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CHAPPLE et al .
CASE DEFINITIONS FOR PERIODONTAL HEALTH AND GINGIVITIS
at isolated sites is ubiquitous, but may fall within the spectrum of “clinical health”. In clinical practice, a case of gingival health on an intact peri- odontium would be a patient with no signs of gingivitis as defined above. In clinical practice, the goal of periodontal treatment on a re- duced periodontium is a patient with no signs of gingivitis as de- fined above. A case of gingival health on a reduced periodontium in a stable periodontitis patient must be distinguished from a case of periodontal health in a reduced periodontium in a non‐periodontitis patient (recession, crown lengthening), because there is a difference in risk for periodontal disease progression. Following treatment of periodontitis, periodontitis patients may not attain a status of complete gingival health based on the above definition. However, evidence has demonstrated that a patient may achieve periodontal stability. Periodontal stability is characterized by successful treatment through control of local and systemic risk factors, resulting in minimal (< 10% of sites 4 ) BOP, no probing depths of 4 mm or greater that bleed on probing, optimal improvement in other clinical parameters and lack of progressive periodontal de- struction. 6 The treated and stable periodontitis patient with current gingival health remains at increased risk of recurrent periodontitis and accordingly must be closely monitored. Figure 1 summarizes the various scenarios that may arise following the transition from health, to gingivitis and ultimately periodontitis. How do we define gingivitis at a site level (biological & clinical)? Defining inflammation at a site level is quite distinct from defining a case of gingivitis. A universal case definition is essential to facilitate population surveillance, for clinicians setting therapeutic targets, and to enable assessment of the efficacy of prevention and/or treat- ment regimes. There are broadly two categories of gingival disease:
Based on available methods to assess gingival inflammation, a gin- givitis case can be simply, objectively and accurately defined and graded using a bleeding on probing score (BOP%), 3 assessed as the proportion of bleeding sites (dichotomous yes/no evaluation) when stimulated by a standardized (dimensions and shape) perio- dontal probe with a controlled ( ∼ 0.25 N) force to the apical end of the sulcus at six sites (mesio‐buccal, buccal, disto‐buccal, mesio‐ lingual, lingual, disto‐lingual) on all teeth present. Limitations of these clinical criteria arise from a lack of standardized periodontal probes (e.g. probe dimensions, taper), examiner variability (probe pressure, angle), patient related factors (biotype, medications, etc.) and smoking. In all references to an “intact periodontium” within this consen- sus, an absence of detectable attachment and/or bone loss is implicit.
How do we define a case of gingival health on an intact and a reduced periodontium for epidemiological purposes?
For an intact periodontium and a reduced and stable periodontium, gingival health is defined as < 10% bleeding sites 4,5 with probing depths ≤3 mm.
How do we define a case of gingival health on an intact and a reduced periodontium for clinical practice? Due to limitations in, and a lack of uptake of, standardized ISO probes and techniques leading to inherent measurement variability in the parameters of gingival health, a patient with periodontal health may exhibit one or two sites with some evidence of clinical gingival in- flammation. Moreover, localized mild and delayed bleeding to probe
FIGURE 1 The transition from periodontal health to gingivitis is reversible following treatment that resolves gingival inflammation. The transition to periodontitis results in attachment loss which, at the present time is irreversible. More importantly, it signposts patients who are at lifelong high risk of recurrent periodontitis. Optimal periodontal therapy can restore gingival health on a reduced periodontium, or may result in mild marginal gingival inflammation at shallow probing pocket depths (≤ 3 mm). However, a history of periodontitis places patients at high risk of recurrent periodontitis and such patients require careful site‐specific monitoring during periodontal maintenance programs
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