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defined. Likewise, mechanisms accounting for the development of generalized periodontitis in young individuals are poorly understood.
The remaining clinical cases of periodontitis which do not have the local characteristics of necrotizing periodontitis or the systemic characteristics of a rare immune disorder with a secondary mani - festation of periodontitis should be diagnosed as “periodontitis” and be further characterized using a staging and grading system that describes clinical presentation as well as other elements that affect clinical management, prognosis, and potentially broader influences on both oral and systemic health. How is a periodontitis case further characterized by stage and grade? An individual case of periodontitis should be further character - ized using a simple matrix that describes the stage and grade of the disease. Stage is largely dependent upon the severity of disease at presentation, as well as on the anticipated complexity of disease management, and further includes a description of extent and distri - bution of the disease in the dentition. Grade provides supplemental information about biological features of the disease including a his - tory‐based analysis of the rate of periodontitis progression; assess - ment 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 general health of the pa - tient. For a complete description of the rationale, determinants, and practical implementation of the staging and grading system, refer to Tonetti et al. 6 Tables 1 and 2 list the framework of the staging and grading system. Do the acute periodontal lesions have distinct features when compared with other forms of periodontitis? Periodontal abscesses, lesions from necrotizing periodontal diseases and acute presentations of endo‐periodontal lesions, share the fol - lowing features that differentiate them from periodontitis lesions: (1) rapid‐onset, (2) rapid destruction of periodontal tissues, underscor - ing the importance of prompt treatment, and (3) pain or discomfort, prompting patients to seek urgent care.
What are the determinants for the mean annual attachment loss based on existing longitudinal studies in adults? A meta‐analysis included in the position paper documented differ - ences in mean annual attachment loss between studies originating from different geographic regions but did not reveal an association with age or sex. It should be emphasized that meta‐analysis of mean data may fail to identify associations due to the loss of information and the lack of accounting for both disease progression and regres - sion. However, approaches that have modelled both progression and regression of CAL have also reported no effect of age or smoking on progression, although age and smoking reduced disease regres - sion (e.g., Faddy et al. 8 ). Individual studies that could not be included in the meta‐analysis have shown effects of smoking, socioeconomic status, previous attachment loss, ethnicity, age, sex, and calculus on mean annual attachment loss. How do we define a patient as a periodontitis case? In the context of clinical care, a patient is a “periodontitis case” if: 1. Interdental CAL is detectable at ≥2 non‐adjacent teeth, or 2. Buccal or oral CAL ≥3 mm with pocketing ≥3 mm is detectable at ≥2 teeth but the observed CAL cannot be ascribed to non‐perio - dontitis‐related 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; and 5) the occurrence of a vertical root fracture. Which different forms of periodontitis are recognized in the present revised classification system? Based on pathophysiology, three clearly different forms of peri - odontitis have been identified: (A) Necrotizing periodontitis (B) Periodontitis as a direct manifestation of systemic diseases (C) Periodontitis Differential diagnosis is based on history and the specific signs and symptoms of necrotizing periodontitis, or the presence or ab - sence of an uncommon systemic disease that alters the host immune response. Periodontitis as a direct manifestation of systemic disease (Albandar et al. 9 , Jepsen et al. 10 ) should follow the classification of the primary disease according to the respective International Statistical Classification of Diseases and Related Health Problems (ICD) codes.
Do periodontal abscesses have a distinct pathophysiology when compared to other periodontitis lesions?
The first step in the development of a periodontal abscess is bacte - rial invasion or foreign body impaction in the soft tissues surround - ing the periodontal pocket, which develops into an inflammatory process that attracts polymorphonuclear neutrophils (PMNs) and low numbers of other immune cells. If the neutrophil‐mediated de - fense process fails to control the local bacterial invasion or clear the foreign body, degranulation, necrosis and further neutrophilic influx may occur, leading to the formation of pus which, if not drained, re - sults in an abscess. Pathophysiologically, this lesion differs in that the low pH within an abscess leads to rapid enzymatic disruption
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