Diagnosis of periodontitis

Diagnosis of periodontitis

A periodontitis case is defined as:

• Interdental clinical attachment loss (CAL) is detected at ≥2 non-adjacent teeth, or
• Buccal or oral CAL ≥3mm with probing pocket depth (PPD) ≥3 mm detected at ≥2 teeth

There is no specific threshold of CAL to define an individual with periodontitis.

The observed CAL should not be due to non-periodontal causes such as:

• Gingival recession due to trauma
• Dental caries extending in the cervical area of a tooth
• Presence of CAL on the distal aspect of a second molar tooth associated with the malposition or extraction of a third molar (wisdom tooth)
• Endodontic lesion
• Vertical root fracture

Diagnosis and classification of periodontitis according to the World Workshop Classification (Jointly created by the European Federation of Periodontology + American Academy of Periodontology)

• Step 1: Initial assessment
  • Carry out a comprehensive 6-point periodontal pocket chart (6PPC) to identify:
    • Interproximal clinical attachment loss (CAL) – CAL is calculated as the sum of recession (shrinkage of the gum) and PPD.
    • Increased PPD ≥4mm
    • Bleeding on probing (BoP)
    • Mobility of teeth
    • Furcation involvement (loss of clinical attachment between roots of multi-rooted teeth)
  • Evaluate full-mouth (or equivalent) radiographs for detectable marginal bone loss, which may indicate periodontitis.

• Step 2: Confirm the extent of the periodontitis
  • Using the 6PPC and radiographs, calculate the % of teeth affected and/or which teeth have been affected.
    • Generalised periodontitis – ≥30% of teeth affected
    • Localised periodontitis – <30% of teeth affected
    • Molar-incisor pattern – involving 1^st molars and/ or incisors

• Step 3: Confirm staging
  • Stage I periodontitis (mild disease) patients will have probing depths ≤4 mm, CAL ≤1-2 mm, horizontal bone loss. No post-treatment tooth loss is expected, indicating the case has a good prognosis going into maintenance.
  • Stage II periodontitis (moderate disease) patients will have probing depths ≤5 mm, CAL ≤3-4 mm, horizontal bone loss. No post-treatment tooth loss is expected, indicating the case has a good prognosis going into maintenance.
  • Stage III periodontitis (severe disease) patients will have probing depths ≥6 mm, CAL ≥5 mm, and may have vertical bone loss and/or furcation involvement of Class II or III. There is the potential for tooth loss from 0 to 4 teeth. The complexity of implant and/or restorative treatment is increased. The patient may require multi-specialty treatment. The overall case has a fair prognosis going into maintenance.
  • Stage IV periodontitis (very severe disease) patients will have probing depths ≥6 mm, CAL ≥5 mm, and may have vertical bone loss and/or furcation involvement of Class II or III. Fewer than 20 teeth may be present and there is the potential for tooth loss of 5 or more teeth. Very complex implant and/or restorative treatment may be needed. The patient will often require multi-specialty treatment. The overall case has a questionable prognosis going into maintenance.

• Step 4: Confirm grading
  • Periodontitis grading evaluates disease progression using direct evidence (e.g., radiographic bone loss over five years) and indirect evidence (% bone loss/age ratio, case phenotype).
  • Grading reflects the following ratios of % bone loss/ age:
    • Grade A: <0.25 (slow)
    • Grade B: 0.25 – 1.0 (moderate)
    • Grade C: >1.0 (rapid)
  • Modifiers include smoking and diabetes status.