Background
Authors were assigned the task to develop case definitions for periodontitis in the context of the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and ...Conditions. The aim of this manuscript is to review evidence and rationale for a revision of the current classification, to provide a framework for case definition that fully implicates state‐of‐the‐art knowledge and can be adapted as new evidence emerges, and to suggest a case definition system that can be implemented in clinical practice, research and epidemiologic surveillance.
Methods
Evidence gathered in four commissioned reviews was analyzed and interpreted with special emphasis to changes with regards to the understanding available prior to the 1999 classification. Authors analyzed case definition systems employed for a variety of chronic diseases and identified key criteria for a classification/case definition of periodontitis.
Results
The manuscript discusses the merits of a periodontitis case definition system based on Staging and Grading and proposes a case definition framework. Stage I to IV of periodontitis is defined based on severity (primarily periodontal breakdown with reference to root length and periodontitis‐associated tooth loss), complexity of management (pocket depth, infrabony defects, furcation involvement, tooth hypermobility, masticatory dysfunction) and additionally described as extent (localized or generalized). Grade of periodontitis is estimated with direct or indirect evidence of progression rate in three categories: slow, moderate and rapid progression (Grade A‐C). Risk factor analysis is used as grade modifier.
Conclusions
The paper describes a simple matrix based on stage and grade to appropriately define periodontitis in an individual patient. The proposed case definition extends beyond description based on severity to include characterization of biological features of the disease and represents a first step towards adoption of precision medicine concepts to the management of periodontitis. It also provides the necessary framework for introduction of biomarkers in diagnosis and prognosis.
Background
Authors were assigned the task to develop case definitions for periodontitis in the context of the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and ...Conditions. The aim of this manuscript is to review evidence and rationale for a revision of the current classification, to provide a framework for case definition that fully implicates state‐of‐the‐art knowledge and can be adapted as new evidence emerges, and to suggest a case definition system that can be implemented in clinical practice, research and epidemiologic surveillance.
Methods
Evidence gathered in four commissioned reviews was analyzed and interpreted with special emphasis to changes with regards to the understanding available prior to the 1999 classification. Authors analyzed case definition systems employed for a variety of chronic diseases and identified key criteria for a classification/case definition of periodontitis.
Results
The manuscript discusses the merits of a periodontitis case definition system based on Staging and Grading and proposes a case definition framework. Stage I to IV of periodontitis is defined based on severity (primarily periodontal breakdown with reference to root length and periodontitis‐associated tooth loss), complexity of management (pocket depth, infrabony defects, furcation involvement, tooth hypermobility, masticatory dysfunction) and additionally described as extent (localized or generalized). Grade of periodontitis is estimated with direct or indirect evidence of progression rate in three categories: slow, moderate and rapid progression (Grade A‐C). Risk factor analysis is used as grade modifier.
Conclusions
The paper describes a simple matrix based on stage and grade to appropriately define periodontitis in an individual patient. The proposed case definition extends beyond description based on severity to include characterization of biological features of the disease and represents a first step towards adoption of precision medicine concepts to the management of periodontitis. It also provides the necessary framework for introduction of biomarkers in diagnosis and prognosis.
A new periodontitis classification scheme has been adopted, in which forms of the disease previously recognized as “chronic” or “aggressive” are now grouped under a single category (“periodontitis”) ...and are further characterized based on a multi‐dimensional staging and grading system. Staging is largely dependent upon the severity of disease at presentation as well as on the complexity of disease management, while grading provides supplemental information about biological features of the disease including a history‐based analysis of the rate of periodontitis progression; assessment 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 patient.
Necrotizing periodontal diseases, whose characteristic clinical phenotype includes typical features (papilla necrosis, bleeding, and pain) and are associated with host immune response impairments, remain a distinct periodontitis category.
Endodontic‐periodontal lesions, 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 are classified according to signs and symptoms that have direct impact on their prognosis and treatment.
Periodontal abscesses are defined as acute lesions characterized by localized accumulation of pus within the gingival wall of the periodontal pocket/sulcus, rapid tissue destruction and are associated with risk for systemic dissemination.
A new periodontitis classification scheme has been adopted, in which forms of the disease previously recognized as “chronic” or “aggressive” are now grouped under a single category (“periodontitis”) ...and are further characterized based on a multi‐dimensional staging and grading system. Staging is largely dependent upon the severity of disease at presentation as well as on the complexity of disease management, while grading provides supplemental information about biological features of the disease including a history‐based analysis of the rate of periodontitis progression; assessment 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 patient.
Necrotizing periodontal diseases, whose characteristic clinical phenotype includes typical features (papilla necrosis, bleeding, and pain) and are associated with host immune response impairments, remain a distinct periodontitis category.
Endodontic‐periodontal lesions, 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 are classified according to signs and symptoms that have direct impact on their prognosis and treatment.
Periodontal abscesses are defined as acute lesions characterized by localized accumulation of pus within the gingival wall of the periodontal pocket/sulcus, rapid tissue destruction and are associated with risk for systemic dissemination.
Periodontitis is a ubiquitous and irreversible inflammatory condition and represents a significant public health burden. Severe periodontitis affects over 11% of adults, is a major cause of tooth ...loss impacting negatively upon speech, nutrition, quality of life and self‐esteem, and has systemic inflammatory consequences. Periodontitis is preventable and treatment leads to reduced rates of tooth loss and improved quality of life. However, successful treatment necessitates behaviour change in patients to address lifestyle risk factors (e.g. smoking) and, most importantly, to attain and sustain high standards of daily plaque removal, lifelong. While mechanical plaque removal remains the bedrock of successful periodontal disease management, in high‐risk patients it appears that the critical threshold for plaque accumulation to trigger periodontitis is low, and such patients may benefit from adjunctive agents for primary prevention of periodontitis.
Aim
The aims of this working group were to systematically review the evidence for primary prevention of periodontitis by preventing gingivitis via four approaches: 1) the efficacy of mechanical self‐administered plaque control regimes; 2) the efficacy of self‐administered inter‐dental mechanical plaque control; 3) the efficacy of adjunctive chemical plaque control; and 4) anti‐inflammatory (sole or adjunctive) approaches.
Methods
Two meta‐reviews (mechanical plaque removal) and two traditional systematic reviews (chemical plaque control/anti‐inflammatory agents) formed the basis of this consensus.
Results
Data support the belief that professionally administered plaque control significantly improves gingival inflammation and lowers plaque scores, with some evidence that reinforcement of oral hygiene provides further benefit. Re‐chargeable power toothbrushes provide small but statistically significant additional reductions in gingival inflammation and plaque levels. Flossing cannot be recommended other than for sites of gingival and periodontal health, where inter‐dental brushes (IDBs) will not pass through the interproximal area without trauma. Otherwise, IDBs are the device of choice for interproximal plaque removal. Use of local or systemic anti‐inflammatory agents in the management of gingivitis has no robust evidence base. We support the almost universal recommendations that all people should brush their teeth twice a day for at least 2 min. with fluoridated dentifrice. Expert opinion is that for periodontitis patients 2 min. is likely to be insufficient, especially when considering the need for additional use of inter‐dental cleaning devices. In patients with gingivitis once daily inter‐dental cleaning is recommended and the adjunctive use of chemical plaque control agents offers advantages in this group.
Background
A new classification of periodontal diseases aimed to identify periodontal disease based on a multidimensional staging and grading system has been recently proposed. However, up to date, ...its prognostic predictive capability has not been investigated. The aim of this study was to assess if parameters included in the new classification were predictive of tooth loss after a long‐term follow‐up (>10 years) in patients with periodontitis.
Methods
Patients presented with periodontitis at the University of Michigan between January 1966 and January 2004 were screened and categorized according to the new classification of periodontitis. Number/Reasons of teeth loss in patients who underwent at least one session/year of maintenance during the entire follow‐up period were extracted and used to analyze the prognostic capabilities of variables (staging, grading, and Extent) included in the new classification.
Results
A total number of 292 patients with a mean follow‐up of 289.7 ± 79.6 months were included. 31 (10.6%) patients were classified as Stage 1, 85 (29.1%) as Stage 2, 146 (50%) as Stage 3, and 30 (10.3%) as Stage 4. For grading, 34 (11.7%) were classified as Grade A, 193 (66.1%) as Grade B, and 65 (22.2%) as Grade C. Results of multilevel Cox regression analyses revealed a statistically significant association between stage (HR:3.73 between Stage 4 and Stage 1) and grade (HR: 4.83 between Grade C and Grade A) at baseline and periodontal related tooth loss, whereas no differences were detected for the extent of periodontitis.
Conclusion
This study provides the initial evidence regarding the predictive ability of the new classification of periodontitis. Patients in either Stage 4 or Grade C showed a significantly higher periodontal‐related tooth loss.
The American Academy of Periodontology (AAP) recently embarked on a Best Evidence Consensus (BEC) model of scientific inquiry to address questions of clinical importance in the treatment of ...periodontal and peri-implant diseases. For each focused question addressed below, there is a critical mass of evidence. However, standing alone, that evidence is, in the judgment of the Expert Panel convened by the AAP, insufficient to support broad conclusions and/or clinical practice guidelines. This article is protected by copyright. All rights reserved.
Conduct a systematic review and meta-analysis on nonsurgical treatment of patients with chronic periodontitis by means of scaling and root planing (SRP) with or without adjuncts.
A panel of experts ...convened by the American Dental Association Council on Scientific Affairs conducted a search of PubMed (MEDLINE) and Embase for randomized controlled trials of SRP with or without the use of adjuncts with clinical attachment level (CAL) outcomes in trials at least 6 months in duration and published in English through July 2014. The authors assessed individual study bias by using the Cochrane Risk of Bias Tool and conducted meta-analyses to obtain the summary effect estimates and their precision and to assess heterogeneity. The authors used funnel plots and Egger tests to assess publication bias when there were more than 10 studies. The authors used a modified version of the US Preventive Services Task Force methods to assess the overall level of certainty in the evidence.
The panel included 72 articles on the effectiveness of SRP with or without the following: systemic antimicrobials, a systemic host modulator (subantimicrobial-dose doxycycline), locally delivered antimicrobials (chlorhexidine chips, doxycycline hyclate gel, and minocycline microspheres), and a variety of nonsurgical lasers (photodynamic therapy with a diode laser, a diode laser, neodymium:yttrium-aluminum-garnet lasers, and erbium lasers).
With a moderate level of certainty, the panel found approximately a 0.5-millimeter average improvement in CAL with SRP. Combinations of SRP with assorted adjuncts resulted in a range of average CAL improvements between 0.2 and 0.6 mm over SRP alone. The panel judged the following 4 adjunctive therapies as beneficial with a moderate level of certainty: systemic subantimicrobial-dose doxycycline, systemic antimicrobials, chlorhexidine chips, and photodynamic therapy with a diode laser. There was a low level of certainty in the benefits of the other included adjunctive therapies. The panel provides clinical recommendations in the associated clinical practice guideline.
Background
A new periodontitis classification was recently introduced involving multidimensional staging and grading. The aim of the study was to assess if individuals well‐trained in periodontics ...consistently used the new classification for patients with severe periodontitis. The secondary goal was to identify “gray zones” related to classifications.
Methods
Participants (raters) individually classified 10 pre‐selected severe periodontitis cases using the 2017 World Workshop classification. An internet case‐based study was conducted after inviting members from American Academy of Periodontology and European Federation of Periodontology. Gold‐standard diagnoses were determined by five experts who developed the new periodontitis classification. Inter‐reliability agreement among raters was assessed using Fleiss Kappa index with the jackknife method for linearly weighted kappa calculations. McNemar test was used to determine symmetry between raters and gold‐standard panel.
Results
A total of 103 raters participated and classified nine clinical cases. Fleiss Kappa values showed moderate inter‐examiner consistency among raters for stage (K value: 0.49; 95% CI, 0.19 to 0.79), grade (K value: 0.50; 95% CI, 0.30 to 0.70) and extent (K value: 0.51; 95% CI, 0.23 to 0.77). When analyzed as composite (stage, grade, extent) a moderate inter‐reliability was present among raters, k = 0.479 (K value: 0.47; 95% CI, 0.442 to 0.515). Agreement between raters and gold‐standard panel was staging 76.6%; grading 82%; and extent 84.8%. In six of nine cases 77% to 99% of raters consistently agreed with gold‐standard panel, and the other three cases had gray zone factors that reduced rater consistency.
Conclusions
Clinicians trained in the 2017 World Workshop periodontitis classification demonstrated moderate concordance in classifying nine severe periodontitis cases, and in six of nine cases raters consistently agreed with the gold‐standard panel.
A panel of experts convened by the American Dental Association Council on Scientific Affairs presents an evidence-based clinical practice guideline on nonsurgical treatment of patients with chronic ...periodontitis by means of scaling and root planing (SRP) with or without adjuncts.
The authors developed this clinical practice guideline according to the American Dental Association's evidence-based guideline development methodology. This guideline is founded on a systematic review of the evidence that included 72 research articles providing clinical attachment level data on trials of at least 6 months' duration and published in English through July 2014. The strength of each recommendation (strong, in favor, weak, expert opinion for, expert opinion against, and against) is based on an assessment of the level of certainty in the evidence for the treatment's benefit in combination with an assessment of the balance between the magnitude of the benefit and the potential for adverse effects.
For patients with chronic periodontitis, SRP showed a moderate benefit, and the benefits were judged to outweigh potential adverse effects. The authors voted in favor of SRP as the initial nonsurgical treatment for chronic periodontitis. Although systemic subantimicrobial-dose doxycycline and systemic antimicrobials showed similar magnitudes of benefits as adjunctive therapies to SRP, they were recommended at different strengths (in favor for systemic subantimicrobial-dose doxycycline and weak for systemic antimicrobials) because of the higher potential for adverse effects with higher doses of antimicrobials. The strengths of 2 other recommendations are weak: chlorhexidine chips and photodynamic therapy with a diode laser. Recommendations for the other local antimicrobials (doxycycline hyclate gel and minocycline microspheres) were expert opinion for. Recommendations for the nonsurgical use of other lasers as SRP adjuncts were limited to expert opinion against because there was uncertainty regarding their clinical benefits and benefit-to-adverse effects balance. Note that expert opinion for does not imply endorsement but instead signifies that evidence is lacking and the level of certainty in the evidence is low.
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