontitis. This is done by measuring CAL by clinical probing and bone loss by radiographic examination. These measurements must include the number of teeth whose loss can be attributed to periodontitis.

Complexity The secondary goal is to determine the complexity involved in controlling the disease and managing the long-term function and aesthetics of the patient’s dentition.

Scoring the stages The severity score is based primarily on interdental attachment loss attributable to periodontitis (CAL) and marginal bone loss. It is assigned based on the worst-affected tooth. The complexity score is based on the complexity of treating the case. It considers factors including the presence of deep probing depths, vertical defects, furcation involvement, tooth hypermobility, drifting and/or flaring of teeth, tooth loss, ridge deficiency, and loss of masticatory function.

22 Mariano Sanz and Periodontitis Review article Maurizio Tonetti

Stage I:

Initial periodontitis

Stage II:

Moderate periodontitis

Stage III:

Severe periodontitis with potential for additional tooth loss

Stage IV:

Advanced periodontitis with extensive tooth loss and potential for loss of dentition

Grading Grading a periodontitis patient involves estimating the future risk of periodontitis progression and the likely responsiveness to standard therapeutic principles. This estimate guides the intensity of therapy and secondary prevention after therapy. Grading adds another dimension and allows the rate of progression to be considered, using direct and indirect evidence. Direct evidence is based on the available longitudinal observation: for example, in the form of older diagnostic-quality radiographs. Indirect evidence is based on the assessment of bone loss at the worst-affected tooth in the dentition as a function of age (measured as radiographic bone loss in percentage of root length divided by the age of the subject). The periodontitis grade can then be modified by the presence of risk factors.

23 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

Clinicians should approach grading by assuming a moderate rate of progression (grade B) and look for direct and indirect measures of whether there is a higher disease progression that would justify the application of grade C. Grade A is applied once the disease is arrested. If the patient has risk factors that have been associated with greater disease progression or lesser responsiveness to bacterial-reduction therapies, the grade score should be raised independently of the primary criterion represented by the rate of progression. For example, a case could be characterised by moderate attachment loss (stage II), where the assumption of a moderate rate of progression (grade B) is modified by the presence of poorly controlled Type-2 diabetes, which is a risk factor that could shift the grade definition to rapid progression (grade C).

Grade A: Grade B: Grade C: Slow rate of Moderate rate Rapid rate progression of progression of progression

FURTHER READING

Kornman KS, Tonetti MS (eds). (2018) Proceedings Herrera D, Retamal-Valdés B, Alonso B, Feres M. (2018) A, Needleman I, Offenbacher S, Seymour GJ, Teles of the World Workshop on the Classification of Acute periodontal lesions (periodontal abscesses R, Tonetti MS. (2018) Periodontitis: Consensus report Periodontal and Periimplant Diseases and Conditions, and necrotising periodontal diseases) and endo- of workgroup 2 of the 2017 World Workshop on the Journal of Clinical Periodontology 45 Special Issue. periodontal lesions. Journal of Clinical Periodontology Classification of Periodontal and Peri-implant Diseases 45 Suppl 20, S78-S94. and Conditions. Journal of Clinical Periodontology 45 Proceedings include: Needleman I, García R, Gkranias N, Kirkwood KL, Suppl 20, S162-S170. Billings M, Holtfreter B, Papapanou PN, Mitnik GL, Kocher T, Iorio AD, Moreno F, Petrie A. (2018) Mean Tonetti MS, Greenwell H, Kornman KS. (2018) Staging Kocher T, Dye BA. (2018) Age-dependent distribution annual attachment, bone level, and tooth loss: A and grading of periodontitis: Framework and of periodontitis in two countries: Findings from systematic review. Journal of Clinical Periodontology proposal of a new classification and case definition. NHANES 2009 to 2014 and SHIP-TREND 2008 to 45 Suppl 20, S112-S129. Journal of Clinical Periodontology 45 Suppl 20, 2012. Journal of Clinical Periodontology 45 Suppl S149-S161. 20, S130-S148. Papapanou PN, Sanz M, Buduneli N, Dietrich T, Feres M, Fine DH, Flemmig TF, García R, Giannobile WV, Tonetti MS, Sanz M. (2019) Implementation of the Fine DH, Patil AG, Loos BG. (2018) Classification and Graziani F, Greenwell H, Herrera D, Kao RT, Kebschull new classification of periodontal diseases: Decision- diagnosis of aggressive periodontitis. Journal of M, Kinane DF, Kirkwood KL, Kocher T, Kornman KS, making algorithms for clinical practice and education. Clinical Periodontology 45 Suppl 20, S95-S111. Kumar PS, Loos BG, Machtei E, Meng H, Mombelli Journal of Clinical Periodontology 46, 398-405. 24 ADVERTISING

25 Review article New Classification of periodontal and peri-implant diseases

PERIODONTITIS: CLINICAL DECISION TREE FOR STAGING AND GRADING.

MARIANO SANZ, MAURIZIO TONETTI.

Mariano Sanz. Professor and chair of periodontology at the University Complutense GUIDANCE FOR CLINICIANS of Madrid and a professor in the faculty of odontology at the University of Oslo (Norway). Periodontitis: clinical decision tree for staging and grading He is chair of the EFP workshop committee, a Based on: member of the EFP executive committee, and Tonetti MS, Sanz M. (2019) Implementation of the new classification of periodontal diseases: Decision-making algorithms president of the Osteology Foundation. for clinical practice and education. Journal of Clinical Periodontology 46, 398-405. Maurizio Tonetti. Clinical professor of periodontology at the Faculty of Dentistry of Hong Kong University and executive director of the European Research Group on Periodontology (ERGOPerio). He is the editor-in-chief of the Journal of Clinical Periodontology and a member of the EFP executive committee.

Correspondence to:

Mariano Sanz

Mariano Sanz Maurizio Tonetti 26 Mariano Sanz and Periodontitis: clinical decision tree for staging and grading Review article Maurizio Tonetti

STEP 1 NEW PATIENT

WHEN SEEING A PATIENT FOR THE FIRST TIME, we should first ask if there is a full-mouth radiograph of adequate quality. If yes, we should assess whether there is detectable marginal bone in any area of the dentition. If bone loss (BL) is detectable, the patient is suspected of having periodontitis. At the same time, irrespective of radiographic records, we must clinically explore the patient and assess interdental clinical attachment loss (CAL). If CAL is detectable, the patient is a possible case of periodontitis. If interdental CAL is not detected, we must evaluate the presence of buccal recessions with probing pocket depths (PPD) greater than 3mm. If such recessions are present, the patient is a possible periodontitis case. If there are no buccal PPD greater than 3mm, we must evaluate full-mouth bleeding on probing (BoP). If this is present in more than 10% of the sites, the patient is diagnosed with gingivitis and if present in less than 10% of sites, the patient is diagnosed with periodontal health.

X-Rays Diagnostic Detectable New patient available Yes quality & Yes marginal bone full-mouth loss

No No No

Yes

Assess interdental Yes CAL loss

No Yes Suspect periodontitis

Buccal or oral rec & Yes PPD >3mm Localised gingivitis

No

BoP 10-30%

Periodontal <10% Measure ≥10% Gingivitis health BoP

BoP >30%

Generalised gingivitis

Proceed to Step 2

27 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

STEP 2 PATIENT SUSPECTED OF PERIODONTITIS

WHEN THE PRESENCE OF INTERDENTAL CAL in the oral examination has identified the patient as a suspected case of periodontitis, we need to ascertain whether this CAL is caused by local factors only – endo-perio lesions, vertical root fractures, caries, restorations, or impacted third molars. If not, we need to ascertain that the interdental CAL is present in more than one non-adjacent tooth. If this is the case, we have a periodontitis patient and we need to make a comprehensive periodontal diagnosis through periodontal charting and full-mouth radiographs. If the periodontal charting does not show PPD of 4mm or more, we need to evaluate full-mouth BoP. When BoP is higher than 10%, the diagnosis is gingival inflammation in a periodontitis patient; when it is lower than 10%, the diagnosis is a patient with a reduced but healthy periodontium. If the periodontal charting shows PPD of 4mm or more, the diagnosis is a periodontitis case that needs to be assessed according to stage and grade.

Endo-perio lesion

Vertical root fracture

Suspect Local factors Yes periodontitis only Caries or restoration

No Impacted wisdom tooth

CAL loss Suspect Assess gingivitis No and monitor >1 N-A tooth periodontitis

Step 1: Step 1: Measure Periodontal Measure BoP charting & BoP radiographs

Periodontitis BoP No PPD 4mm Yes or more case

No BoP BoP + Periodontal & bone appraisal Reduced but healthy Gingival inflammation periodontium patient in periodontitis patient

Staging & grading

28 Mariano Sanz and Periodontitis: clinical decision tree for staging and grading Review article Maurizio Tonetti

STEP 3A PATIENT IS A PERIODONTITIS CASE WHOSE STAGE NEEDS TO BE ESTABLISHED

TO ESTABLISH THE STAGE of an individual case of periodontitis, the following information is needed: full mouth x-rays, a periodontal chart, and a periodontal history of tooth loss (PTL). First, we assess the extent of the disease, by assessing whether the CAL/ BL affects less than 30% of the teeth (local) or 30% or more (generalised). Then, we define the stage of the disease by assessing severity (using CAL, BL, and PTL) and complexity (by assessing PPD, furcation and intrabony lesions, tooth hypermobility, secondary occlusal trauma, bite collapse, drifting, flaring, or having fewer than 10 occluding pairs of teeth).

Periodontitis case Periodontal chart Periodontal history (PTL) Full mouth x-rays Periodontitis < 30 % case Periodontal Extent & bone (% teeth) appraisal 30% Periodontitis or more case Severity & complexity

Severity of CAL loss, bone loss, breakdown periodontal tooth loss

Pocket depth, intrabony defects, furcation, tooth hypermobility, Complexity of secondary occlusal trauma, management bite collapse, drifting, flaring, <10 occluding pairs

Stage I Stage II Stage III Stage IV periodontitis periodontitis periodontitis periodontitis

Proceed to grading

29 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

STEP 3B STAGES III AND IV VERSUS I AND II

IF CAL is greater than 5mm or if the BL affects the middle third of the root or beyond in more than two adjacent teeth, the diagnosis is either Stage III or IV. If CAL is 5mm or less in fewer than two teeth, we should look for furcation lesions (degrees II and III). If these are present, the diagnosis is either Stage III or IV. If absent, we should check PPD and if these are greater than 5mm in more than two adjacent teeth, the diagnosis is either Stage III or IV. If PPD are between 3-5 mm, we should assess PTL. If there is PTL, the diagnosis is either Stage III or IV. If not, the diagnosis is Stage I or II. Regarding pocket depth, clinical judgement should be applied to use this criterion to upgrade from Stages I & II to Stage III. For example, in the presence of pseudo pockets, the periodontitis case should stay as Stage II.

Periodontitis case

< 30 % Localised Periodontal & bone Extent appraisal (% teeth)

> 30 % Generalised Severity & complexity

Class II or III Coronal Level of furcation third bone/CAL < 5 mm loss No

Yes

Pocket depth* > 5 mm

Stage III or IV periodontitis 3-5 mm

Periodontal Yes tooth loss

No

Stage I or II periodontitis

* Clinical judgement should be applied to use this criterion to upgrade Proceed to from Stages I & II to Stage III. For example, in the presence of pseudo grading pockets, the periodontitis case should stay as Stage II.

30 Mariano Sanz and Periodontitis: clinical decision tree for staging and grading Review article Maurizio Tonetti

STEP 3C STAGES I, II, III, AND IV

STAGES I and II are based on the level of CAL and BL. The diagnosis is Stage I if: (a) BL is less than 15% and (b) CAL is between 1-2mm. The diagnosis is Stage II if: (a) BL is between 15% and 33% and (b) CAL is between 3-4mm. The diagnosis is Stage III if: (a) BL affects the middle third of the root or beyond, (b) CAL is 5mm or more, (c) PTL is four teeth or fewer, (d) 10 or more occluding pairs are present, and (e) in the absence of bite collapse, drifting, flaring, or a severe ridge defect. The diagnosis is Stage IV if: (a) BL affects the middle third of the root or beyond, (b) CAL is 5mm or more, (c) PTL is more than four teeth, (d) there are fewer than 10 occluding pairs, or (e) when there is bite collapse, drifting, flaring, or a severe ridge defect.

Periodontitis case

< 30 % Localised Periodontal & bone Extent appraisal (% teeth)

˃ 30 % Generalised Severity & complexity

BL coronal third Class II or III Level of Perio tooth CAL < 5mm bone/CAL loss > 4 furcation loss No

1-4 BL middle third CAL CAL 5mm or more

Yes 10 or more Pocket > 5 mm depth occluding No pairs

3-5 mm Yes Stage IV periodontitis

Bite Stage III collapse, Periodontal Yes or IV drifting, Yes tooth loss periodontitis flaring

No No

Level of Stage I or II bone/CAL periodontitis loss Severe Sí ridge effect

No BL <15% BL 15-33% CAL 1-2 mm CAL 3-4 mm Stage III periodontitis

Stage I Stage II Proceed to periodontitis periodontitis grading

31 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

STEP 4A GRADING WHEN THERE ARE NO EXISTING RECORDS

WHEN PREVIOUS PERIODONTAL RECORDS ARE NOT AVAILABLE, the bone loss/ age (BL/A) ratio should be calculated from the full-mouth radiographs. If BL/A is between 0.25 and 1.0, the diagnosis is Grade B periodontitis. If less than 0.25, the diagnosis is Grade A periodontitis: if higher than 1.0, the diagnosis is Grade C periodontitis. Grades A and B can be modified if the patient smokes or is diabetic. A patient who smokes 10 or more cigarettes per day will be changed to Grade C, while one who smokes fewer than 10 cigarettes will be upgraded to B. Similarly, a diabetic patient with HbA1c below 7.0 will be upgraded to B and one with HbA1c of 7.0 or more upgraded to C.

Periodontitis case

Grade A periodontitis < 0,25

Previous Apply records No Bone Grade B 0.25-1.0 periodontitis grade available loss/age modifiers

Yes > 1,0 Grade C periodontitis

Estimate progression (5 years)

Smoking Diabetes Proceed No diabetes to 4b

No smoking <10/day 10 or more/day Yes Yes HbA1c<7.0 HbA1c 7.0 or more

No change Upgrade Upgrade in grade to B to C

32 Mariano Sanz and Periodontitis: clinical decision tree for staging and grading Review article Maurizio Tonetti

STEP 4B GRADING WHEN THERE ARE EXISTING RECORDS

WHEN THE PATIENT’S PERIODONTAL RECORDS ARE AVAILABLE, the rate of periodontitis progression over the previous five years should be calculated. If progression is less than 2mm, the diagnosis is Grade B periodontitis. If there has been no progression in five years, the diagnosis is Grade A periodontitis. When the progression has been 2mm or more, the diagnosis is Grade C periodontitis. Grades A and B can be upgraded to a higher grade if the patient smokes or is diabetic. A patient who smokes 10 or more cigarettes per day will be changed to Grade C, while one who smokes fewer than 10 cigarettes will be upgraded to B. Similarly, a diabetic patient with HbA1c below 7.0 will be upgraded to B and one with HbA1c of 7.0 or more upgraded to C.

Periodontitis case

Grade A periodontitis No progression

Previous Level of Apply Yes Grade B records progression < 2 mm periodontitis grade available (5 years) modifiers

No 2 mm or more Grade C periodontitis

Estimate bone loss by age

Smoking Diabetes No diabetes Proceed to 4a No smoking <10/day 10 or more/day Yes Yes HbA1c<7.0 HbA1c 7.0 or more

No change Upgrade Upgrade in grade to B to C

FURTHER READING

Kornman KS, Tonetti MS (eds). (2018) Proceedings Herrera D, Retamal-Valdes B, Alonso B, Feres M. (2018) A, Needleman I, Offenbacher S, Seymour GJ, Teles of the World Workshop on the Classification of Acute periodontal lesions (periodontal abscesses R, Tonetti MS. (2018) Periodontitis: Consensus report Periodontal and Periimplant Diseases and Conditions, and necrotising periodontal diseases) and endo- of workgroup 2 of the 2017 World Workshop on the Journal of Clinical Periodontology 45 Special Issue. periodontal lesions. Journal of Clinical Periodontology Classification of Periodontal and Peri-implant Diseases 45 Suppl 20, S78-S94. and Conditions. Journal of Clinical Periodontology 45 Proceedings include: Needleman I, García R, Gkranias N, Kirkwood KL, Suppl 20, S162-S170. Billings M, Holtfreter B, Papapanou PN, Mitnik GL, Kocher T, Iorio AD, Moreno F, Petrie A. (2018) Mean Tonetti MS, Greenwell H, Kornman KS. (2018) Staging Kocher T, Dye BA. (2018) Age-dependent distribution annual attachment, bone level, and tooth loss: A and grading of periodontitis: Framework and of periodontitis in two countries: Findings from systematic review. Journal of Clinical Periodontology proposal of a new classification and case definition. NHANES 2009 to 2014 and SHIP-TREND 2008 to 45 Suppl 20, S112-S129. Journal of Clinical Periodontology 45 Suppl 20, 2012. Journal of Clinical Periodontology 45 Suppl S149-S161. Papapanou PN, Sanz M, Buduneli N, Dietrich T, Feres 20, S130-S148. M, Fine DH, Flemmig TF, García R, Giannobile WV, Tonetti MS, Sanz M. (2019) Implementation of the Fine DH, Patil AG, Loos BG. (2018) Classification and Graziani F, Greenwell H, Herrera D, Kao RT, Kebschull new classification of periodontal diseases: Decision- diagnosis of aggressive periodontitis. Journal of M, Kinane DF, Kirkwood KL, Kocher T, Kornman KS, making algorithms for clinical practice and education. Clinical Periodontology 45 Suppl 20, S95-S111. Kumar PS, Loos BG, Machtei E, Meng H, Mombelli Journal of Clinical Periodontology 46, 398-405. 33 ADVERTISING

34 ADVERTISING

35 Review article New Classification of periodontal and peri-implant diseases

SYSTEMIC AND OTHER PERIODONTAL CONDITIONS.

SØREN JEPSEN.

Søren Jepsen. Professor and chair of the Department of Periodontology, Operative GUIDANCE FOR CLINICIANS and Preventive Dentistry at the University of Bonn, Germany. He has served on the executive • Numerous systemic disorders can affect the initiation and progression of periodontitis, committee of the European Federation of or can negatively impact the periodontal structures. Periodontology (EFP) as chair of its research committee (2004-2010), as a board member • The new classification of gingival recession is based on interproximal attachment loss (2012-2017), and as president (2015-2016). He and combines clinical parameters, including gingival phenotype, and characteristics of was also co-chair of the organising committee the exposed root surface. for the AAP/EFP World Workshop on the • Occlusal forces can damage teeth and the periodontal attachment apparatus. Classification of Periodontal and • Developmental or acquired conditions associated with teeth or prostheses may Peri-implant Diseases and Conditions (2017), predispose to diseases of the periodontium. and scientific chair of EuroPerio9 (2018). Prof Jepsen has lectured and published extensively, • Periodontal abscesses and endo-periodontal lesions can also affect the periodontium. has received numerous awards, and is associate editor of the Journal of Clinical Periodontology and an editorial-board member of Clinical Oral Implants Research, the European Journal of Oral Implantology, and the Chinese Journal of Dental Research.

Correspondence to:

Søren Jepsen

Søren Jepsen 36 Søren Jepsen Systemic and other periodontal conditions Review article

INTRODUCTION

HUMAN PERIODONTAL DISEASES encompass a wide spectrum of conditions in addition to gingival diseases and periodontitis. Some of these are related to plaque biofilm while others arise independently of biofilm accumulation and may either be modified by the biofilm or be uninfluenced by it. It was the remit of working group 3 of the 2017 World Workshop to review and update the 1999 classification on periodontal manifestations of systemic diseases and developmental and acquired conditions, and to develop case definitions and diagnostic considerations. PERIODONTAL MANIFESTATIONS OF SYSTEMIC DISEASES AND CONDITIONS

THERE ARE RARE SYSTEMIC DISORDERS, such as Papillon–Lefèvre syndrome, that result in the early presentation of severe periodontitis. They have a major impact on the loss of periodontal tissues by influencing periodontal inflammation. Such conditions are grouped together as “periodontitis as a manifestation of systemic disease” and classification is based on the primary systemic disease (using ICD-10 codes). There are more common systemic diseases – such as diabetes mellitus – that are important modifiers of the course of periodontitis. However, diabetes-associated periodontitis should not be regarded as a distinct diagnosis – diabetes is now included in the new clinical classification of periodontitis as a descriptor in the grading process. In a similar way, smoking – now regarded as nicotine dependence and as a chronic relapsing medical disorder with major negative effects on the periodontium – is now also included as a descriptor in the grading process. Other systemic conditions, such as neoplastic diseases, can affect the periodontal tissues independently of biofilm-induced inflammation. They are also classified based on the primary systemic disease (using ICD-10 codes) and are now grouped together as “systemic diseases or conditions that affect the periodontal supporting tissues.”

A case of “periodontitis” in a patient with uncontrolled diabetes mellitus. This is not a case of “periodontitis as a direct manifestation of systemic disease”

37 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

Periodontitis as a manifestation of systemic disease

Systemic disorders with major impact on loss of periodontal tissues by influencing periodontal inflammation:

• Genetic disorders -- Diseases associated with immunological disorders (e.g. Papillon-Lefèvre syndrome) -- Diseases affecting the oral mucosa and gingival tissue (e.g. epidermolysis bullosa) -- Diseases affecting connective tissues (e.g. Ehlers-Danlos syndromes) -- Metabolic and endocrine disorders (e.g. hypophosphatasia • Acquired immunodeficiency diseases (e.g. HIV infection) • Inflammatory diseases (e.g. inflammatory bowel disease

Other systemic disorders that influence the pathogenesis of periodontal diseases:

• Diabetes mellitus • Obesity • Smoking (nicotine dependence)

Systemic diseases or conditions that affect the periodontal supporting tissues

Systemic disorders that can result in loss of periodontal tissues independently of periodontitis:

• Neoplasms (e.g. oral squamous-cell carcinoma) • Other disorders that may affect periodontal tissues (e.g. Langerhans cell histiocytosis)

38 Søren Jepsen Systemic and other periodontal conditions Review article

MUCOGINGIVAL CONDITIONS

THE IMPORTANCE OF THE GINGIVAL PHENOTYPE – including gingival thickness and width – is now recognised and a new classification for gingival recessions has been introduced. This combines clinical parameters such as the gingival phenotype, the interproximal attachment loss, and the characteristics of the exposed root surface.

Classification of mucogingival conditions (gingival phenotype) and gingival recessions

Gingival site Tooth site

Recession Gingiva Width of CEJ Step depth thickness keratinised (A/B) (+/-) gingiva

No recession

RT1

RT2

RT3

RT = recession type (Cairo et al. 2011) CEJ = cemento-enamel junction (Class A = detectable CEJ, Class B = undetectable CEJ) Step = root-surface concavity (Class + = presence of a cervical step > 0.5mm) Class – = absence of a cervical step > 0.5mm) (Pini Prato et al. 2010)

RT1 RT2 RT3 - REC with no loss of - REC with loss of - REC with loss of interproximal CAL interproximal CAL interproximal CAL - Interproximal CEJ is - Interproximal loss of CAL - Interproximal loss of CAL not visible is less than or equal to is greater than loss of buccal CAL loss buccal CAL

A patient with multiple gingival recession defects of various recession types, gingival phenotypes and root-surface conditions. Individual case assessments (tooth by tooth) are required to facilitate adequate treatment planning. (Photo: K. Jepsen).

39 Graphics RT1, RT2, RT3 courtesy H. Dommisch. Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

O C C L U S A L T R A U M A A N D T R A U M A T I C O C C L U S A L F O R C E S

TRAUMATIC OCCLUSAL FORCE, which replaces the term “excessive occlusal force” of the previous (1999) classification, is any occlusal force that results in injury to teeth (such as excessive wear or fracture) and/or to the periodontal attachment apparatus. Occlusal trauma is a histological term to describe the injury of the periodontal attachment apparatus. The presence of traumatic occlusal forces and occlusal trauma may be indicated by one or more of the following: (a) fremitus (adaptive tooth mobility), (b) progressive tooth mobility, (c) thermal sensitivity, (d) excessive occlusal wear, (e) tooth migration, (f) discomfort/pain on chewing, (g) fractured teeth, (h) radiographically widened periodontal ligament space, (i) root resportion, (j) hypercementosis. It should be noted that some of the signs and symptoms of traumatic occlusal forces and occlusal trauma may also be associated with other conditions. Therefore, an appropriate differential analysis must be performed to rule out alternative aetiological factors.Traumatic occlusal forces lead to adaptive mobility in teeth with normal support (primary occlusal trauma) and to progressive mobility in teeth with reduced support (secondary occlusal trauma), usually requiring splinting. There is no evidence from human studies that traumatic occlusal forces accelerate the progression of periodontitis or that they can cause non-carious cervical lesions or gingival recessions.

Cervical enamel projections are an example of tooth-related factors that can predispose to loss of periodontal sup- porting tissues – in this case severe buccal furcation involvement of the first molar. (Photo: K. & S. Jepsen).

40 Søren Jepsen Systemic and other periodontal conditions Review article

PROSTHESIS-RELATED AND TOOTH-RELATED FACTORS

Classification of factors related to teeth and to dental prostheses that can affect the periodontium

A. Localised tooth-related factors that modify or predispose to biofilm-induced gingival diseases/periodontitis

1. Tooth anatomical factors

2. Root fractures

3. Cervical root resorption, cemental tears

4. Root proximity

5. Altered passive eruption

B. Localised dental-prosthesis-related factors

1. Restoration margins placed within the supracrestal attached tissues

2. Clinical procedures related to the fabrication of indirect restorations

3. Hypersensitivity/toxicity reactions to dental materials

This section is expanded in the new classification. It comprises all factors that modify or predispose to biofilm-induced gingival diseases/periodontitis. • The term “biologic width” is replaced by “supracrestal tissue attachment”, consisting of junctional-epithelium and supracrestal connective tissue. • An infringement of restorative margins within the supracrestal connective-tissue attachment is associated with inflammation and loss of periodontal supporting tissue. • The design, fabrication, delivery, and materials used for tooth-supported/retained restorations and fixed dental prosthetic procedures can be associated with plaque retention, gingival recession, and loss of periodontal supporting tissue. • Tooth anatomical factors (i.e. cervical enamel projections, enamel pearls, developmental grooves), root proximity, abnormalities and fractures, and tooth relationships in the dental arch are related to gingival inflammation induced by dental-plaque biofilm and loss of periodontal supporting tissues. PERIODONTAL ABSCESSES

CASE DEFINITION: A periodontal abscess is a localised accumulation of pus located within the gingival wall of the periodontal pocket/sulcus, resulting in a significant tissue breakdown. The primary detectable signs or symptoms associated with a periodontal abscess may involve ovoid elevation in the gingiva, along the lateral part of the root, and bleeding on probing. Other signs and symptoms include pain, suppuration on probing, deep periodontal pockets, and increased tooth mobility.

41 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

A periodontal abscess may develop in a pre-existing periodontal pocket – for example, in patients with untreated periodontitis, under supportive therapy, after scaling and root planing, or after systemic antimicrobial therapy. A periodontal abscess occurring at a site that was previously periodontally healthy is commonly associated with a history of impaction or harmful habits.

Classification of periodontal abscesses based on the aetiological factors involved

Untreated periodontitis Non-responsive to Periodontal Acute periodontitis therapy abscess in exacerbation periodontitis Supportive periodontal therapy patients (in a pre-existing Post-scaling periodontal Post-surgery pocket) After treatment Systemic antimicrobials Post-medication Other drugs: nifedipine Dental floss, orthodontic Impaction elastic, toothpick, rubber dam or popcorn hulls Wire or nail biting and Harmful habits clenching Orthodontic forces or a Periodontal Orthodontic factors abscess in non cross-bite periodontitis Gingival overgrowth patients (not mandatory Invaginated tooth, to have a a Severe anatomic alterations dens evaginatus, pre-existing or odontodysplasia periodontal Cemental tears, enamel Minor anatomic pocket) pearls, or development Alteration of alterations root surface grooves Iatrogenic conditions Perforations Fissure or fracture, Severe root damage cracked-tooth syndrome Post-surgery

ENDO-PERIODONTAL LESIONS

ENDO-PERIODONTAL LESIONS should be classified according to signs and symptoms that have direct impact on their prognosis and treatment (such as the presence or absence of fractures and perforations, and the presence or absence of periodontitis). Case definition: An endo-periodontal lesion is a pathological communication between the pulpal and periodontal tissues at a given tooth that may occur in an acute or a chronic form. The primary signs associated with this lesion are deep periodontal pockets extending to the root apex and/or a negative/altered response to pulp-vitality tests. Other signs/symptoms may include: (a) radiographic evidence of bone loss in the apical or furcation region, (b) spontaneous pain or pain on palpation/percussion, (c) purulent exudate/suppuration, (d) tooth mobility, (e) sinus tract/fistula, (f) crown and/or gingival colour alterations. Signs observed in endo-periodontal lesions associated with traumatic and/or iatrogenic factors may include root perforation, fracture/cracking, or external root resorption. These conditions drastically impair the prognosis of the involved tooth.

42 Søren Jepsen Systemic and other periodontal conditions Review article

Classification of endo-periodontal lesions

Endo-periodontal Root fracture or cracking lesion with root Root-canal or pulp-chamber perforation damage External root resorption

Grade 1 - narrow deep periodontal pocket in one tooth surface Endo-periodontal lesion in Grade 2 - wide deep periodontal pocket periodontitis in one tooth surface patients Grade 3 - deep periodontal pocket Endo-periodontal in more than one tooth surface lesion without root damage Grade 1 - narrow deep periodontal pocket in one tooth surface Endo-periodontal lesion in non Grade 2 - wide deep periodontal pocket periodontitis in one tooth surface patients Grade 3 - deep periodontal pocket in more than one tooth surface

Endo-periodontal lesion (Grade 3) in a periodontitis patient (Photo: H. Dommisch).

FURTHER READING

Kornman KS, Tonetti MS (eds). (2018) Proceedings Ercoli C, Caton JG. (2018) Dental prostheses and tooth- conditions: Consensus report of workgroup 3 of of the World Workshop on the Classification of related factors. Journal of Clinical Periodontology 45 the 2017 World Workshop on the Classification Periodontal and Periimplant Diseases and Conditions, Suppl 20, S207-S218. of Periodontal and Peri-Implant Diseases and Conditions. Journal of Clinical Periodontology 45 Journal of Clinical Periodontology 45 Special Issue. Fan J, Caton JG. (2018) Occlusal trauma and excessive Suppl 20, S219-S229. occlusal forces: narrative review, case definitions, Proceedings include: and diagnostic considerations. Journal of Clinical Papapanou PN, Sanz M, Buduneli N, Dietrich T, Feres Albandar JM, Susin C, Hughes FJ. Manifestations of Periodontology 45 Suppl 20, S199-S206. M, Fine DH, Flemmig TF, García R, Giannobile WV, systemic diseases and conditions that affect the Graziani F, Greenwell H, Herrera D, Kao RT, Kebschull Herrera D, Retamal-Valdes B, Alonso B, Feres M. (2018) M, Kinane DF, Kirkwood KL, Kocher T, Kornman KS, periodontal attachment apparatus: case definitions Acute periodontal lesions (periodontal abscesses Kumar PS, Loos BG, Machtei E, Meng H, Mombelli and diagnostic considerations: S171-S189. and necrotising periodontal diseases) and endo- A, Needleman I, Offenbacher S, Seymour GJ, Teles Cairo F, Nieri M, Cincinelli S, Mervelt J, Pagliaro U. periodontal lesions. Journal of Clinical Periodontology R, Tonetti MS. (2018) Periodontitis: Consensus report (2011) The interproximal clinical attachment level to 45 Suppl 20, S78-S94. of workgroup 2 of the 2017 World Workshop on the classify gingival recessions and predict root coverage Jepsen S, Caton JG, Albandar JM, Bissada NF, Bouchard Classification of Periodontal and Peri-implant Diseases outcomes: an explorative and reliability study. Journal P, Cortellini P, Demirel K, De Sanctis M, Ercoli C, Fan and Conditions. Journal of Clinical Periodontology 45 of Clinical Periodontology 38, 661-666. J, Geurs NC, Hughes FJ, Jin L, Kantarci A, Lalla E, Suppl 20, S162-S170. Cortellini P, Bissada NF. (2018) Mucogingival conditions Madianos PN, Matthews D, McGuire MK, Mills MP, Pini-Prato G, Franceschi D, Cairo F, Nieri M, Rotundo in the natural dentition: narrative review, case Preshaw PM, Reynolds MA, Sculean A, Susin C, West R. (2010) Classification of dental surface defects in definitions and diagnostic considerations. Journal of NX, Yamazaki K. (2018) Periodontal manifestations areas of gingival recession. Journal of Periodontology Periodontology 89 Suppl 1, S190-S198. of systemic diseases and developmental and acquired 81, 885-890. 43 Review article New Classification of periodontal and peri-implant diseases

PERI-IMPLANT HEALTH, PERI-IMPLANT MUCOSITIS, AND PERI-IMPLANTITIS.

TORD BERGLUNDH.

Tord Berglundh. Professor and chair at the Department of Periodontology at the Institute GUIDANCE FOR CLINICIANS of Odontology, Sahlgrenska Academy at the University of Gothenburg, • The previous (1999) classification of periodontal diseases did not include peri-implant Sweden. He is co-editor of the textbook Clinical diseases and conditions. Periodontology and Implant Dentistry and associate editor of the journals Clinical Oral • The 2017 World Workshop presented case definitions and considered the Implants Research and the EFP’s Journal of characteristics of peri-implant health, peri-implant mucositis, and peri-implantitis. Clinical Periodontology. He is a member of • Bleeding on probing (BoP) is used to distinguish between healthy and inflamed the editorial board of the Journal of Dental peri-implant mucosa. Research and serves as a referee on several • Bone loss is used to differentiate between peri-implant mucositis and peri-implantitis. other journals. He has received numerous • The progression of peri-implantitis is faster than that observed in periodontitis and scientific awards and produced about 230 scientific publications within the field of occurs in a non-linear and accelerating pattern. dental implants, periodontal and peri-implant diseases, immunology, genetics, tissue integration, and regeneration. INTRODUCTION

ALTHOUGH A CLASSIFICATION of peri-implant diseases and conditions was addressed for the first time in the 2017 World Workshop, definitions of peri-implant diseases had previously been presented at several editions of the EFP’s European Workshop on Periodontology. But the term “definition” has often provoked misunderstanding. There is a clear need to distinguish between a disease definition and a case definition. Disease definitions are Correspondence to: descriptive and present the typical characteristics of the disease, whereas case definitions Tord Berglundh should provide the clinical guidelines for diagnosis (i.e. how to assess the condition).

Tord Berglundh 44 Tord Berglundh Peri-implant health, peri-implant mucositis, and peri-implantitis Review article

At the 2017 World Workshop on Periodontology, Working Group 4 presented case definitions and addressed focussed questions on the characteristics of peri-implant health, peri-implant mucositis, and peri-implantitis. The most important part of the case definitions is finding bleeding or suppuration on probing (BoP) and bone loss assessed in radiographs. BoP is the key tool to distinguish between healthy and inflamed peri-implant mucosa, while bone loss is used to differentiate between peri-implant mucositis and peri- implantitis. Bone loss in this context should exceed possible crestal-bone-level changes resulting from initial bone remodelling after implant placement. PERI-IMPLANT HEALTH

PERI-IMPLANT HARD AND SOFT TISSUES are formed as a result of a wound-healing process following implant installation. The formation of new bone in contact with the implant is recognised as osseointegration, while the establishment of peri-implant mucosa includes the build-up of a junctional epithelium and a connective-tissue zone in contact with components of the implant. Peri-implant health is characterised by the absence of clinical signs of inflammation, such as swelling, redness, and BoP. It is not possible, however, to define a range of probing depths that are compatible with health. In addition, peri-implant health can exist around implants with reduced bone support. There are different scenarios in which peri-implant health may coincide with reduced bone support, as peri-implant health can be achieved at sites successfully treated for peri-implantitis. In addition, healing following implant placement in sites with ridge deficiencies may result in a bone level located apical of the implant margin and with parts of the peri-implant mucosa facing the intraosseous portion of the implant.

Case definition of peri-implant health in day-to-day clinical practice: • absence of clinical signs of inflammation; • absence of bleeding/suppuration on gentle probing; • no increase in probing depth compared to previous examinations; • no bone loss.

Figure 1. Peri-implant health.

45 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

PERI-IMPLANT MUCOSITIS

PERI-IMPLANT MUCOSITIS is characterised by an inflammatory lesion in the soft tissues surrounding an implant in the absence of loss of supporting bone. The lesion is located lateral to the junctional/pocket epithelium but does not extend into the supracrestal connective tissue zone “apical” of the junctional/pocket epithelium. The main clinical characteristic of peri-implant mucositis is bleeding on gentle probing, while other clinical signs of inflammation – such as erythema and swelling – may also occur. An increase in probing depth is often observed in the presence of peri-implant mucositis because of swelling or a decrease in probing resistance. There is strong evidence that plaque is the aetiological factor involved in peri-implant mucositis. There is also evidence that peri-implant-mucositis lesions can resolve after the reinstitution of plaque- control procedures.

Case definition of peri-implant mucositis in day-to-day clinical practice: • bleeding and/or suppuration on gentle probing; • no bone loss.

Figure 2. Peri-implant mucositis.

PERI-IMPLANTITIS

PERI-IMPLANTITIS is a plaque-associated pathological condition that occurs in tissues around dental implants. It is characterised by inflammation in the peri-implant mucosa and loss of supporting bone. Peri-implantitis sites exhibit clinical signs of inflammation including bleeding on probing and/or suppuration, increased probing depths and/ or recession of the mucosal margin, and radiographic bone loss compared to previous examinations. Peri-implantitis lesions extend apical of the junctional/pocket epithelium and are larger than those at peri-implant mucositis and periodontitis sites. Peri-implant mucositis is assumed to precede peri-implantitis. Data indicate that patients diagnosed with peri-implant mucositis may develop peri-implantitis, especially in the absence of regular maintenance care. The progression of peri-implantitis is faster than that observed in periodontitis and occurs in a non-linear and accelerating pattern.

46 Tord Berglundh Peri-implant health, peri-implant mucositis, and peri-implantitis Review article

The association between plaque and peri-implantitis is underpinned by evidence demonstrating that patients with poor plaque control who do not attend regular maintenance therapy are at higher risk of developing peri-implantitis and that anti- infective treatment strategies are successful in arresting disease progression. There is also strong evidence that there is an increased risk for peri-implantitis in patients who have a history of severe periodontitis. Data identifying smoking and diabetes as potential risk indicators for peri-implantitis are inconclusive.

Figure 3. Peri-implantitis.

Case definition of peri-implantitis in day-to-day clinical practice: • bleeding and/or suppuration on gentle probing; • increased probing depth compared to previous examinations; • bone loss.

Table 1. Case definitions in day-to-day clinical practice for peri-implant health, peri-implant mucositis, and peri-implantitis.

Peri-implant health Peri-implant mucositis Peri-implantitis

No BoP BoP BoP

No bone loss* No bone loss* Bone loss*

*beyond crestal-bone-level changes resulting from initial bone remodelling

47 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

In the absence of previous examination data, a diagnosis of peri-implantitis can be based on the combination of: • bleeding and/or suppuration on gentle probing; • probing depths of ≥6mm; • bone levels ≥3mm apical of the most coronal portion of the intra-osseous part of the implant.

Case definitions in epidemiological studies The same criteria used to define peri-implant health and peri-implant mucositis in day- to-day clinical practice should be applied in epidemiological studies. Similarly, the case definition of peri-implantitis in epidemiological studies is: • bleeding and/or suppuration on gentle probing; • increased probing depth compared to previous examinations; • bone loss. Epidemiological studies need to take into account the error of measurements in relation to assessments of bone-level changes. Bone loss should be reported using thresholds exceeding the measurement error (mean 0.5mm). Epidemiological studies should ideally include previous examinations performed after the first year of implant loading. In the absence of previous radiographic examination data, bone levels ≥3mm apical of the most coronal portion of the intra-osseous part of the implant, together with bleeding and/or suppuration on probing, are consistent with the diagnosis of peri-implantitis. CONCLUSION

THE PROPOSED CASE definitions should be viewed within the context of that there is no “generic” implant and that there are numerous implant designs with different surface characteristics and varying surgical and loading protocols.It is necessary to probe peri-implant tissues to assess changes in BoP and probing depth. It is recommended that clinicians obtain baseline radiographic and probing measurements following the completion of the implant-supported prosthesis.

FURTHER READING

Kornman KS, Tonetti MS (eds). (2018) Proceedings Tarnow D, Tomasi C, Wang HL, Zitzmann N. (2018) Renvert S, Persson GR, Pirih FQ, Camargo PM. (2018) of the World Workshop on the Classification of Peri-implant diseases and conditions: Consensus Peri-implant health, peri-implant mucositis, and Periodontal and Periimplant Diseases and Conditions, report of workgroup 4 of the 2017 World Workshop peri-implantitis: Case definitions and diagnostic Journal of Clinical Periodontology 45 Special Issue. on the Classification of Periodontal and Peri- considerations. Journal of Clinical Periodontology 45 Implant Diseases and Conditions. Journal of Clinical Suppl 20, S278-S285. Proceedings include: Periodontology 45 Suppl 20, S286-S291. Schwarz F, Derks J, Monje A, Wang H-L. (2018) Peri- Araujo MG, Lindhe J. (2018) Peri-implant health. Journal Hämmerle CHF, Tarnow D. (2018) The etiology of hard- implantitis. Journal of Clinical Periodontology 45 of Clinical Periodontology 45 Suppl 20, S230-S236. and soft-tissue deficiencies at dental implants: A Suppl 20, S246-S266. Berglundh T, Armitage G, Araujo MG, Avila-Ortiz G, narrative review. Journal of Clinical Periodontology Blanco J, Camargo PM, Chen S, Cochran D, Derks 45 Suppl 20, S267-S277. J, Figuero E, Hämmerle CHF, Heitz-Mayfield LJA, Heitz-Mayfild LJA, Salvi G. (2018) Peri-implant mucositis. Huynh-Ba G, Iacono V, Koo KT, Lambert F, McCauley Journal of Clinical Periodontology 45 Suppl 20, L, Quirynen M, Renvert S, Salvi GE, Schwarz F, S237-S245. 48 ADVERTISING

49 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases’

periodonciaclínica

50 NEW CLASSIFICATION OF PERIODONTAL AND PERI-IMPLANT DISEASES

Clinical case 1. Generalized gingivitis Ana Marcos Terán, María Rioboo, Ignacio Sanz Martín, clinical Ion Zabalegui Clinical case 2. Generalized periodontitis. Stage I. Grade B cases María Rioboo, Ignacio Sanz Martín, Ana Marcos Terán, Ion Zabalegui, Marta Escribano Clinical case 3. Generalized periodontitis. Stage III. Grade B Ana Marcos Terán, María Rioboo, Ignacio Sanz Martín, Ion Zabalegui Clinical case 4. Periodontitis. Stage III. Grade C Ignacio Sanz Martín, Ana Marcos Terán, Ion Zabalegui, María Rioboo Clinical case 5. Generalized periodontitis. Stage IV. Grade C Ana Marcos Terán, María Rioboo, Ignacio Sanz Martín, Ion Zabalegui

51 52 Clinical case

CLINICAL CASE 1. GENERALIZED GINGIVITIS.

ANA MARCOS TERÁN, MARÍA RIOBOO, IGNACIO SANZ MARTÍN, ION ZABALEGUI.

Ana Marcos Terán. Private practice exclusively in periodontology in Bilbao. ABSTRACT María Rioboo. European Doctorate in Dentistry (UCM). Master’s degree in periodontology A CASE IS DESCRIBED that was diagnosed six years ago as generalized gingivitis and and implants (UCM) and accreditation by the which is also classified as generalized gingivitis under the new classification of stages and EFP. Associate professor of the Department of grades. In this clinical case, at first sight a significant alteration of the gingival tissue was Clinical Specialities of the UCM. appreciated and, to apply the decision tree, a complete periapical radiographic series was Ignacio Sanz Martín. Teacher of the master’s made, along with an intraoral exploration and a periodontogram which was incomplete degree in periodontology of the Complutense – because of the patient’s discomfort during the periodontal probing. In Step 1, we could University of Madrid (UCM). Guest lecturer, already classify our patient as generalized gingivitis because of the presence of bleeding Department of Periodontology at Tufts on probing (BoP) >30%. In Step 2 and in the absence of periodontal probing, but based on University School of Dental Medicine. the radiographs, we detected that in specific sectors the patient presented bone loss (BL), Ion Zabalegui. Private practice exclusively in which could lead us to establish the stage of localized periodontitis. Despite the position of periodontology in Bilbao. the bone in the anteroinferior teeth it was classified as generalized gingivitis because this was clinically considered to be an over-eruption of sextant V. Regarding the complexity of Correspondence to: treatment – which is another factor to consider – the case presents dental crowding which Ana Marcos Terán complicates not only the treatment but also the long-term prognosis of the teeth if it is not [email protected] corrected.

53 Ana Marcos Terán María Rioboo Ignacio Sanz Martín Ion Zabalegui Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

CASE PRESENTATION

MALE 31-YEAR-OLD PATIENT who visits initially for diagnosis and whose main motive is that he wakes up in the morning with the teeth and the gums stained with blood. The patient is ASA type 1 and regarding his dental history a prophylaxis was preformed three years ago. According to the House classification, we classify him as a philosophical patient. In the extraoral exploration we find the absence of lip seal and in the intraoral exploration we find maxillary torus as well as dental crowding, anterior open bite, and changes in the volume and colour of the gum presenting an oedematous and reddened gingival margin. In terms of parafunctional habits, the patient an oral breather and presents an atypical swallowing habit.

Figure 1. Clinical appearance of the inflammation and crowding of the patient at the first visit.

The radiographic series shows integrity of the bone ridge although it seems that at the anteroinferior level the bone level is found to be more apical. It is observed clinically that the anteroinferior sector is over-erupted, a factor that has to be taken into account when classifying this patient. In addition, there is a caries in #26 distal.

Figure 2. Periapical radiographic series.

54 Ana Marcos Terán et al. Clinical case 1. Generalized gingivitis Clinical case

The periodontal exploration shows both a plaque index and bleeding index of 100%, without recession and without evaluated probing depth because of the discomfort referred to by the patient. In addition, an analysis of the quality of breath was preformed finding relative levels of volatile sulphurous compounds (especially dimethyl sulphide).

Figure 3. Incomplete periodontogram and results of measurements with OralChroma® of the volatile sulphurous compounds.

55 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

DIAGNOSIS

TODAY, with the new classification and the new algorithm we would have been able to follow the following clinical decision-making tree.

X-Rays Diagnostic Detectable New patient available Yes quality & Yes marginal bone full-mouth loss

No No No

Yes

Assess interdental Yes CAL loss

No Yes Suspect periodontitis

Buccal or oral rec & Yes PPD >3mm Localised gingivitis

No

BoP 10-30%

Periodontal <10% Measure ≥10% Gingivitis health BoP

BoP >30%

Generalised gingivitis

Proceed to Step 2

Our clinical case presents a complete periapical radiographical series in which there is no suspicion of periodontitis. In evaluating the x-rays, it is observed that there is no apparent interproximal attachment loss or vestibular or lingual recession greater than 3 mm. In addition, there is a bleeding index considerably above 10%, for which reason the patient receives the diagnosis of generalized gingivitis.

56 Ana Marcos Terán et al. Clinical case 1. Generalized gingivitis Clinical case

TREATMENT

BECAUSE OF THE DENTAL MALPOSITION and frequent oral breathing, the patient was sent to the orthodontist and the ear, nose, and throat (ENT) specialist. Instructions in oral hygiene were given and basic anti-inflammatory periodontal treatment through scaling and root planing under local anaesthetic. After 3 weeks, a new exploration was performed with intraoral and periodontal registration to confirm the patient’s healing, appreciating both clinical and periodontal gingival health.

Figure 4. Photographs taken 3 weeks after the anti-inflammatory periodontal treatment.

57 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

As can be noted both in the images and in the periodontal exploration, the bleeding and plaque indices have reduced significantly and the gingival aspect – in terms of colour, shape, size, volume, and texture – has improved and is considered compatible with periodontal health.

Figure 5. Periodontogram and OralChroma® data 3 weeks after the anti-inflammatory periodontal treatment.

DISCUSSION

THE PATIENT presented a significant alteration of gingival tissue during the initial visit. A change of colour, form, and texture was appreciated as well as a disappearance of the stippling of the gingival tissue. All these are characteristic signs of gingival inflammation. This case is also of interest as the clinical judgement led to classifying the patient with gingivitis and not periodontitis even though it was observed that the position of the bone in the inferior incisors seemed to indicate bone loss. After clinically observing that the inferior incisors were over-erupted, it was decided to maintain the classification of gingivitis. It is equally important to highlight that an initial periodontogram could not be performed on the patient because of the discomfort that it presented. If we had had the possibility of probing the inferior incisors, we would have been able to establish a more precise diagnosis. The rapid resolution of the symptoms and the return of the tissue to a state of health seems to indicate that, in effect, the case was correctly diagnosed.

58 ADVERTISING

59 60 Clinical case

CLINICAL CASE 2. GENERALIZED PERIODONTITIS. STAGE I. GRADE B.

MARÍA RIOBOO, IGNACIO SANZ MARTÍN, ANA MARCOS TERÁN, ION ZABALEGUI, MARTA ESCRIBANO.

María Rioboo. European Doctorate in Dentistry (UCM). Master’s degree in periodontology ABSTRACT and implants (UCM) and accreditation by the EFP. Associate professor of the Department of PRESENTED BELOW IS the diagnosis of a case, applying the decision trees published Clinical Specialities of the UCM. in the implementation of the current classification (Tonetti and Sanz 2019). To that end, Ignacio Sanz Martín. Teacher of the master’s the four steps that are recommended have been followed. In the first step, the bitewing degree in periodontology of the Complutense x-rays lead to the suspicion that the patient may have periodontitis, which is confirmed University of Madrid (UCM). Guest lecturer, in the second step with the complete periodontogram. The third step establishes, on the Department of Periodontology at Tufts University School of Dental Medicine. one hand, the extent of the disease – in this case generalized, given that attachment loss is present in >30% of the teeth – and, on the other hand, that this is a stage I case Ana Marcos Terán. Private practice exclusively as the attachment loss is of 1-2 mm and the bone loss < 15%. In the fourth and final in periodontology in Bilbao. step, the degree is determined with data: age and % of bone loss, and with the presence Ion Zabalegui. Private practice exclusively in of the smoking risk factor. Being a smoker of 5 cigarettes/day modifies the degree that periodontology in Bilbao. the patient presents in respect of his age and % of bone loss, becoming a grade B. The Marta Escribano. Doctorate in Dentistry diagnosis that is thus established, following the decision tree, is generalized periodontitis (UCM). Master’s degree in periodontology and stage I, grade B. implants (UCM) and accreditation by the EFP. Collaborating teacher of the master’s degree in periodontology at the UCM. PATIENT HISTORY

MALE 28-YEAR-OLD PATIENT, systematically healthy, smoker of 5 cigarettes per day who came for a consultation on the recommendation of his orthodontist. He is the bearer of a fixed orthodontic apparatus. Oral breather, and in the oral anamnesis a large accumulation of bacterial plaque is detected, along with gingival inflammation, bleeding, and food impaction. He does not perform correct oral hygiene and did not refer Correspondence to: to making use of techniques of interproximal hygiene. In terms of dental history, he does María Rioboo not present any absence, caries, or previous restorations. The patient presents numerous [email protected] malpositioned teeth, mostly located in the lower arch.

61 María Rioboo Ignacio Sanz Martín Ana Marcos Terán Ion Zabalegui Marta Escribano Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

Figure 1. Panoramic x-ray, bitewing, and intraoral clinical situation at maximum intercuspidation.

62 María Rioboo et al. Clinical case 2. Generalized periodontitis. Stage I. Grade B. Clinical case

Figure 2. Intraoral situation by sextant.

63 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

STEP 1 In the first visit, marginal bone loss is detected in the bitewing x-rays and it is thus suspected that this is a patient with periodontitis. A compete periodontal study was performed and STEP 2.

X-Rays Diagnostic Detectable New patient available Yes quality & Yes marginal bone full-mouth loss

No No No

Yes

Assess interdental Yes CAL loss

No Yes Suspect periodontitis

Buccal or oral rec & Yes PPD >3mm Localised gingivitis

No

BoP 10-30%

Periodontal <10% Measure ≥10% Gingivitis health BoP

BoP >30%

Generalised gingivitis

Proceed to Step 2

64 María Rioboo et al. Clinical case 2. Generalized periodontitis. Stage I. Grade B. Clinical case

Figure 3. Periodontogram and periapical x-ray series.

65 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

STEP 2 On not detecting local factors and with attachment loss > 1 mm in more than one non- adjacent tooth (the probing depths are > 4 mm in interproximal), it is confirmed as a case of periodontitis and STEP 3 is then performed to determine the stage and the grade.

Endo-perio lesion

Vertical root fracture

Suspect Local factors Yes periodontitis only Caries or restoration

No Impacted wisdom tooth

CAL loss Suspect Assess gingivitis No and monitor >1 N-A tooth periodontitis

Step 1: Step 1: Measure Periodontal Measure BoP charting & BoP radiographs

Periodontitis BoP No PPD 4mm Yes or more case

No BoP BoP + Periodontal & bone appraisal Reduced but healthy Gingival inflammation periodontium patient in periodontitis patient

Staging & grading

66 María Rioboo et al. Clinical case 2. Generalized periodontitis. Stage I. Grade B. Clinical case

STEP 3A At this point, we establish the extent. In this case, the attachment loss affects more than 30% of the teeth (pocket depths > 4 mm in more than 30%), so it would therefore be treated as generalized periodontitis.

Periodontitis case Periodontal chart Periodontal history (PTL) Full mouth x-rays Periodontitis < 30 % case Periodontal Extent & bone (% teeth) appraisal 30% Periodontitis or more case Severity & complexity

Severity of CAL loss, bone loss, breakdown periodontal tooth loss

Pocket depth, intrabony defects, furcation, tooth hypermobility, Complexity of management secondary occlusal trauma, bite collapse, drifting, flaring, <10 occluding pairs

Stage I Stage II Stage III Stage IV periodontitis periodontitis periodontitis periodontitis

Proceed to grading

67 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

STEP 3B Then we would distinguish if the case is in stages I-II or III-IV. Starting with the severity, the patient presents detectable attachment loss < 5mm and radiographic bone loss in the first third of the root, type I furcation, and no absent teeth; thus, the patient is stage I or II.

Periodontitis case

< 30 % Localised Periodontal & bone Extent appraisal (% teeth)

> 30 % Generalised Severity & complexity

Coronal Level of Class II or III bone/CAL furcation third < 5 mm loss No

Yes

Pocket depth* > 5 mm

Stage III or IV periodontitis 3-5 mm

Periodontal Yes tooth loss

No

Stage I or II periodontitis

Proceed to grading

68 María Rioboo et al. Clinical case 2. Generalized periodontitis. Stage I. Grade B. Clinical case

STEP 3C To distinguish if it is stage I or II, we focus on the percentage of bone loss, which in this case is < 15%, and on the attachment loss, which is of 1-2 mm. Thus, the patient could be diagnosed with stage I generalized periodontitis.

Periodontitis case

< 30 % Localised Periodontal & bone Extent appraisal (% teeth)

˃ 30 % Generalised Severity & complexity

BL coronal third Level of Class II or III Perio tooth CAL < 5mm bone/CAL loss > 4 furcation loss No

1-4 BL middle third CAL CAL 5mm or more

Yes 10 or more Pocket > 5 mm depth occluding No pairs

3-5 mm Yes Stage IV periodontitis

Bite Stage III collapse, Periodontal Yes or IV drifting, Yes tooth loss periodontitis flaring

No No

Level of Stage I or II bone/CAL periodontitis loss Severe Sí ridge effect

No BL <15% BL 15-33% CAL 1-2 mm CAL 3-4 mm Stage III periodontitis

Stage I Stage II Proceed to periodontitis periodontitis grading

69 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

PASO 4 With no previous records of the patient, bone loss is then estimated according to age to determine the grade. The bone loss could be estimated at 8% (with periapical x-ray of the most affected tooth) which, in a patient aged 28 years, would give a result of 0.28, which would result in a grade A. But in this case the grade is modified by smoking as the patient is a smoker of 5 cigarettes/day and would therefore move to grade B.

Periodontitis case

Grade A periodontitis < 0,25

Previous Apply records No Bone Grade B 0.25-1.0 periodontitis grade available loss/age modifiers

Yes > 1,0 Grade C periodontitis

Estimate progression (5 years)

Smoking Diabetes Proceed No diabetes to 4b

No smoking <10/day 10 or more/day Yes Yes HbA1c<7.0 HbA1c 7.0 or more

No change Upgrade Upgrade in grade to B to C

70 María Rioboo et al. Clinical case 2. Generalized periodontitis. Stage I. Grade B. Clinical case

TREATMENT

AFTER A SYSTEMIC PHASE OF ADVICE on quitting smoking (Fargeström test), the basic anti-inflammatory phase was performed consisting of instructions in oral hygiene and scaling and root planing by quadrants in two sessions, together with the adjuvant use of chlorhexidine 0.12%, twice daily for two weeks. In addition, during this phase, the wisdom teeth were extracted for orthodontic reasons.

Figure 4. Re-evaluation periodontogram after the initial phase in which the significant reduction of all the indices (plaque reduced to 10% and bleeding to 6%) and the substantial reduction of pocket depths, leaving only 2% of shallow pockets as well as closing the type I mandibular furcations.

71 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

Figure 5. Intraoral clinical photographs in occlusion and by sextant, where one appreciates the change of gingival colour, the appearance of interdental spaces, and a good plaque control maintained by the patient despite the orthodontic apparatus.

DISCUSSION

ONE OF THE CLINICAL SITUATIONS that is hardest to diagnose at the right time is the start of periodontitis in cases where the patient presents signs of gingival inflammation where the bone loss is still not very evident, as could be seen in this case. One of the points that we could question in the diagnosis of this case is the extent of the disease. Because of this it is important to differentiate if there are pseudo-pockets and detect the cementoenamel junction (CEJ). While the patient presents pockets > 4 mm in more than 30% of sites, the radiographic bone loss seems to be evident in < 30% of sites. In terms of the stage, the pocket depths the patient presents also cause us to wonder whether it is stage II (pockets > 5 mm) or even stage III for having pockets > 6 mm. As described in the implementation of the current classification (Tonetti and Sanz 2019), clinical judgement should be applied in terms of the parameter of pocket depth (PD) to categorize a patient as one stage or another. In this case, they could be attributed to pseudo-pockets as the bone loss is < 15% and the PI is 1-2 mm. It would be necessary to consider that the condition as an oral breather plays a role in the gingival hyperplasia that leads to the formation of pseudo-pockets, which can confuse us when diagnosing the patient.

BIBLIOGRAPHICAL REFERENCES

Tonetti MS, Sanz M. (2019) Implementation of the new classification of periodontal diseases: Decision- making algorithms for clinical practice and education Journal of Clinical Peridontology 46, 398-405. 72 ADVERTISING

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73 74 Clinical case

CLINICAL CASE 3. GENERALIZED PERIODONTITIS. STAGE III. GRADE B.

ANA MARCOS TERÁN, MARÍA RIOBOO, IGNACIO SANZ MARTÍN, ION ZABALEGUI.

Ana Marcos Terán. Private practice exclusively in periodontology in Bilbao. ABSTRACT María Rioboo. European Doctorate in Dentistry (UCM). Master’s degree in periodontology THIS CLINICAL CASE explains step by step the decisions-making in classifying, using and implants (UCM) and accreditation by the the new classification algorithm, a case of generalized periodontitis stage III grade EFP. Associate professor of the Department of B. Initially the suspicion of periodontitis is confirmed with the record of a complete Clinical Specialities of the UCM. periodontogram. Suspecting periodontitis, x-rays are analysed to see if the attachment Ignacio Sanz Martín. Teacher of the master’s loss affects more than 30% of sites, in which case we would classify the case as generalized degree in periodontology of the Complutense periodontitis. In the next step, we establish the stage based on the severity of the case University of Madrid (UCM). Guest lecturer, taking into account clinical attachment loss, bone loss, and the complexity of the case with Department of Periodontology at Tufts an infrabony defect at #11 and fanning of the teeth (the main reason for the consultation University School of Dental Medicine. is because of the increase in the inter-incisive diastema). For these reasons, we classify Ion Zabalegui. Private practice exclusively in the patient as generalized periodontitis stage III; and finally, to obtain the grade we periodontology in Bilbao. evaluate the ratio BL/age and in our case the patient presents a bone loss of 75% and an age of 45 years, for which the ratio is greater than 1 with no additional risk factor, and the patient is classified as generalized periodontitis stage III, grade B. CASE PRESENTATION

A 45-YEAR-OLD WOMAN PATIENT who attends the clinic sent by her general dentist Correspondence to: to evaluate the periodontal state of her mouth, The main reason for the patient’s Ana Marcos Terán consultation is: I note bad breath, bleeding and inflammation since four years ago despite [email protected] three years in periodontal treatment. In addition, the upper incisors have flared.

75 Ana Marcos Terán María Rioboo Ignacio Sanz Martín Ion Zabalegui Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

In terms of her medical history, the patient presents a chronic autoimmune thyroiditis and thus without need for treatment. She has been an ex-smoker for 5 years. Her dental history indicates the patient’s interest in resolving her periodontal problem, as periodontal access surgery has just been performed in the mandible four weeks earlier and prophylaxis has been performed frequently for a long time. She also had orthodontic treatment 9 years ago.

Figure 1. Initial clinical appearance with alteration of all the gingival morphological aspects: colour, size, form, and texture.

No noteworthy signs were found in the extraoral examination, although the intraoral examination detected a congenital diastema between the central incisors which was treated 9 years ago; an overbite of 6 mm with occlusal trauma in protrusive (eccentric fremitus). The gingival aspect presents an evident increase in size, change in colour with reddened gums, very inflamed – especially in sextant II – as well as loss of the scalloped and fine shape and habitual texture compatible with gingival health Suspecting periodontitis, the patient was offered a complete radiographic examination. The patient brought a panoramic x-ray and, given the situation with her thyroids, it was decided not to perform a complete periapical series. Two periapical x-rays of the anterior- superior sextant were performed, the zone most affected by attachment loss and marginal- bone loss.

b)

c) a)

Figure 2. a) Initial panoramic x-ray; b) and c) peri-apical x-rays in which one appreciates significant attachment loss in mesial of 11 and moderate in mesial of 21. 76 Ana Marcos Terán et al. Clinical Case 3. Generalized Periodontitis. Stage III. Grade B Clinical case

A full clinical examination was also performed, recording all the periodontal parameters reflected in the periodontogram (Florida Probe System® FL, USA). Her results showed periodontal pockets ≥ 6 mm in 70% of sites, a bleeding index of 100%, and a plaque index of 48%. In addition, she presented mobility of grade I in the superior incisors.

Figure 3. Initial periodontogram showing the degree of inflammation and periodontal pockets.

As complementary diagnostic tests, volatile sulphurous compounds were measured (Oral Chroma®), this being one of her concerns in seeking the consultation. Similarly, qualitative microbiological analysis was performed, taking into account the pattern of inflammation despite the fact that the patient has had three years of periodontal treatment with her habitual dentist and without clinical improvement, using a DNA probe (Sunstar, Guidor). Her result revealed the presence of Porphyromonas Gingivalis, Tannerella Forshytia, and Treponema Denticola, all of which belong to the “red” series (World Workshop 1996), as well as others belonging to the “orange” series (Prevotella intermedia, Parvimonas micra and Fusobacterium nucleatum).

77 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

Figure 4. Result of the qualitative periodontal analysis carried out at the first visit as a complementary test, with the aim of determining the profile of the periodontal infection presented by the patient. Result of the study using OralChroma® altered by the prior use of chlorhexidine mouth rinse. 78 Ana Marcos Terán et al. Clinical Case 3. Generalized Periodontitis. Stage III. Grade B Clinical case

In 2013, the patient was diagnosed, according to Armitage’s classification, with a moderate generalized chronic periodontitis, advanced localized periodontitis, and bleeding on probing of 100%. In terms of the inter-arch relationship, there was an overbite of 6 mm and an overjet of 4 mm, as well as occlusal trauma and fremitus in eccentric dissolution in the anterior front and augmented congenital interincisal diastema. As treatment, anti-inflammatory periodontal treatment was proposed and carried out consisting of instructions in oral hygiene and in scaling and root planing in 24 hours (Full-Mouth Disinfection-Kinane 2004). After 4 weeks, full periodontal records were taken to evaluate the response, as can be appreciated in the photographs and periodontal data (Florida Probe System®).

Figure 5. Appearance after anti-inflammatory periodontal treatment.

Later, advanced regenerative periodontal treatment was performed in sextant II with the elimination of the irritants and polishing of the development furrow on the root surface of #11 mesiopalatine and the application of enamel-derived proteins (Emdogain®, Straumann), as well as metronidazole 500 mg every 8 hours for 7 days.

Figure 6. 79 Appearance after the cicatrization of advanced periodontal regenerative treatment with Emdogain® (Straumann). Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

With the New Classification of the 2017 World Workshop on Periodontal and Peri- implant Diseases and Conditions (“the World Workshop”), this patient would have been categorized as periodontitis stage III, grade B.

severity of complexity Staging disease at of disease = presentation + management

information on biological rate of risk Grading = features + progression + assessment of disease

To classify the periodontitis presented by the patient in stages and grades, we turn to the decision-making algorithm Suspecting periodontitis in our patient, clinical attachment loss (CAL) is measured in more than one tooth and x-rays are performed in the anterior sextant (the most-affected zone) as well as periodontal probing to record the interproximal attachment loss which does not involve only local factors, and a complete periodontogram is performed. The patient presents periodontitis, as probing depths of > 4 mm were found at various sites. Once the patient is diagnosed with periodontitis, it will be necessary establish the stage and the grade.

80 Ana Marcos Terán et al. Clinical Case 3. Generalized Periodontitis. Stage III. Grade B Clinical case

Endo-perio lesion

Vertical root fracture

Suspect Local factors Yes periodontitis only Caries or restoration

No Impacted wisdom tooth

CAL loss Suspect Assess gingivitis No and monitor >1 N-A tooth periodontitis

Step 1: Step 1: Measure Periodontal Measure BoP charting & BoP radiographs

Periodontitis BoP No PPD 4mm Yes or more case

No BoP BoP + Periodontal & bone appraisal Reduced but healthy Gingival inflammation periodontium patient in periodontitis patient

Staging & grading

First, we will evaluate the extent of the disease, analysing whether the CAL or the bone loss (BL) affects more than 30% of sites, as is the case here, which will be classified as generalized periodontitis. To establish the stage of periodontitis in this patient, we assess the severity (through the CAL, BL and teeth lost to periodontitis), and the complexity (evaluating the PD: probing depth) of the periodontitis. With this patient, we have a generalized periodontitis, stage III (pockets in more than 30% of sites, vertical defect at #11), grade B because of the BL/age ratio and absence of risk factors.

81 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

Periodontitis case Periodontal chart Periodontal history (PTL) Full mouth x-rays Periodontitis < 30 % case Periodontal Extent & bone (% teeth) appraisal 30% Periodontitis or more case Severity & complexity

Severity of CAL loss, bone loss, breakdown periodontal tooth loss

Pocket depth, intrabony defects, furcation, tooth hypermobility, Complexity of management secondary occlusal trauma, bite collapse, drifting, flaring, <10 occluding pairs

Stage I Stage II Stage III Stage IV periodontitis periodontitis periodontitis periodontitis

Proceed to grading

82 Ana Marcos Terán et al. Clinical Case 3. Generalized Periodontitis. Stage III. Grade B Clinical case

Periodontitis case

< 30 % Localised Periodontal & bone Extent appraisal (% teeth)

˃ 30 % Generalised Severity & complexity

BL coronal third Level of Class II or III Perio tooth CAL < 5mm bone/CAL loss > 4 furcation loss No

1-4 BL middle third CAL CAL 5mm or more

Yes 10 or more Pocket > 5 mm depth occluding No pairs

3-5 mm Yes Stage IV periodontitis

Bite Stage III collapse, Periodontal Yes or IV drifting, Yes tooth loss periodontitis flaring

No No

Level of Stage I or II bone/CAL periodontitis loss Severe Sí ridge effect

No BL <15% BL 15-33% CAL 1-2 mm CAL 3-4 mm Stage III periodontitis

Stage I Stage II Proceed to periodontitis periodontitis grading

83 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

Periodontitis case

Grade A periodontitis < 0,25

Previous Apply records No Bone Grade B 0.25-1.0 periodontitis grade available loss/age modifiers

Yes > 1,0 Grade C periodontitis

Estimate progression (5 years)

Smoking Diabetes Proceed No diabetes to 4b

No smoking <10/day 10 or more/day Yes Yes HbA1c<7.0 HbA1c 7.0 or more

No change Upgrade Upgrade in grade to B to C

Fortunately, in this case we have information about its development 5 years later. Periodontal stability is observed both in the clinical images and in the periodontal and radiographic records, and in some zones there is even clinical attachment gain as well as the partial correction of the diastema.

84 Ana Marcos Terán et al. Clinical Case 3. Generalized Periodontitis. Stage III. Grade B Clinical case

Figure 7. Control x-ray series carried out at 5 years, which shows the maintenance of the level of radiographic insertion, as well as gain between the central incisors, compared with the x-rays of the figure.

Figure 8. Periodontogram 5 years later.

BIBLIOGRAPHICAL REFERENCES

Armitage GC. (2005) Dignosis and classification of Apatzidou DA, Kinane DF. (2004) Quadrant root periodontal diseases. Periodontology 2000 9, 9-21. planing versus same-day full-mouth root planing. I: Clinical findings. Journal of Clinical Periodontology 31,132-140.

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CLINICAL CASE 4. PERIODONTITIS. STAGE III. GRADE C.

IGNACIO SANZ MARTÍN, ANA MARCOS TERÁN, ION ZABALEGUI, MARÍA RIOBOO.

Ignacio Sanz Martín. Teacher of the master’s degree in periodontology of the Complutense ABSTRACT University of Madrid (UCM). Guest lecturer, Department of Periodontology at Tufts THIS CLINICAL CASE presents a detailed, step-by-step description of the diagnosis of University School of Dental Medicine. a patient with periodontitis in stage III, grade C, according to the new classification of Ana Marcos Terán. Private practice exclusively periodontal diseases. In the first step, it is confirmed through periodontal probing that the in periodontology in Bilbao. patient has attachment loss. Step 2 shows attachment loss > 1 mm in more than one non- Ion Zabalegui. Private practice exclusively in adjacent tooth, and probing depths of > 4 mm. In step 3A, with the patient presenting 30% periodontology in Bilbao. of teeth with attachment loss, the case is classified as generalized periodontitis. In step María Rioboo. European Doctorate in Dentistry 3B, having two teeth with grade II furcation, it is classified as stage III or IV. Next, in step (UCM). Master’s degree in periodontology 3C, not having lost more than five teeth, having more than 10 opposing pairs, presenting and implants (UCM) and accreditation by the bite collapse, and having occlusal stability, the case is classified as stage III. Finally, the EFP. Associate professor of the Department of patient has approximately 40% bone loss in tooth 12; this value divided by her age of 32 Clinical Specialities of the UCM. years gives a result > 1, for which reason the case is classified as grade C. ANTECEDENTS AND CASE PRESENTATION

A 32-YEAR-OLD WOMAN PATIENT who is referred to the clinic by her general dentist; the patient does not bring previous x-rays. Basic periodontal therapy was performed 12 months previously. Nonetheless, despite the treatment performed, the patent still Correspondence to: presents localized pockets and bleeding on probing. The patient is a smoker of a packet of Ignacio Sanz Martín cigarettes per day. She does not take medication, has no known allergies, and has not be [email protected] diagnosed with any medical condition.

89 Ignacio Sanz Martín Ana Marcos Terán Ion Zabalegui María Rioboo Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

In terms of dental history, before receiving basic periodontal therapy the patient visited the dentist at least once a year and an annual prophylaxis was performed. At the time of the visit, she was brushing once per day, and not using interproximal brushes or dental floss. She referred to having lost 16 and 26 because of caries. In addition, the patient has a tongue piercing. The day of the first consultation shows a plaque index of 72% and a bleeding index of 73%. Grade I furcation at 17, 27, 36, 37 and 46, and grade II at 17 and 27.

Figure 1. Clinical situation at maximum intercuspidation.

Figure 2. Periodontogram at the time of the first visit.

In addition, she presents fremitus at 12 and 22. In the same way, 22 presents pathological migration and the patient says that she has noticed that this tooth has moved during the last year.

90 Ignacio Sanz Martín et al. Clinical case 4. Periodontitis. Stage III. Grade C. Clinical case

Figure 3. The patient’s smile.

DIAGNOSIS ACCORDING TO THE NEW CLASSIFICATION

STEP 1 As the patient did not provide radiographic records, during the first visit clinical attachment loss was detected; suspecting periodontitis, we proceed to step 2.

X-Rays Diagnostic Detectable New patient available Yes quality & Yes marginal bone full-mouth loss

No No No

Yes

Assess interdental Yes CAL loss

No Yes Suspect periodontitis

Buccal or oral rec & Yes PPD >3mm Localised gingivitis

No

BoP 10-30%

Periodontal <10% Measure ≥10% Gingivitis health BoP

BoP >30%

Generalised gingivitis

Proceed to Step 2

91 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

STEP 2 Not detecting local factors, there is attachment loss > 1 mm in more than one non- adjacent tooth, and having probing depths > 4 mm, it is confirmed as a case of periodontitis and we proceed to step 3 to determine the stage and the grade.

Endo-perio lesion

Vertical root fracture

Suspect Local factors Yes periodontitis only Caries or restoration

No Impacted wisdom tooth

CAL loss Suspect Assess gingivitis No and monitor >1 N-A tooth periodontitis

Step 1: Step 1: Measure Periodontal Measure BoP charting & BoP radiographs

Periodontitis BoP No PPD 4mm Yes or more case

No BoP BoP + Periodontal & bone appraisal Reduced but healthy Gingival inflammation periodontium patient in periodontitis patient

Staging & grading

92 Ignacio Sanz Martín et al. Clinical case 4. Periodontitis. Stage III. Grade C. Clinical case

Figure 4. Periapical radiographic series.

STEP 3A Once the periapical series has been carried out, it can be shown that the patient has more than 30% of teeth with attachment loss, so it is classified as generalized periodontitis.

Periodontitis case Periodontal chart Periodontal history (PTL) Full mouth x-rays Periodontitis < 30 % case Periodontal Extent & bone (% teeth) appraisal 30% Periodontitis or more case Severity & complexity

Severity of CAL loss, bone loss, breakdown periodontal tooth loss

Pocket depth, intrabony defects, furcation, tooth hypermobility, Complexity of management secondary occlusal trauma, bite collapse, drifting, flaring, <10 occluding pairs

Stage I Stage II Stage III Stage IV periodontitis periodontitis periodontitis periodontitis

Proceed to grading

93 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

STEP 3B Having two teeth with grade II furcation, it is classified as stage III or IV.

Periodontitis case

< 30 % Localised Periodontal & bone Extent appraisal (% teeth)

> 30 % Generalised Severity & complexity

Class II or III Coronal Level of furcation third bone/CAL < 5 mm loss No

Yes

Pocket depth* > 5 mm

Stage III or IV periodontitis 3-5 mm

Periodontal Yes tooth loss

No

Stage I or II periodontitis

Proceed to grading

94 Ignacio Sanz Martín et al. Clinical case 4. Periodontitis. Stage III. Grade C. Clinical case

STEP 3C Not having lost more than 4 teeth, having more than 10 opposing pairs, and not presenting bite collapse, it is classified as stage III, despite the pathological migration at 12 which is not considered sufficient to classify the patient as stage IV.

Periodontitis case

< 30 % Localised Periodontal & bone Extent appraisal (% teeth)

˃ 30 % Generalised Severity & complexity

BL coronal third Class II or III Level of Perio tooth CAL < 5mm bone/CAL loss > 4 furcation loss No

1-4 BL middle third CAL CAL 5mm or more

Yes 10 or more Pocket > 5 mm depth occluding No pairs

3-5 mm Yes Stage IV periodontitis

Bite Stage III collapse, Periodontal Yes or IV drifting, Yes tooth loss periodontitis flaring

No No

Level of Stage I or II bone/CAL periodontitis loss Severe Sí ridge effect

No BL <15% BL 15-33% CAL 1-2 mm CAL 3-4 mm Stage III periodontitis

Stage I Stage II Proceed to periodontitis periodontitis grading

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STEP 4A With no previous records of the patient, the bone loss is estimated according to the age of the patient to determine the grade.

Periodontitis case

Grade A periodontitis < 0,25

Previous Apply records No Bone Grade B 0.25-1.0 periodontitis grade available loss/age modifiers

Yes > 1,0 Grade C periodontitis

Estimate progression (5 years)

Smoking Diabetes Proceed No diabetes to 4b

No smoking <10/day 10 or more/day Yes Yes HbA1c<7.0 HbA1c 7.0 or more

No change Upgrade Upgrade in grade to B to C

96 Ignacio Sanz Martín et al. Clinical case 4. Periodontitis. Stage III. Grade C. Clinical case

STEP 4B Bone loss of 40% is detected on 12 teeth divided by 32 years gives a result > 1, so the case is classified as grade C.

Periodontitis case

Grade A periodontitis No progression

Previous Level of Apply Yes Grade B records progression < 2 mm periodontitis grade available (5 years) modifiers

No 2 mm or more Grade C periodontitis

Estimate bone loss by age

Smoking Diabetes No diabetes Proceed to 4a No smoking <10/day 10 or more/day Yes Yes HbA1c<7.0 HbA1c 7.0 or more

No change Upgrade Upgrade in grade to B to C

97 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

TREATMENT

INITIAL PHASE: despite the performance of basic periodontal therapy 12 months earlier and clinically observing that there are still deposits of subgingival calculus, it is decided to carry out a new session of scaling and root planing. As part of the initial therapy, the patient visited her family doctor who prescribed medication to quit smoking, with positive results. Three months later, the re-evaluation is carried out and it is observed that there are deep residual probing depths in the four quadrants; it is decided to carry out a surgical phase that involves performing regenerative surgery in the first, second, and third quadrants and resective surgery in the fourth, Regenerative surgery: third quadrant. At the time of the periodontal re-evaluation, residual pockets are found in mesial of 36 and 37.

Figure 5. Re-evaluation periodontogram after the initial phase.

98 Ignacio Sanz Martín et al. Clinical case 4. Periodontitis. Stage III. Grade C. Clinical case

Figure 6. Pre-operation photograph which shows a probing depth of 7-8 mm and x-ray showing the angular bone defects.

Figure 7. Once the flap has been elevated with a papilla-preservation technique and the granulation tissue of the defect has been removed, the bone loss and attachment loss at the inferior molars is observed.

Figure 8. A collagen membrane and an allogenic demineralized bone substitute are used.

99 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

Figure 9. Suture using ePTFE and Guidor stitches.

Figure 10. Clinical image one year after regenerative therapy.

Initial

Figure 11. X-ray images showing the radiographic changes on the regenerated tissue and the mineralization of the intrabony defect.

100 Ignacio Sanz Martín et al. Clinical case 4. Periodontitis. Stage III. Grade C. Clinical case

Figure 12. Post-operative clinical image which shows probing depths of 6-7 mm and periapical radiographies that show bone loss at 15 and 16.

Figure 13. Papilla preservation is performed in the zones of 14-15 and 15-16.

Figure 14. Images after elevating the flap and removing the granulation tissue of the defect at mesial of 16. A bone substitute and resorbable collagen membrane was placed and primary closure is performed.

101 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

Figure 15. Clinical and radiographic image 6 months after regenerative therapy in which a radiographic filling of the defect can be observed.

Figure 16. Periodontogram 6 months after completing surgical periodontal therapy.

102 Ignacio Sanz Martín et al. Clinical case 4. Periodontitis. Stage III. Grade C. Clinical case

Figure 17. Clinical images at the time of placement of the fixed apparatus.

Figure 18. Clinical image after completing orthodontic treatment.

DISCUSSION

THE CASE PRESENTED IN this article has been used to illustrate the sequence of diagnosis according to the new classification of periodontal disease. In this case, it has been decided to classify the patient as stage III despite having a pathological migration at tooth 12. In this specific case, it has been considered that this migration was one-off and localized as the patient presented stable occlusion in the other teeth. It has thus been decided to give more weight to factors such as the presence of more than 10 opposing pairs, the fact that the lost pieces had been extracted because of caries, and that the patient did not present a collapse of the bite or defects of the alveolar ridge. With all this, the case was resolved with an interdisciplinary approach (characteristic of stage IV). Despite this fact, the treatments of orthodontics, implantology, and prosthesis performed were considered relatively simple given the minimal dental movements needed to align the teeth and the good bone availability for placing an implant at 28. In these clinical situations, it must be the dentist who, through their judgement and experience, decides the stage evaluating the degree of complexity in the case. In the same way, it is important to emphasize that the degree of bone loss in the patient immediately puts her case in grade C because of the ratio of the percentage of bone loss. If this ratio had been lower, it would have been necessary to increase to grade C because of her smoking habit of more than 20 cigarettes per day at the time of the first visit.

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CLINICAL CASE 5. GENERALIZED PERIODONTITIS. STAGE IV. GRADE C.

ANA MARCOS TERÁN, MARÍA RIOBOO, IGNACIO SANZ MARTÍN, ION ZABALEGUI.

Ana Marcos Terán.Private practice exclusively in periodontology in Bilbao. ABSTRACT María Rioboo. European Doctorate in Dentistry (UCM). Master’s degree in periodontology WE PRESENT THE CLINICAL CASE of a patient to classify it using the new and implants (UCM) and accreditation by the classification of stages and grades following the decision-making tree (Tonetti and Sanz EFP. Associate professor of the Department of 2019). In light of the main reason for the first consultation, the patient is given a complete Clinical Specialities of the UCM. periodontal examination with periapical x-ray series and complete periodontogram. Once Ignacio Sanz Martín. Teacher of the master’s the presence of periodontitis is established in step 2, we move to step 3a to determine the degree in periodontology of the Complutense extent of the attachment loss, in this case > 30%, classifying our patient as generalized University of Madrid (UCM). Guest lecturer, periodontitis. In the following step, the severity of the case is verified to establish the Department of Periodontology at Tufts stage, and our patient presents an attachment loss > 5 mm and a radiographic bone loss University School of Dental Medicine. superior to the middle third of the roots, which means it would be stage III or IV. Turning Ion Zabalegui. Private practice exclusively in to the severity to be able to assign the stage with more precision, our case presents periodontology in Bilbao. dental migration with mesialization of the molars adjacent to the edentulous sections and fanning of the anterior teeth because of loss of posterior support, as well as furcation lesions and dental mobility; we thus have a case of generalized periodontitis, stage IV. Correspondence to: Finally, to obtain the grade in this case without previous records that allow us to evaluate Ana Marcos Terán the evolution of the periodontitis, we use the BL/age ratio, which is > 1, so it is grade C [email protected] even though there are no further risk factors such as smoking or diabetes.

107 Ana Marcos Terán María Rioboo Ignacio Sanz Martín Ion Zabalegui Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

CASE PRESENTATION

MALE 50-YEAR-OLD PATIENT who comes to the periodontist sent by his family. He had never been to the dentist. His main reason for the consultation is: to put an end to the chaos in my mouth which, out of fear, I have not taken care of and now I have a general discomfort in the whole mouth and mobility of the teeth. In terms of his medical history, he is an ASA type I patient, non-smoker. In this case, we will apply the decision-making tree for the classification of periodontitis by stages and grades. A new patient for whom a complete radiographic study is performed, along with full extra- and intraoral examination and recording of periodontal parameters.

X-Rays Diagnostic Detectable New patient available Yes quality & Yes marginal bone full-mouth loss

Yes

Suspect periodontitis

Proceed to Step 2

Figure 1. Step 1. New patient, first visit with parameters of bone loss and attachment loss; suspected of periodontitis.

108 Ana Marcos Terán et al. Clinical case 5. Generalized periodontitis. Stage IV. Grade C. Clinical case

In the extraoral examination we find an anomaly only in the breathing habit, which is mainly oral. In the intraoral examination a congenital interincisive diastema and a narrow band of keratinized tissue is found in #43 buccal. In addition, a large quantity of bacterial deposits is noted and a gingival-margin appearance with significant changes of size, shape, texture, and colour. As can be observed in Figures 2 and 3, the gums appear enlarged, oedematous, shiny, and purplish in colour.

Figures 2 and 3. Frontal, lateral, and lingual photographs of the first visit.

109 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

Figure 4. Periapical radiographical series where bone loss (BL) is observed.

The periapical radiographic examination shows clearly detectable bone loss (BL). Also, the complete periodontal study reveals clinical attachment loss (CAL), recessions, deep probing depth, and a high bleeding index. With these diagnostic tests we can suspect that the patient has periodontitis and we can continue to the clinical decision-making tree for the classification of stages and grades.

Figures 5 and 6. Complete periodontogram with Florida® probe where the loss of clinical attachment (CAL) is appreciated and Oral-Chroma® diagram with high levels of volatile sulphurous compounds.

110 Ana Marcos Terán et al. Clinical case 5. Generalized periodontitis. Stage IV. Grade C. Clinical case

As an additional diagnostic test, the quality of breath was measured using Oral- Chroma®, and the sample registered high values of volatile sulphurous compounds (VSC) – both hydrogen sulphide (H2S) and methyl mercaptan (CH3SH) – present in the metabolism of certain proteins and in the bacterial waste material. In 2016, this patient was diagnosed according to the 1999 classification as chronic advanced generalized periodontitis, generalized recessions, furcation lesions, generalized mobility, severe objective halitosis, caries in #26 distal and congenital diastemas by agenesis.

Periodontitis case Periodontal Suspect Local factors chart periodontitis only Periodontal history (PTL) Full mouth x-rays No Periodontitis < 30 % case Periodontal Extent & bone (% teeth) appraisal CAL loss Suspect >1 N-A tooth 30% Periodontitis periodontitis or more case

Periodontal charting & radiographs

PPD 4mm Yes Periodontitis or more case

Periodontal & bone appraisal

Staging & grading Proceed to grading

Figures 7 and 8. Steps 2 and 3a of the decision-making tree for the classification of stage and grade.

111 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

In the current classification, we would follow step 2 and, using the records taken, we Periodontitis confirm that it is periodontitis because there is bone loss (BL), clinical attachment loss case (CAL), bleeding on probing, and furcation lesions, which leaves us at step 3a. This step is the one that considers the extent of the disease, in such way that if periodontitis affects more than 30% of the teeth it is considered generalized. Once the extent is established, Periodontal & bone we move to step 3b to classify the sage, starting with the severity. This patient presence appraisal CAL > 5 mm and radiographic BL > middle 1/3 of the roots, thus this is a patient with periodontitis stage III or IV. Severity & complexity We are in the step to establish the stage according to the complexity and in our case the patient presents PD > 6 mm, dental migration with mesialization, and fanning of the teeth in the edentulous sections, mobility of grade I to II, class II furcation lesions, and a defect of the crestal bone, which means that our patient presents generalized periodontitis Level of bone/CAL stage IV. loss

Periodontitis case

< 30 % Localised Periodontal Stage III or IV & bone Extent periodontitis appraisal (% teeth)

˃ 30 % Generalised Figure 9. Severity & complexity Step 3b.

Level of Perio tooth bone/CAL loss > 4 loss

1-4 BL middle third CAL CAL 5mm or more

10 or more occluding No pairs

Yes Stage IV periodontitis

Bite Stage III collapse, or IV drifting, Yes periodontitis flaring

No

Severe Sí ridge effect

Proceed to grading

Figure 10. Step 3c. 112 Ana Marcos Terán et al. Clinical case 5. Generalized periodontitis. Stage IV. Grade C. Clinical case

Once the patient’s stage has been classified, the grade is estimated with the progression of the disease which, if there are no previous records, is established using a ratio between bone loss and the age of the patient and taking risk factors into account. In this specific case, the patient would be classified as generalized periodontitis stage IV, grade C.

Periodontitis Periodontitis case case

Grade A periodontitis Periodontal < 0,25 & bone appraisal

Previous Apply Severity & complexity records No Bone Grade B 0.25-1.0 periodontitis grade available loss/age modifiers

Level of > 1,0 bone/CAL Grade C loss periodontitis

BL middle third CAL CAL 5mm or more

Smoking Diabetes No diabetes

No smoking <10/day 10 or more/day Yes Yes HbA1c<7.0 HbA1c 7.0 or more

Stage III or IV No change Upgrade Upgrade periodontitis in grade to B to C

Figure 11. Step 4a. BL/age ratio >1 (85% de BL/50 years), thus the diagnosis is grade C.

The patient received basic periodontal treatment that consisted of oral-hygiene instruction and motivation techniques, and scaling and root planing.

113 Periodoncia Clínica 01 2019 / 15 ‘New classification of periodontal and peri-implant diseases‘

Figure 12. Post-treatment frontal and lateral photographs. Periodontal parameters taken at the re-evaluation visit 6 weeks after the treatment.

Figure 13. Result of the measurement of volatile sulphurous compounds – one of the main reasons for the patient’s consultation – significantly reduced after the treatment.

The patient is now is in the phase of preventive treatment for periodontal reinfection every four months and evaluating the possibility of an orthodontic treatment to establish a better inter-arch relationship, as well as to improve the posterior collapse.

BIBLIOGRAPHICAL REFERENCES

Tonetti MS, Sanz M. (2019) Implementation of the new classification of periodontal diseases: Decision-making algorithms for clinical practice and education. Journal of Clinical Periodontology 46, 398-405. 114 ADVERTISING GMT 60588 GB © Nobel Biocare Services AG, 2019. All rights reserved. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is is or else is stated nothing if are, trademarks logotype and all other the Nobel Biocare Nobel Biocare, reserved. All rights 2019. ServicesAG, 60588 GB © Nobel Biocare GMT not images are Product information. more for nobelbicare.com/trademarks to Please refer Nobel Biocare. of trademarks in a certain case, the context from evident current for sales of�ice Nobel Biocare the local Please contact sale in all markets. for cleared/released be regulatory not may Disclaimer: Some products scale. to necessarily dentist. a licensed See of the order on or sale by to this device restricts law States) (United Federal Caution: use only. prescription For assortment and availability. product and precautions. warnings contraindications, including indications, information, prescribing full for Use Instructions For Surface chemistry cells can’t resist.

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Long-term impact of powered toothbrush on oral health: 11-year scientific cohort study Oral B Enamel-derived matrix stabilizes articles blood clotting and improves clinical cicatrization in deep pockets after flapless periodontal therapy: a of randomized clinical trial Straumann Clinical efficacy of an oscillating rotary interest toothbrush with exclusive head design and ultrafine bristles Sunstar to Clinical results of alveolar-ridge augmentation with yxoss cbr®: a retrospective study businesses Inibsa Dental A clinical investigation shows the efficacy of Colgate® Total in controlling halitosis Colgate

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LONG-TERM IMPACT OF POWERED TOOTHBRUSH ON ORAL HEALTH: 11-YEAR COHORT STUDY.

such as average probing depth CLINICAL RELEVANCE BIBLIOGRAPHICAL REFERENCE variables and average attachment loss; dental-health data such as Scientific thinking of the study: caries indices CAOD and CAOS), electric brushes have been in the SCIENTIFIC ARTICLES OF INTEREST TO BUSINESSES SCIENTIFIC ARTICLES OF INTEREST TO BUSINESSES Pitchika V, Pink C, Völzke H, Welk A, adjusting potential covariables of market for a long time and their Kocher T, Holtfreter B. (2019) Long- term impact of powered toothbrush the initial data. efficacy has been demonstrated in on oral health: 11-year cohort study. numerous clinical and observational Journal of Clinical Periodontology 46, RESULTS studies. However, the long-term 713-722. The number of participants efficacy of electric brushes in a included at the start of the study specific population had not been was 2,819 (SHIP-1). During the studied. 11-year observation period, the number of users of electric brushes Main findings: users of electric AIM OF STUDY increased from 18.3 % (SHIP-1) brushes presented a reduction in This study seeks to evaluate the to 36.9 % (SHIP-3). These were the progression of probing depth long-term effects over 11 years of the youngest, had significantly and clinical attachment loss. Over electric toothbrushes on periodontal lower average measurements for the long term, this was translated health, caries, and tooth loss in an probing depth and progression into maintenance of more teeth in adult population in Pomerania, of attachment loss (21%) and the mouth. Germany. presented an increase of the CAOS index that was 17.7% lower. In Practical implications: electric MATERIAL AND METHOD addition, they presented an average toothbrushes seem to be a Participants were included from of 19.5% more teeth in the mouth preventive tool that is effective in the Study of Health in Pomerania than users of manual brushes. the maintenance of oral health. (SHIP) which had data of Dental professionals should consultations and dental check- CONCLUSIONS therefore recommend their use. ups during the time of the study In the long term, electric (SHIP-1, SHIP-2, SHIP-3). Models toothbrushes seem to be efficient using linear regression analysis in reducing probing depth and the were applied with mixed effects progression of clinical attachment between exposure (manual brush loss as well as increasing the versus electric brush) and result number of teeth maintained in the variables (periodontal-health data mouth.

Rate of Rate of variation variation % difference Variable in users in users (electric vs p-value (average) of manual of electric manual) brushes brushes

Probing depth 0.41 0.32 -22 % p < 0.05

Clinical 0.93 0.74 -21 % p < 0.05 attachment loss

CAOS 7.43 6.11 -17,7 % p < 0.05

Number of teeth 1.86 1.5 19,5 % p < 0.05 present

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ENAMEL-DERIVED MATRIX STABILIZES BLOOD CLOTTING AND IMPROVES CLINICAL CICATRIZATION IN DEEP POCKETS AFTER FLAPLESS PERIODONTAL THERAPY:

A RANDOMIZED CLINICAL TRIAL. SCIENTIFIC ARTICLES OF INTEREST TO BUSINESSES

the groups in relation to D-dimer (p CONCLUSIONS BIBLIOGRAPHICAL REFERENCE < 0.001). The application of EMD The application of EDM after was also associated with a greater a non-surgical SRP led to a Graziani F, Gennai S, Petrini M, Bettini periodontal cicatrization, a fact lesser fibrinolysis and a greater L, Tonetti M. (2019) Enamel matrix shown by a greater reduction of periodontal cicatrization in deep derivative stabilizes blood clot and pockets. These initial observations PD and clinical attachment gain in improves clinical healing in deep pockets justify carrying out future studies after flapless periodontal therapy: A sites with PD ≥ 6 mm and a greater on the potential for modulation of Randomized Clinical Trial. Journal of number of cases without residual Clinical Periodontology 46, 231-240. the local and systemic results of PD ≥ 6 mm (p < 0.05) at 3 months. non-surgical SRP.

AIM After a non-surgical periodontal treatment (SRP) a response to the acute phase was induced. The main objective of this trial was to compare the inflammation and the a) a) clinical results of the acute phase (24 hours) and in the medium term (3 months) after SRP with or without the application of enamel- derived matrix (EDM) in sites with probing depths (PD) ≥ 6 mm. b) b)

METHODS Thirty-eight subjects affected by periodontitis were randomly assigned to SRP or SRP + EDM. Periodontal parameters were c) c) recorded at the starting point and at 3 months. Serological samples were taken at the starting point, 1 month, and 90 days after the treatment. d) d) RESULTS The two treatments triggered an intense acute inflammation on day 1, returning to the initial values at 3 months. The levels of D-dimer and cystatin C did not e) e) present marked increases in the Figure 1. Figure 2. Clinical application of EDM on the mesial Clinical application of EDM on the mesial group treatment with SRP + EDM papilla of tooth 1.1. a) probing before papilla of tooth 2.1. a) probing before 24 hours after the treatment, in treatment; b) instrumentation with treatment; b) instrumentation with ultrasound; c) application of PrefGel; d) ultrasound; c) application of PrefGel; d) comparison with SRP. A significant application of EDM; e) results three months application of EDM; e) results three months difference was observed between after the instrumentation. after the instrumentation. 122 ADVERTISING

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CLINICAL EFFECTIVENESS OF OSCILLATING ROTARY TOOTHBRUSH WITH TAPERED FILAMENTS.

pulsating electric toothbrush and when compared with manual with the head of the Oral-B Indicator brushes with conventional filaments. BIBLIOGRAPHICAL REFERENCES 35 manual toothbrush for its capacity The new GUM oscillating rotary to reach and remove artificial electric brush has ultrafine filaments plaque deposits from hard-to-reach in the two exterior rows of the SCIENTIFIC ARTICLES OF INTEREST TO BUSINESSES SCIENTIFIC ARTICLES OF INTEREST TO BUSINESSES Hoogteijling F, Hennequin-Hoenderdos NL, Van der Weijden GA, Slot DE. (2018) interproximal and subgingival sites. upper and lower parts of the head to The effect of tapered toothbrush The efficacy of interproximal strengthen its interproximal access filaments compared to end-rounded access was evaluated using an and in the last row of the lateral part filaments on dental plaque, gingivitis artificial plaque substrate around to increase subgingival access. and gingival abrasion: A systematic simulated teeth. The efficacy of the review and meta-analysis. International subgingival access was determined CONCLUSION Journal of Dental Hygiene 16, 3-12. using a simulated gum prepared In the laboratory tests carried out, Yacoob M, Worthington HV, Deacon SA, with a space of 0.2 mm between the there was a subgingival access that Deery C, Walmsley AD, Robinson PG, gum and the substrate of artificial was significantly greater in the GUM Glenny AM. (2014) Powered versus plaque that covered the simulated oscillating-rotating electrical brush manual toothbrushing for oral health. teeth. The results of the maximum and in Oral-B Precision Clean, in Cochrane Database of Systematic depth of plaque removed was comparison with the manual brush. Reviews 17, CD002281. registered on the same artificial Nonetheless, these measurements Vibhute A, Vandana KL. (2012) The plaque substrate placed below the were similar and not statistically effectiveness of manual versus gum and around the simulated teeth. significant between the two brushes, powered toothbrushes for plaque which both have great value. removal and gingival health: A mata- RESULTS In terms of the results on analysis. Journal of Indian Society of The general value of the effectiveness interproximal access, the values were Periodontology 16, 156-160. in interproximal access of the new considerably higher for the GUM GUM electric head indicated that electric brush than for the Oral-B it was significantly more effective electrical and manual brushes. INTRODUCTION that the Oral-B electric and In this way, the effectiveness in GUM has recently developed a new manual brushes (p < 0.001). The interproximal access of the double rechargeable electric toothbrush that average value of the effectiveness row of ultrafine filaments of GUM incorporates an oscillating-rotating in subgingival access for the GUM Power in comparison with the head with a unique design that electric brush and the Oral-B electric standard elongated nylon filaments combines ultrafine filaments with brush with the Precision Clean head of Oral-B Precision Clean is a conical tip to clean the difficult- were also significantly more effective demonstrated. to-access gingival and dental areas when compared to the Oral-B together with standard nylon Indicator 35 manual toothbrush CLINICAL RELEVANCE filaments to clean wider dental in subgingival access (p < 0.001). The presence of biofilm in surfaces. There was no significant difference interproximal and subgingival in subgingival access between the areas results in the development of AIM gingivitis if this dental plaque is not The aim of this study was to evaluate GUM and Oral-B electric brushes (p > 0.005). removed regularly and carefully. the efficacy of the exclusive head The superior efficacy shown by the design of the new GUM electric DISCUSSION head of the GUM oscillating rotary toothbrush with ultrafine filaments Both in electric and in manual electrical brush – which reaches a with conical tips in interproximal and brushes, ultrafine filaments with deeper level in those areas compared subgingival access, in comparison conical tips have been demonstrated with manual brushes – indicates with the Oral-B electric toothbrush to be effective in reducing plaque and that using this exclusive head of with the Precision Clean head and gingivitis and in achieving a better ultrafine filaments can be effective with the manual toothbrush Oral-B hygiene in the interdental areas and in the treatment and prevention of Indicator 35. the gingival and subgingival margin, gingivitis. The effectiveness in removing plaque in areas of difficult access was evaluated together with the possible Table 1. Interproximal Access Efficacy (IAE) Means and standard deviations relevance of this new GUM electric Product IAE Mean, cm (SD) toothbrush to the treatment and prevention of gingivitis. New GUM oscilating-rotating power toothbruh head 1.13 (0.10) Oral-B Precision Clean power toothbruh head 1.07 (0.09) MATERIAL AND METHODS This laboratory study compared the Oral-B Indicator Compact 35 Soft manual toothbruh 0.98 (0.15) new GUM oscillating rotary electric toothbrush with a unique head Table 2. Subgingival Access Efficacy (SAE) Means and standard deviations design, which combines standard Product SAE Mean, mm (SD) nylon filaments with ultrafine filaments with conical tips, with New GUM oscilating-rotating power toothbruh head 1.40 (0.22) the Precision Clean head of the Oral-B Precision Clean power toothbruh head 1.38 (0.36) Oral-B Pro 3000 oscillating-rotating- Oral-B Indicator Compact 35 Soft manual toothbruh 0.01 (0.07)

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CLINICAL RESULTS OF ALVEOLAR-RIDGE AUGMENTATION WITH YXOSS CBR®: A RETROSPECTIVE STUDY.

to leave the bone defect exposed. Despite an average follow-up of BIBLIOGRAPHICAL REFERENCE Autologous bone is collected with 12 ± 6 months, none of the 44 placed a scraper from an intraoral zone implants was lost (100% survival or the iliac ridge. The Yxoss CBR® rate). Sagheb K, Schiegnitz E, Moergel M, mesh is filled with a mixture of DISCUSSION Walter C, Al-Nawas B, Wagner autologous bone and Geistlich Bio- W. (2017) Clinical outcome of The rate of exposure of the mesh Oss® (50:50) or with autologous bone alveolar ridge augmentation with in this study is 33%, but it was individualized CAD-CAM-produced only. Two micro-screws are used to not necessary to remove the SCIENTIFIC ARTICLES OF INTEREST TO BUSINESSES titanium mesh. International Journal fix the mesh in the correct position. mesh prematurely in any case. of Implant Dentistry 3, 36. In terms of the treated cases, the mesh is left uncovered, covered In addition, the exposure of the with Geistlich Bio-Gide® resorbable mesh did not affect the final result collagen membrane, or covered with as it was possible to place all the a double layer of Geistlich Bio-Gide® implants in the desired position. INTRODUCTION resorbable collagen membrane Exposure of the titanium mesh The use of conventional titanium followed by platelet-rich fibrin (PRF) is a common complication, with meshes has been widely described membranes. At 6 months, the re- rates between 0 and 80% in the for vertical and/or horizonal bone entries for the removal of the mesh international literature. augmentation in edentulous ridges. are performed with simultaneous To prevent these exposures, it These conventional meshes are placement of the implants. is important to manage the soft designed as flat sheets that the A cone-beam computerized tissues well in a way that achieves surgeon must cut and fold to suit tomography (CBCT) is performed tension-free flaps over the mesh. each defect. This step requires before the surgery and another at 6 The results show that exposures time and is complex. In addition, months at the time of the re-entry. of the mesh were less frequent in the edges and borders of these cut the group treated with Geistlich meshes can potentially provoke RESULTS Bio-Gide® membrane and PRF damage in the gums and exposures. In all the cases, the personalized which also achieved a greater bone CAD-CAM technology provides titanium mesh could be placed formation than in the control group. us with a solution to these problems. easily. Cicatrization took place In this study, the augmentation Based on the data from cone- without incident in 14 cases (67%) achieved through the modified based computerised tomography until re-entry at 6 months. In 7 poncho technique presented fewer (CBCT) and on a digital workflow, cases (33%) there was an exposure exposures than the cases where individualized titanium meshes can of the mesh after a period of crestal incisions were used. All the be created that adapt perfectly to between 5 and 12 weeks after its dehiscences occurred in the zone of the bone defect. placement. All the dehiscences were the suture. Thus, positioning the in the zone of the suture. Patients margin of the wound in vestibular AIMS with the mesh exposed performed and at a certain distance from the To present the clinical results of a mouth rinses with chlorhexidine. It mesh reduces the risk of exposing it. titanium mesh based on CAD-CAM was not necessary to perform any technology (Yxoss CBR®), combined premature removal of the mesh and CONCLUSIONS with a mix of autogenous particulate all the planned implants could be The results show that the bone and deproteinized bovine bone placed. Thus, the exposures did not personalized titanium meshes material, to regenerate horizontal have any negative influence on the produced using CAD-CAM and/or vertical bone defects. clinical result of the procedure and technologies are safe and a the success rate of the bone-graft predictable procedure for large MATERIAL AND METHODS procedure was 100%. augmentations of the ridge. The Retrospective study which analysed The comparison of the CBCT management of the soft tissues all the cases of bone augmentation before and six months after the is one of the most critical points ® performed with the Yxoss CBR surgery shows an average vertical of the technique; although an mesh between December 2014 and increase of 6.5 ± 1.7 mm and an exposure of the mesh does not January 2017 at the University of average horizontal increase of 5.5 ± imply the complete loss of bone Mainz (Germany), with a total of 17 1.9 mm. augmentation. patients with 21 titanium meshes. No patient was excluded from this study. In terms of the configuration of the defect, an initial crestal incision or a modified poncho incision is made. A mucoperiosteal flap is raised and debridement of the cicatricial tissue is performed

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128 A CLINICAL INVESTIGATION SHOWS THE EFFICACY OF COLGATE® TOTAL IN CONTROLLING HALITOSIS.

used Colgate® Total experienced COMPLEMENTARY OTHER PUBLISHED STUDIES WITH a move towards a “pleasant” INFORMATION ABOUT THE THESE PRODUCTS: breath (Figure 1). TRIAL • The participants who used PRODUCTS UNDER SCIENTIFIC ARTICLES OF INTEREST TO BUSINESSES SCIENTIFIC ARTICLES OF INTEREST TO BUSINESSES Colgate® Total showed a Delgado E, García-Godoy F, Montero- INVESTIGATOIN statistically significant reduction Aguilar M, Mateo LR, Ryan M. (2018) • Trial toothpaste: zinc (zinc A clinical investigation of a dual zinc of 38.9% in the organoleptic oxide, zinc citrate) at 0.96%, plus arginine dentifrice in reducing scores in relation to the basal arginine at 1.5%, and 1,450 established dental plaque and gingivitis point (Figure 2). over a six-month period of product ppm of fluoride (Colgate® Total; • In comparison with the group use. The Journal of clinical dentistry 29 Colgate-Palmolive Company, that used conventional fluoride Special Issue A, 33-40. New York, NY). toothpaste, the participants Prasad KV, Therathil SG, Agnihotri A, • Control toothpaste: conventional of the Colgate® Total group Sreenivasan PK, Mateo LR, Cummins D. fluoride toothpaste with 1,450 (2018) The effects of two new dual zinc presented a statistically ppm of fluoride: (MaxFresh Tea; plus arginine dentifrices in reducing significant reduction in halitosis Colgate-Palmolive Company, oral bacteria in multiple locations in of 30.8%. the mouth: 12-hour whole mouth New York, NY). antibacterial protection for whole BASIC DATA OF THE PARTICIPANTS IN THE TRIAL mouth health. The Journal of clinical CLINICAL TRIAL dentistry 29 Special Issue A, 33-40. The trial included 80 adult • Randomized clinical trial, participants with good dental Manus LM1, Daep CA1, Begum-Gafur double-blind and with parallel health. R1, Makwana E1, Won B1, Yang groups. Y1, Huang XY1, Maloney V1, Trivedi HM1, Wu D1, Masters JG1. (2018) • 80 participants completed the METHODS Enhanced in vitro zinc bioavailability study. The participants were randomly through rational design of a dual zinc • Duration of 3 weeks. assigned to one of two treatment plus arginine dentifrice. The Journal of • Performed in Chengdu, People’s groups. The basal organoleptic clinical dentistry 29 Special Issue A, 10-19. Republic of China. scores were recorded, after three • Accepted for publication in weeks evaluated by a panel Lee C et al, The Journal of Clinical Dentistry, aceptado para su publicación en 2018 Journal of Clinical Dentistry, made up of four qualified and 2018. Hu et al., “A clinical synchronized assessors, using a investigation of the efficacy 9-point hedonic organoleptic scale. of a Dual Zinc plus Arginine STUDY PROCEDURE toothpaste for controlling oral Basal point malodor”. RESULTS - Evaluation of halitosis. This clinical trial evaluated the PRACTICAL IMPLICATIONS - Brushing 2 times a day for efficacy of the new Colgate® Total Colgate® Total toothpaste with dual 1 minute with the assigned toothpaste with dual zinc plus zinc and arginine offers patients toothpaste. arginine in reducing halitosis one a better control of halitosis, even 3 weeks night (12 hours) after brushing, 12 hours after brushing, compared - Evaluation of the halitosis 12 after using the product for 3 weeks. with a conventional fluoride hours after the last use of the • After using the product for 3 toothpaste after three weeks of product. weeks, 90% of the group that continuous use. CONCLUSIÓN Colgate® Total toothpaste with dual zinc and arginine – which contains zinc (zinc oxide, zinc citrate) at 0.96%, arginine at 1.5%, and 1,450 ppm of fluoride in the form of sodium fluoride in a silica base – produces a significantly greater reduction in halitosis compared with a conventional fluoride toothpaste – containing 1,450 ppm of fluoride in the form of sodium fluoride in a silica base – 12 hours after brushing (after one night) Figure 1. Organoleptic scores one night (12 Figure 2. Percentage variation in the hours) after brushing in comparison with the organoleptic scores. after using the product over three basal point. weeks. 129 NEW CLASSIFICATION OF PERIODONTAL Periodoncia Clínica Conclusions AND PERI-IMPLANT DISEASES

NEW CLASSIFICATION OF PERIODONTAL AND PERI-IMPLANT DISEASES.

MARIANO SANZ, PANOS N. PAPAPANOU. GUEST EDITORS OF PERIODONCIA CLÍNICA N.º 15

IT IS A PLEASURE FOR The most important change from the 1999 classification US to share this issue, is the recognition of three types of periodontitis: necrotizing which summarizies the new periodontitis, periodontitis as a manifestation of systemic classification of periodontal and diseases, and periodontitis that combines the entities previously peri-implant diseases, with our known as chronic and aggressive. Spanish-speaking colleagues. The stages depend on the severity of the case at the time of This new classification is the product of a fruitful collaboration examining the patient and taking into account the complexity between the European Federation of Periodontology (EFP) and of managing the case considering when multidisciplinary the American Association of Periodontology (AAP) which also approaches or advanced reconstructive therapies are required. included representative of societies of periodontology from all The grade provides valid additional information on the practical over the world. The preparation of the expert meeting began at biological aspects of the disease, such as the ratio of disease the start of 2015 and the meeting itself took place in Chicago on progression, the risk of future progression, and the identification November 9-11, 2017. of risk factors that can negatively affect the results. A total of 19 systematic reviews and four consensus reports We hope that with these issues of Periodoncia Clínica our in areas related to periodontology and dental implants were colleagues can introduce this valid tool into their everyday made that supported the decisions taken when updating the 1999 practice and enjoy the advantages that its use confers. classification. This issue number 15 presents an outline of how to use the classification following a series of practical algorithms to diagnose patients with periodontal disease, and it is accompanied by five REFERENCIA clinical cases whose objective is to put this classification into (1) Kornman KS, Tonetti MS (eds). (2018) Proceedings of the World Workshop on the practice and illustrate it with practical examples. The reader Classification of Periodontal and Periimplant Diseases and Conditions, Journal of Clinical Periodontology 45 Special Issue. is advised to complement this information with the consensus articles that can be accessed for free at the website of the Journal of Clinical Periodontology (1). Issue number 16 of Periodoncia Clínica will also be focused on developing the various clinical entities in more detail in several articles whose aim is to go deep into each condition and encourage the clinical application of the new classification. This new classification represents an advance that will allow patients to be diagnosed and treated correctly; in the same way it will allow scientists to conduct research that can advance the fields of aetiology, pathogenesis, progress, and treatment of periodontal and peri-implant diseases. periodonciaclínica

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