Application of the new periodontal classification: generalised periodontitis

Two clinical cases are presented here to demonstrate application of the 2017 World Workshop classification of periodontal and peri-implant diseases and conditions in daily practice.

The World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions was convened in 2017 and resulted in the publication of a new classification system in 2018.1 This replaces the formerly used Armitage Classification.2 The complete Workshop proceedings are available to clinicians for free online via the European Federation of Periodontology (EFP) website.3 The new system incorporates significant changes from previous classification systems that may be pertinent to Irish dental healthcare professionals, as reviewed recently in this Journal.4 Perhaps the most significant of these changes is the process for diagnosing and classifying periodontitis, which incorporates staging and grading of each case.5 The diagnosis of individual periodontitis cases has been simplified by the publication of diagnostic decision trees by several of the major periodontal organisations. For pragmatic reasons, the current series utilises the decision tree published by the British Society of Periodontology (BSP), so readers may find it useful to refer to this decision tree while evaluating each case. The decision tree is available free to dental professionals on the BSP website.6

Case 1

This case assimilates patient history, clinical and radiographic findings from a 61-year-old female patient who attended the Dublin Dental University Hospital (DDUH) for periodontal assessment, in order to establish a clinical case diagnosis. To assist readers in understanding the new classification system, the rationale for the clinical diagnosis is presented.

FIGURE 1: Orthopantomogram (OPG) of patient taken at time of referral by GDP. 

FIGURE 2: Clinical photograph at initial presentation at DDUH. Note extraction of mandibular anterior teeth by GDP since initial referral. 

Clinical findings

What is the diagnosis using the new classification?
The diagnosis in this case is:

  • generalised periodontitis;
  • Stage IV, grade C;
  • currently unstable; and,
  • risk factors: former smoker.

How this diagnosis was reached

  • This is a periodontitis case as clinical attachment loss is present at ≥2 non-adjacent teeth.
  • This is a generalised periodontitis case as >30% of teeth are affected by attachment loss/bone loss.
  • Stage IV was selected based on the site of greatest bone loss severity (based on the radiographic assessment: 90% bone loss of tooth 42 equating to apical third of the root).
  • Grade C was chosen based on calculation of the ratio of percentage bone loss at the worst site divided by patient age being >1.0 (90% bone loss ÷ 61 [age] = 1.48).
  • The disease was identified as currently unstable based on the presence of PPD ≥5mm.

Case 2

This case assimilates patient history, clinical and radiographic findings from a 51-year-old male patient who attended the Dublin Dental University Hospital (DDUH) for periodontal assessment, in order to establish a clinical case diagnosis. Once again, the rationale for the clinical diagnosis is presented.

FIGURE 3: Orthopantomogram (OPG) of patient taken at initial periodontal assessment. 

FIGURE 4: Clinical photograph at initial presentation at DDUH. 

References

1. Caton, J.G., Armitage, G., Berglundh, T., et al. A new classification scheme for periodontal and peri-implant diseases and conditions – introduction and key changes from the 1999 classification. J Clin Periodontol 2018; 45 (Suppl. 20): S1-S8.

2. Armitage, G.C. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999; 4 (1): 1-6.

3. European Federation of Periodontology. New classification micro-site. [Internet]. [Accessed November 25, 2020]. www.efp.org/publications-education/new-classification/.

4. Lee Kin, R., Reynolds, I. Introduction to the new classification on periodontal and peri-implant diseases and conditions. J Irish Dental Assoc 2019; 65 (4): 202-206.

5. Tonetti, M.S., Greenwell, H., Kornman, K.S. Staging and grading of periodontitis: framework and proposal of a new classification and case definition. J Clin Periodontol 2018; 45 (Suppl. 20): S149-S161.

6. British Society of Periodontology. Flowchart implementing the 2017 Classification. [Internet]. [Accessed November 25, 2020]. www.bsperio.org.uk/assets/downloads/111_153050_bsp-flowchart-implementing-the-2017-classification.pdf.

Ian Reynolds
Practice limited to periodontology and implant dentistry
reynoldsperio@gmail.com

David Naughton
Postgraduate student in Periodontology, Dublin Dental University Hospital

Lewis Winning
Division of Restorative Dentistry & Periodontology, Dublin Dental University Hospital

Peter Harrison
Division of Restorative Dentistry & Periodontology, Dublin Dental University Hospital