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PAPAPANOU et al .
TABLE 1B Classification of periodontitis based on grades that reflect biologic features of the disease including evidence of, or risk for, rapid progression, anticipated treatment response, and effects on systemic health
Grade should be used as an indicator of the rate of periodontitis progression. The primary criteria are either direct or indirect evidence of progression. Whenever available, direct evidence is used; in its absence indirect estimation is made using bone loss as a function of age at the most affected tooth or case presentation (radiographic bone loss expressed as percentage of root length divided by the age of the subject, RBL/age). Clinicians should ini - tially assume grade B disease and seek specific evidence to shift towards grade A or C, if available. Once grade is established based on evidence of progression, it can be modified based on the presence of risk factors. CAL = clinical attachment loss; HbA1c = glycated hemoglobin A1c; RBL = radio - graphic bone loss.
2. Despite substantial differences in the overall severity of attach - ment loss between the two population samples analyzed by Billings et al. 3 , suggesting presence of cohort effects, common patterns of CAL were identified across different ages, along with consistencies in the relative contribution of recession and pocket depth to CAL. The findings suggest that it is feasible to introduce empirical evi - dence‐driven thresholds of attachment loss that signify dispropor - tionate severity of periodontitis with respect to age. 3. Longitudinal mean annual attachment level change was found to vary considerably both within and between populations. Surprisingly, neither age nor sex had any discernible effects on CAL change, but geographic location was associated with differences. Overall, the position paper argued that the existing evidence neither supports nor refutes the differentiation between forms of periodontal dis - eases based upon progression of attachment level change. 4. Necrotizing periodontal diseases are characterized by three typical clinical features (papilla necrosis, bleeding, and pain) and are associated with host immune response impairments,
which should be considered in the classification of these condi - tions (Table 2). Endodontic‐periodontal lesions are defined by a pathological communication between the pulpal and periodontal tissues at a given tooth, occur in either an acute or a chronic form, and should be classified according to signs and symptoms that have direct impact on their prognosis and treatment (i.e., presence or absence of fractures and perforations, and presence or absence of perio - dontitis) (Table 3). Periodontal abscesses most frequently occur in pre‐existing peri - odontal pockets and should be classified according to their etiol - ogy. They are characterized by localized accumulation of pus within the gingival wall of the periodontal pocket/sulcus, cause rapid tissue destruction which may compromise tooth prognosis, and are associated with risk for systemic dissemination (Table 4). 5. A periodontitis case definition system should include three compo - nents: (a) identification of a patient as a periodontitis case, (b) iden - tification of the specific type of periodontitis, and (c) description of
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