Implementation of the new classification of periodontal diseases: Decision‐making algorithms for clinical practice and education

Abstract

Background Implementation of the new classification of periodontal diseases requires careful navigation of the new case definitions and organization of the diagnostic process along rationale and easily applicable algorithms. The aim of this report was to describe the rationale for one such approach designed for clinical practice and education. Methods The authors developed empiric decision‐making algorithms based on the new classification to effectively discriminate between the key periodontal diagnoses of periodontal health, gingivitis and periodontitis. Results A stepwise approach is proposed that includes (a) a sensitive screening step able to discriminate periodontal health, gingivitis and suspect periodontitis; (b) a specific confirmation step to provide differential diagnosis between periodontitis and the other conditions characterized by attachment loss; (c) a step to assess the severity and complexity of management of the periodontitis case (staging); and (d) a step to assess the risk profile of the case (grading). Specific decision‐making algorithms are described for all steps of the diagnostic process. Conclusions The proposed process allows discrimination between the different case definitions of periodontal health and disease. The diagnostic accuracy and cost‐effectiveness of the process need to be validated in prospective trials generalizable to operators with different level of expertise, different populations and clinical settings.

Active MMP-8 (aMMP-8) as a Grading and Staging Biomarker in the Periodontitis Classification

“…The boxand-whiskers plots illustrate the median, quartiles, and extreme values. Previously validated cut-off of 20 ng/mL for aMMP-8 assays [10] and cut-off of 10% for BOP [1,49] Finally, in this sample, the range of BOP and VPI levels were wide among healthy patients compared with the diseased patients (stage I-III and Grades A-C). Regarding periodontitis patients, the same applies to BOP and VPI levels among Grade A patients when compared to Grade B patients (Figure 1).…”

“…Previous studies have also shown that BOP poorly predicts future periodontal breakdown (positive predictive value for repeated incidence of BOP was ≤ 30%), but the continuous absence of BOP correlates much better with periodontal stability [2,[45][46][47][48]. For example, Joss et al [48] suggested a cut-off of 20% for BOP, while in the new classification system a threshold of 10% for BOP is suggested to define periodontal health [49]. However, as Figure 1 shows, despite the positive association between BOP and both stage and grade, the two cut-offs are likely to cause a large number of false positives.…”

“…The box-and-whiskers plots illustrate the median, quartiles, and extreme values. Previously validated cut-off of 20 ng/mL for aMMP-8 assays[10] and cut-off of 10% for BOP[1,49] marked in thefigure.…”

Diagnosing tooth wear, a new taxonomy based on the revised version of the Tooth Wear Evaluation System (TWES 2.0)

“…This should make adaptation to the new taxonomy easier for dentists in daily practice. As with the periodontal classification, this new taxonomy for tooth wear offers the possibility of forming decision trees based on the findings 40 . In contrast to the periodontal classification, however, the tooth wear taxonomy aimed to be simple and straightforward to make it self‐explanatory.…”

Salivary levels of specialized pro‐resolving lipid mediators as indicators of periodontal health/disease status

“…(a) inter-dental CAL detectable at ≥2 non-adjacent teeth; (b) buccal or lingual CAL ≥3 mm with pocketing >3 mm detectable at ≥2 teeth (Papapanou et al, 2018;Tonetti et al, 2018). Once the periodontal diagnosis was defined, staging and grading of disease were F I G U R E 1 Flow chart illustrating the progress of cases/participants through the study performed using the 2017 World Workshop classification (Caton et al, 2018;Papapanou et al, 2018;Tonetti et al, 2018;Tonetti & Sanz, 2019). Accordingly, stage was defined as: stage I (initial periodontitis), stage II (moderate periodontitis), stage III (severe periodontitis with potential for additional tooth loss) and stage IV (advanced periodontitis with extensive tooth loss and potential for loss of dentition).…”