EFP Guide

THE ESSENTIAL EFP GUIDE TO PERIODONTOLOGY

About the EFP

The European Federation of Periodontology (EFP) is a global non-profit organisation with a European core that promotes periodontal science and practice, and awareness of oral health and gum disease. Its vision is “Better oral health for all”. Through the Journal of Clinical Periodontology, the EFP disseminates the latest research findings, helping to translate evidence into practice. Additionally, it develops clinical practice guidelines to provide evidence-based treatment pathways for periodontitis and peri-implant diseases, supporting oral-healthcare professionals worldwide.

About the Perio Classification

The perio classification is based on the findings of the World Perio Workshop convened to update the classification of all periodontal and peri-implant diseases and conditions, held in Chicago, US in November 2017. This workshop was jointly organised by the EFP and the American Academy of Periodontology (AAP) to agree on a new evidence-based, consensus knowledge base for a revised, global classification to be used by oral health professionals everywhere. In accordance with the approach behind the perio classification, the EFP works in a set of evidence-based clinical guidelines on the treatment of periodontitis and peri- implant diseases.

About the EFP guidelines

Based on the scientific outcomes of recent Perio Workshop meetings, the EFP has started producing a set of S3-level clinical practice guidelines. These provide oral-healthcare professionals all over the world with precise therapeutic pathways based on individual patient diagnoses, and to make recommendations on specific interventions to get the best possible treatment results for patients with periodontitis and peri- implant diseases.

THE ESSENTIAL EFP GUIDE TO PERIODONTOLOGY

The EFP Probe represents an important step forward in periodontal care, aligning daily clinical practice with today’s evidence-based classification and S3-level clinical practice guidelines. Developed in collaboration with HuFriedyGroup, the EFP Probe reflects the federation’s commitment to advancing clinical excellence in periodontology and demonstrates the commitment to providing clinicians with reliable, precise, and practice-oriented tools. It was designed to help clinicians apply periodontal classifi- cation and clinical practice guidelines directly at the chair- side. The probe not only integrates screening and treatment into a single instrument, but also facilitates determining— based on the EFP guidelines—whether a situation is healthy, requires non-surgical therapy, or may need surgical treatment. At the same time, it functions as a full periodontal probe, featuring a ball tip that assists in assessing overhangs and plaque-retentive factors. It includes 14 durable measurement bands (1–15mm, skipping 2mm) designed for clarity and long-term accuracy, and was engineered to support both screening and detailed periodontal charting without requiring multiple instruments. By connecting scientific rigour with everyday usability, the EFP Probe helps clinicians deliver periodontal care that is precise, standardised, and fully aligned with the EFP guidelines. EFP Probe: putting classification and guidelines into practice

Learn more at the EFP website

View features

THE ESSENTIAL EFP GUIDE TO PERIODONTOLOGY

Quick navigation

New Classification of periodontal and peri-implant diseases

• Periodontal health and gingivitis • Periodontitis • Periodontitis: clinical decision tree for staging and grading • Systemic and other periodontal conditions • Peri-implant health, peri-implant mucositis, and peri-implantitis Infographics •Treatment of stage I-III periodontitis • Treatment of stage IV periodontitis • Recommendations for the prevention of peri-implant diseases

Papers • Periodontal health and gingival diseases and conditions on an intact and a reduced perio- dontium: Consensus report of workgroup 1 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions • Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classifica- tion of Periodontal and Peri-Implant Diseases and Conditions • Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report of workgroup 3 of the 2017 World Workshop on the Classification of Perio- dontal and Peri-Implant Diseases and Conditions • Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions • A new classification scheme for periodontal and peri-implant diseases and conditions – Intro- duction and key changes from the 1999 classification • Treatment of stage I–III periodontitis—The EFP S3 level clinical practice guideline • Treatment of stage IV periodontitis: The EFP S3 level clinical practice guideline • Prevention and treatment of peri-implant diseases—The EFP S3 level clinical practice guide- line

World Workshop: Workgroup 1

Periodontal health, gingival diseases and conditions

Iain Chapple Brian Mealey

Chairs:

Four expert position papers

Periodontal health Niklaus P. Lang and P. Mark Bartold Dental plaque-induced gingival conditions Shinya Murakami, Iain Chapple, Brian Mealey, and Angelo Mariotti Non-plaque-induced gingival diseases Palle Holmstrup, Jacqueline Plemons, and Joerg Meyle Plaque-induced gingivitis: Case definition and diagnostic considerations Leonardo Trombelli, Roberto Farina, Cléverson Silva, and Dimitris Tatakis

Expert paper 1: Periodontal health

• Is there a holistic definition of periodontal health?

• Does “pristine periodontal health” exist?

• If pristine health exists, is that “normality” (95% population)?

• Is there a biological level of inflammation consistent with clinical gingival health & homeostasis? Clinical vs pristine health.

• Can periodontitis enter into “remission”?

Biological phenotype versus clinical phenotype

What can we use for perio?

• A biological phenotype exists in gingivitis. • The biological phenotype can be mapped to clinical changes. • Such a biological phenotype has not yet been defined for periodontitis.

Biological model for stages from health to gingivitis

Plaque

Early plaque accumulation

Heavy plaque accumulation

Plaque levels associated with clinical health

Progression of gingivitis

Gingivitis

Health

Neuropeptide release

Epithelial cell activation and neutrophil infiltrate

Acute-phase response

• IL-1 β • Cathepsin G • Elastase

Biomarkers

Substance P

α− 1 antitrypsin

We cannot do this yet for periodontitis. It is too complex: there is no single cause.

Gingival transcriptome data for CP versus AgP

Adjusted model-based clustering of transcriptomic data using finite mixtures generated two distinct clusters of patients that did not align with the current classification of chronic and aggressive periodontitis.

Behavioural risk factors absent

Behavioural risk factors present

Environmental risk factors absent

Environmental risk factors evident

Gingivitis

Clinical Health

Periodontitis

Antibody

DAMPs Haem ↑ GCF

Complement

Connective tissue & bone damage

Proportionate host response

Incipient dysbiosis (quorum- sensing bacteria)

Frank dysbiosis (pathogenic biofilm)

Disproportionate host response (hyper- inflammatory)

PMNs ++

PMNs +++

Health- promoting biofilm = Symbiosis

Proportionate host response

PMNs

Plasma cells

T & B cells

Cytokines

Antigens

Chronic non- resolving inflammation

Antigens Gingipains LPS

Antigens Bact’l DNA fMLP

Failed resolution of inflammation

Virulence Factors

Prostanoids MMPs

High biomass

Low biomass

Resolving inflammation

Non-resolving inflammation

LPS

Oxidative Stress

Genetic risk factors absent

Genetic risk factors present

Epigenetic effects not evident

Epigenetic effects evident

Chapple 2015

WHO definition of health

“Health is a state of complete physical, mental and social well-being and not merely an absence of disease or infirmity.” WHO 1948: 19456 No 2:1

Thus, periodontal health should be defined as a state free from inflammatory periodontal disease that allows an individual to function normally and avoid physical or mental consequences due to current or past disease.

This is a complex definition: how do we create an objective set of measures for this?

Pristine health: Does it exist? Is it natural?

FREE GINGIVAE

Gingival margin Sulcular epithelium (SE)

Gingival crevice/ sulcus

Junctional epithelium (JE)

Gingivae

Alveolar bone

Periodontal ligament

Neuro- vascular bundle Periodontal ligament (PDL)

Alveolar bone

Cementum

GCF

Alveolar bone AB Alveologingival fibres AGF Cementum CE Circular fibres CF Dentogingival fibres DGF

SE OE GC

Sulcular/ crevicular epithelium

Enamel EN

External oral epithelium EOE GCT Gingival connective tissue GS Gingival sulcus JE Junctional epithelium SE Sulcular epithelium RR Rete ridges

GCT

enamel

DGF

AGF

Principal fibres of periodontal ligament

enamel

PDL

Terminal cell of JE

Attached gingiva

Gingival groove

Free gingiva

What are the clinical features of Pristine Health?

Stippling

Muco-gingival junction

Triangular papilla

Changes in histology arise after only four days of plaque exposure

What does clinical health look like?

Case versus site Is clinical inflammation compatible with health? Can there be a site of inflammation that is also a case of clinical health?

Periodontal health − conclusions

• Periodontal health is defined as: “An absence of clinically detectable inflammation.” • “There is a biological level of immune surveillance consistent with clinical gingival health & homeostasis.” • “Clinical health can be restored following treatment of gingivitis and periodontitis.” • “A case of clinical health represents a different situation to a ‘site’ of clinical health.”

How do we classify clinical gingival health?

• Clinical gingival health on an intact periodontium. (An intact periodontium refers to an absence of detectable attachment and/or bone loss).

• Clinical gingival health on a reduced periodontium: - Stable periodontitis patient (successful treatment); - Non-periodontitis patient (e.g. recession, crown-lengthening surgery).

Expert paper 2: Plaque-induced gingival conditions

Critical questions: • Define plaque-induced gingivitis on an intact & a reduced periodontium. • Define a reduced periodontium (previous periodontitis vs non-periodontitis patient). • What are the predisposing factors – local risk factors? • What are the modifying factors – systemic risk factors? • Can we reduce the number of categories?

Plaque-induced gingival conditions

Is this a case of clinical health (with sites of gingival inflammation)?

Or is it a case of gingivitis?

Predisposing and modifying factors

Local risk factors ( predisposing factors)

• Dental plaque-biofilm retention factors: o Tooth anatomy o Restoration margins, etc. • Oral dryness: o ↓ saliva flow o ↓ saliva quality • e.g. Sjögren’s, medications, mouth-breathing

Predisposing and modifying factors

Systemic risk factors ( modifying factors)

• Smoking • Metabolic factors (hyperglycemia) • Nutritional factors (Vitamin C) • Pharmacological agents • ↑ sex steroids (puberty, pregnancy) • Haematological conditions

Expert paper 3: Non-plaque-induced gingival diseases

1. Genetic/developmental disorders. 2. Specific infections. 3. Inflammatory and immune conditions. 4. Reactive processes (epulides). 5. Neoplasms. 6. Endocrine, nutritional, and metabolic disorders. 7. Traumatic lesions. 8. Gingival pigmentation.

1. Genetic/developmental disorders

HGF

Juvenile hyaline fibromatosis

Sebaceous naevus of Jadassohn

2. Specific infections

Gingival herpes simplex I

Molluscum contegeosum

Histoplasma capsulatum

3. Inflammatory and immune conditions

Plasma cell gingivitis

C1-esterase inhibitor dysfunction

Disseminated pyogenic granuloma

Erosive lichen planus

Erythema multiforme

Systemic lupus erythematosis

4. Reactive processes (epulides)

Fibrous epulis

Vascular epulis

Pregnancy epulis

Peripheral giant cell granuloma

5. Neoplasms

Proliferative verrucous leukoplakia

Non-Hodgkins lymphoma

Chondrosarcoma

Squamous cell carcinoma

6. Endocrine, nutritional, and metabolic disorders

Giant cell tumour of bone

Scurvy – Vitamin C deficiency

7. Traumatic lesions

Cocaine-induced necrosis

Gingivitis artefacta

8. Gingival pigmentation

AZT pigmentation

Smoker’s melanosis

Expert paper 4: Plaque-induced gingivitis: Case definition and diagnostic considerations

• BoP = only objective measure • We cannot measure severity • So limited to extent (<10%, 30% rule)

Periodontal probes: There is a critical need for a new ISO standard

WHO probe C-type

UNC PCP-15 probe: UNC PCP-15 probe

What is needed is a probe that provides “constant force” and goes to 15mm

Health and gingivitis on an intact periodontium and on a reduced periodontium: underpinning principles

Classification

Periodontitis patient

Patient with periodontal health

Gingivitis patient

Periodontal therapy

Periodontitis patient : Stable BoP <10% PPD ≤ 4mm No BoP at 4mm sites

Periodontitis patient : Remission BoP ≥ 10% PPD ≤ 4mm No BoP at 4mm sites

Periodontitis patient : Unstable PPD ≥ 5mm or PPD ≥ 4mm & BoP

Periodontal Health

Diagnosis

Gingivitis

Once a periodontitis patient, always a periodontitis patient. But such a patient can be a case of health.

MJaurnche 20107

June

The 4mm non-bleeding site (closed pocket) represents health in a treated patient

No BoP 5 x 4mm PPD All other PPDs 3mm

2017 case definitions of health and gingivitis

Intact periodontium

Health

Gingivitis

Probing attachment loss Probing pocket depths (assuming no pseudo pockets) Bleeding on probing Radiological bone loss Reduced periodontium in a non-periodontitis patient

< 3mm

<10%

Yes

Health

Gingivitis

Yes

Probing attachment loss Probing pocket depths (assuming no pseudo pockets) Bleeding on probing Radiological bone loss Successfully treated and stable periodontitis patient Probing attachment loss Probing pocket depths (all sites & assuming no pseudo pockets) Bleeding on probing Radiological bone loss

< 3mm

< 10%

Yes

Health Possible

Possible

Gingival inflammation

Yes

< 3mm

< 4mm (no site >4mm with BoP)

< 10%

Yes (> 10%)

Yes

• Attempts to classify periodontitis have struggled to decide if there are different diseases or variations of a single disease. • There is no evidence to support differentiating “chronic” and “aggressive” periodontitis. • Three forms of periodontitis have been identified: (1) periodontitis, (2) necrotising periodontitis, (3) periodontitis as a direct manifestation of systemic diseases. • A classification system must include complexity and risk factors as well as disease severity. • Individual cases of periodontitis should be characterised according to the stage and grade of the disease.

Authors Mariano Sanz and Maurizio Tonetti

European Federation of Periodontology

Published March 2019

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 substantial overlap, the lack of a clear pathobiology- based distinctions between categories, diagnostic imprecision, and difficulties in implementation. 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.

Periodontitis

Guidance for clinicians

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.

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

Periodontitis

Guidance for clinicians

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. 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. 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.

Periodontitis

Guidance for clinicians

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

information on biological features of disease

= Grading

rate of progression +

risk assessment +

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.

Periodontitis

Guidance for clinicians

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.

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

Periodontitis

Guidance for clinicians

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. 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: Slow rate of progression

Grade B: Moderate rate of progression

Grade C: Rapid rate of progression

Periodontitis

Guidance for clinicians

Further reading

Proceedings of the World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions, co-edited by Kenneth S. Kornman and Maurizio S. Tonetti. Journal of Clinical Periodontology , Volume 45, Issue S20, June 2018.

Proceedings include:

- - Papapanou PN, Sanz M, et al. Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions, S162-S170. - - Herrera D, Retamal-Valdes B, Alonso B, Feres M. Acute periodontal lesions (periodontal abscesses and necrotising periodontal diseases) and endo-periodontal lesions, S78-S94. - - Fine DH, Patil AG, Loos BG. Classification and diagnosis of aggressive periodontitis, S95-S111. - - Needleman I, Garcia R, Gkranias N, et al. Mean annual attachment, bone level, and tooth loss: A systematic review, S112-S129. - - Billings M, Holtfreter B, Papapanou PN, Mitnik GL, Kocher T, Dye BA. Age-dependent distribution of periodontitis in two countries: Findings from NHANES 2009 to 2014 and SHIP-TREND 2008 to 2012, S130-S148. - - Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition, pages S149-S161. Tonetti, MS & Sanz M. Implementation of the New Classification of Periodontal Diseases: Decision-making Algorithms for Clinical Practice and Education . Journal of Clinical Periodontology , 2019.

Authors

Mariano Sanz

Maurizio Tonetti

Mariano Sanz is professor and chair of periodontology at the University Complutense of Madrid and a professor in the faculty of odontology at the University of Oslo (Norway). He is chair of the EFP workshop committee, a member of the EFP executive committee, and president of the Osteology Foundation. Maurizio Tonetti is 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.

Periodontitis

Guidance for clinicians

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.

European Federation of Periodontology

About the EFP The European Federation of Periodontology (EFP) is an umbrella organisation of 35 national scientific societies devoted to promoting research, education, and awareness of periodontal science and practice. It represents more than 14,000 periodontists and gum-health professionals in Europe alone. In addition to 31 European members, the EFP has recently welcomed four international associate members from Asia, the Middle East, and Latin America.

www.efp.org www.efp.org/newclassification

European Federation of Periodontology Avenida Doctor Arce, 14. Office 38 28002 Madrid Spain

Periodontitis: clinical decision tree for staging and grading

02.

Guidance for clinicians

Authors Mariano Sanz and Maurizio Tonetti

European Federation of Periodontology

Published March 2019

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.

Diagnostic quality & full-mouth

Detectable marginal bone loss

X-Rays available

Yes

New patient

Yes

Assess interdental CAL loss

Yes

Suspect periodontitis

Yes

Buccal or oral rec & PPD ˃3mm

Yes

Localised gingivitis

BoP 10-30%

Periodontal health

Measure BoP

≥ 10%

Gingivitis

< 10%

BoP ˃30%

Generalised gingivitis

Proceed to Step 2

Periodontitis: clinical decision tree for staging and grading Based on: Tonetti, MS & Sanz M. Implementation of the New Classification of Periodontal Diseases: Decision-making Algorithms for Clinical Practice and Education . Journal of Clinical Periodontology , 2019.

Periodontitis: clinical decision tree for staging and grading

Guidance for clinicians

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 periodontitis

Local factors only

Yes

Caries or restoration

Impacted wisdom tooth

Suspect periodontitis

Assess gingivitis and monitor

CAL loss ˃1 N-A tooth

Step 1: Measure BoP

Periodontal charting & radiographs

PPD 4mm or more

Periodontitis case

BoP

Yes

No BoP

BoP +

Periodontal & bone appraisal

Reduced but healthy periodontium patient

Gingival inflammation in periodontitis patient

Staging & grading

Periodontitis: clinical decision tree for staging and grading

Guidance for clinicians

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 case

< 30%

Periodontal & bone appraisal

Extent (% teeth)

30% or more

Periodontitis case

Severity & complexity

CAL loss, bone loss, periodontal tooth loss

Severity of breakdown

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

Complexity of management

Stage I periodontitis

Stage II periodontitis

Stage III periodontitis

Stage IV periodontitis

Proceed to grading

Periodontitis: clinical decision tree for staging and grading

Guidance for clinicians

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

Localised

< 30%

Periodontal & bone appraisal

Extent (% teeth)

Generalised

˃ 30%

Severity & complexity

Level of bone/CAL loss

Coronal third < 5 mm

Class II or III furcation

Yes

Pocket depth *

˃ 5 mm

Stage III or IV periodontitis

3-5 mm

Periodontal tooth loss

Yes

Stage I or II periodontitis

Proceed to grading

* 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: clinical decision tree for staging and grading

Guidance for clinicians

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

Localised

< 30%

Periodontal & bone appraisal

Extent (% teeth)

Generalised

˃ 30%

Severity & complexity

Level of bone/CAL loss

BL coronal third CAL < 5mm

Class II or III furcation

Perio tooth loss

˃4

1-4

BL middle third CAL CAL 5mm or more

Yes

10 or more occluding pairs

Pocket depth

˃5 mm

3-5 mm

Stage IV periodontitis

Yes

Bite collapse, drifting, flaring

Periodontal tooth loss

Stage III or IV periodontitis

Yes

Level of bone/CAL loss

Stage I or II periodontitis

Severe ridge effect

Yes

BL <15% CAL 1-2 mm

BL 15-33% CAL 3-4 mm

Stage III periodontitis

Stage I periodontitis

Stage II periodontitis

Proceed to grading

Periodontitis: clinical decision tree for staging and grading

Guidance for clinicians

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 records available

Apply grade modifiers

Grade B periodontitis

Bone loss/age

0.25-1.0

Yes

˃1.0

Grade C periodontitis

Estimate progression (5 years)

Smoking

Diabetes

No diabetes

Proceed to 4b

Yes HbA1c 7.0 or more

Yes HbA1c < 7.0

< 10/day

No smoking

10 or more/day

No change in grade

Upgrade to B

Upgrade to C

Periodontitis: clinical decision tree for staging and grading

Guidance for clinicians

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

Level of progression (5 years)

Apply grade modifiers

Previous records available

Grade B periodontitis

Yes

< 2 mm

2 mm or more

Grade C periodontitis

Estimate bone loss by age

Smoking

Diabetes

No diabetes

Proceed to 4a

Yes HbA1c 7.0 or more

Yes HbA1c < 7.0

< 10/day

No smoking

10 or more/day

No change in grade

Upgrade to B

Upgrade to C

Periodontitis: clinical decision tree for staging and grading

Guidance for clinicians