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
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Guidance for clinicians
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