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SANZ et al .
TABLE 7 Periodontitis stage Periodontitis stage
Stage I
Stage II
Stage III
Stage IV
Severity
Interdental CAL at site of greatest loss
1–2 mm
3–4 mm
≥5 mm or extending to middle third of the root
≥8 mm or extending to apical third of the root
Radiographic bone loss Coronal third (<15%)
Coronal third (15%–33%)
Extending to Middle third Extending to Apical third
Tooth loss
No Perio Tooth Loss
Perio tooth loss ≤ 4 teeth Perio tooth loss ≥ 5 teeth
Complexity
Local
Probing depth 3–4 Mostly
Probing depth 4–5 Mostly
In addition to Stage II Complexity Probing depth ≥6 Vertical bone loss ≥3 Furcation II or III Moderate ridge defect
In addition to Stage III Complexity Need for complex rehabilitation due to:
horizontal bone loss
horizontal bone loss
Masticatory dysfunction Secondary occlusal trauma (Tooth mobility ≥ 2) Bite collapse, drifting, flaring Less than 20 remaining teeth (10 opposing pairs) Severe ridge defect
Extent &
Add to Stage as descriptor
For each Stage, describe extent as localized (<30% of teeth involved), generalized or molar incisor pattern
distribution
Note: The initial Stage should be determined using CAL; if not available then RBL should be used. Information on tooth loss that can be attributed primarily to periodontitis – if available – may modify stage definition. This is the case even in the absence of complexity factors. Complexity factors may shift the Stage to a higher level, for example furcation II or III would shift to either Stage III or IV irrespective of the CAL. The distinction between Stage III and Stage IV is primarily based on complexity factors. For example, a high level of tooth mobility and/or posterior bite collapse would indicate a Stage IV diagnosis. For any given case only some, not all, complexity factors may be present, however, in general it only takes 1 complexity factor to shift the diagnosis to a higher Stage. It should be emphasized that these case definitions are guidelines that should be applied using sound clinical judgment to arrive at the most appropriate clinical diagnosis. For post-treatment patients CAL and RBL are still the primary stage determinants. If a stage shifting complexity factor(s) were eliminated by treatment, the stage should not retrogress to a lower stage since the original stage complexity factor should always be considered in maintenance phase management. Adapted from: Tonetti, Greenwell and Kornman 2018. Abbreviations: CAL, clinical attachment loss; RBL, radiographic bone loss.
4.1 | Clinical pathway for a diagnosis of periodontitis
• Cemental tears (Jepsen et al., 2018) • External root resorption lesions (Jepsen et al., 2018) • Tumours or other systemic conditions extending to the periodon - tium (Jepsen et al., 2018) • Trauma-induced local recession (Jepsen et al., 2018) • Endo-periodontal lesions (Herrera, Retamal-Valdes, Alonso, & Feres, 2018) • Periodontal abscess (Herrera et al., 2018) • Necrotizing periodontal diseases (Herrera et al., 2018)
A proposed algorithm has been used by the EFP to assist clini - cians with this periodontal diagnosis process when examining a new patient (Tonetti & Sanz, 2019). It consists of four sequential steps:
1. Identifying a patient suspected of having periodontitis 2. Confirming the diagnosis of periodontitis
3. Staging the periodontitis case 4. Grading the periodontitis case
4.3 | Sequence for the treatment of periodontitis stages I, II and III
4.2 | Differential Diagnosis
Patients, once diagnosed, should be treated according to a pre-estab - lished stepwise approach to therapy that, depending on the disease stage, should be incremental, each including different interventions. An essential prerequisite to therapy is to inform the patient of the diagnosis, including causes of the condition, risk factors, treatment alternatives and expected risks and benefits including the option of no treatment. This discussion should be followed by agreement on a personalized care plan. The plan might need to be modified during
Periodontitis should be differentiated from the following clinical conditions (not an exhaustive list of conditions and diseases):
• Gingivitis (Chapple et al., 2018) • Vertical root fracture (Jepsen et al., 2018) • Cervical decay (Jepsen et al., 2018)
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