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.
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.
Background
The global burden of periodontal diseases remains high. Population growth trends, changes in risk factors and improved tooth retention will increase the socio‐economic burden of ...periodontitis that is responsible for 3.5 million years lived with disability, 54 billion USD/year in lost productivity and a major portion of the 442 billion USD/year cost for oral diseases.
Methods
In the context of the Milan World Exhibition 2015 “Feeding the Planet, Energy for Life,” a green paper was developed and offered for global consultation by the European Federation of Periodontology. The final draft was endorsed by professional organizations around the world and is presented to stakeholders as a call for global action.
Results
Specific actions for the public, policymakers, educators and professional organizations have been identified in the areas of prevention, detection and care. These actions align public interest and knowledge, need for self‐care, professional intervention and policies to the best scientific evidence to proactively promote periodontal health and effectively manage the global burden of periodontal diseases, in accordance with WHO/UN priorities and strategies for tackling common non‐communicable diseases via the Common Risk Factor Approach.
Conclusions
A strong and coherent body of evidence allows identification of actionable preventive, diagnostic and therapeutic strategies to effectively promote periodontal health and general wellbeing, and better manage the socio‐economic consequences. Action requires consideration of the specific national scenarios.
Evidence indicates that periodontal regeneration is an efficacious and predictable procedure for the treatment of isolated and multiple intrabony defects. Meta‐analyses from systematic reviews ...indicate an added benefit, in terms of clinical attachment level gain, when demineralized freeze‐dried bone allograft, barrier membranes and active biologic products/compounds are applied in addition to open flap debridement. On the other hand, a consistent amount of variability of the outcomes is evident among different studies and within the experimental population of each study. This variability is explained, at least in part, by different patient and defect characteristics. Patient‐related factors include smoking habit, compliance with home oral hygiene and residual inflammation after cause‐related therapy. Defect‐associated factors include defect depth and radiographic angle, the number of residual bony walls, pocket depth and the degree of hypermobility. In addition, surgical‐related variables, such as surgical skill, clinical experience and knowledge, and application of the different regenerative materials, have a significant impact on clinical outcomes. This paper presents a strategy to optimize the clinical outcomes of periodontal regeneration. The surgical design of the flap, the use of different regenerative materials and the application of appropriate passive sutures are discussed in this review along with the scientific foundations.
Background
The recently introduced 2017 World Workshop on the classification of periodontitis, incorporating stages and grades of disease, aims to link disease classification with approaches to ...prevention and treatment, as it describes not only disease severity and extent but also the degree of complexity and an individual's risk. There is, therefore, a need for evidence‐based clinical guidelines providing recommendations to treat periodontitis.
Aim
The objective of the current project was to develop a S3 Level Clinical Practice Guideline (CPG) for the treatment of Stage I–III periodontitis.
Material and Methods
This S3 CPG was developed under the auspices of the European Federation of Periodontology (EFP), following the methodological guidance of the Association of Scientific Medical Societies in Germany and the Grading of Recommendations Assessment, Development and Evaluation (GRADE). The rigorous and transparent process included synthesis of relevant research in 15 specifically commissioned systematic reviews, evaluation of the quality and strength of evidence, the formulation of specific recommendations and consensus, on those recommendations, by leading experts and a broad base of stakeholders.
Results
The S3 CPG approaches the treatment of periodontitis (stages I, II and III) using a pre‐established stepwise approach to therapy that, depending on the disease stage, should be incremental, each including different interventions. Consensus was achieved on recommendations covering different interventions, aimed at (a) behavioural changes, supragingival biofilm, gingival inflammation and risk factor control; (b) supra‐ and sub‐gingival instrumentation, with and without adjunctive therapies; (c) different types of periodontal surgical interventions; and (d) the necessary supportive periodontal care to extend benefits over time.
Conclusion
This S3 guideline informs clinical practice, health systems, policymakers and, indirectly, the public on the available and most effective modalities to treat periodontitis and to maintain a healthy dentition for a lifetime, according to the available evidence at the time of publication.
Aims: Periodontitis has been associated with an increased risk of cardiovascular events. The nature of the association is unclear because both periodontitis and cardiovascular disease (CVD) share a ...host of risk factors. Intervention trials are critical to explore the relationship. If the association were causal, successful periodontal therapy will lead to an attenuation of the effect – CVD.
Material and Methods: The paper reviewed the design and the results of intervention trials aimed at improving systemic inflammation, endothelial dysfunction, carotid atherosclerosis and cardiovascular events.
Results: Early systematic reviews and a definitive controlled clinical trial indicate that intensive periodontal therapy results in a decrease in systemic inflammation and an improvement of endothelial dysfunction in systemically healthy subjects. A pilot trial has indicated the feasibility to assess the impact of periodontal therapy on carotid atherosclerosis in a primary cardiac prevention design.
Conclusions: Efforts to test causality in the relationship between periodontitis and CVD are ongoing. Evidence to date is consistent with the notion that severe generalized periodontitis causes systemic inflammation and endothelial dysfunction. Periodontitis has effects that go beyond the oral cavity and its treatment and prevention may contribute to the prevention of atherosclerosis.
Background
This consensus report is concerned with the association between periodontitis and atherosclerotic cardiovascular disease (ACVD). Periodontitis is a chronic multifactorial inflammatory ...disease caused by microorganisms and characterized by progressive destruction of the tooth supporting apparatus leading to tooth loss; as such, it is a major public health issue.
Aims
This report examined biological plausibility, epidemiology and early results from intervention trials.
Plausibility
Periodontitis leads to entry of bacteria in the blood stream. The bacteria activate the host inflammatory response by multiple mechanisms. The host immune response favors atheroma formation, maturation and exacerbation.
Epidemiology
In longitudinal studies assessing incident cardiovascular events, statistically significant excess risk for ACVD was reported in individuals with periodontitis. This was independent of established cardiovascular risk factors. The amount of the adjusted excess risk varies by type of cardiovascular outcome and across populations by age and gender. Given the high prevalence of periodontitis, even low to moderate excess risk is important from a public health perspective.
Intervention
There is moderate evidence that periodontal treatment: (i) reduces systemic inflammation as evidenced by reduction in C‐reactive protein (CRP) and improvement of both clinical and surrogate measures of endothelial function; but (ii) there is no effect on lipid profiles – supporting specificity. Limited evidence shows improvements in coagulation, biomarkers of endothelial cell activation, arterial blood pressure and subclinical atherosclerosis after periodontal therapy. The available evidence is consistent and speaks for a contributory role of periodontitis to ACVD. There are no periodontal intervention studies on primary ACVD prevention and there is only one feasibility study on secondary ACVD prevention.
Conclusions
It was concluded that: (i) there is consistent and strong epidemiologic evidence that periodontitis imparts increased risk for future cardiovascular disease; and (ii) while in vitro, animal and clinical studies do support the interaction and biological mechanism, intervention trials to date are not adequate to draw further conclusions. Well‐designed intervention trials on the impact of periodontal treatment on prevention of ACVD hard clinical outcomes are needed.
Background
Periodontal regeneration can change tooth prognosis and represents an alternative to extraction in teeth compromised by severe intra‐bony defects. The aim of this study was to compare ...periodontal regeneration (PR) with tooth extraction and replacement (TER) in a population with attachment loss to or beyond the apex of the root in terms of professional, patient‐reported and economic outcomes.
Methods
This was a 10‐year randomized controlled clinical trial. 50 stage III or stage IV periodontitis subjects with a severely compromised tooth with attachment loss to or beyond the apex were randomized to PR or TER with either an implant‐ or a tooth‐supported fixed partial denture. Subjects were kept on a strict periodontal supportive care regimen every 3 months and examined yearly. Survival and recurrence analysis were performed.
Results
88% and 100% survival rates were observed in the PR and TER groups. Complication‐free survival was not significantly different: 6.7–9.1 years for PR and 7.3–9.1 years for TER (p = .788). In PR, the observed 10‐year attachment gain was 7.3 ± 2.3 mm and the residual probing depths were 3.4 ± 0.8 mm. Recurrence analysis showed that the 95% confidence interval of the costs was significantly lower for PR compared with TER throughout the whole 10‐year period. Patient‐reported outcomes and oral health‐related quality‐of‐life measurements improved in both groups.
Conclusions
Periodontal regeneration can change the prognosis of hopeless teeth and is a less costly alternative to tooth extraction and replacement. The complexity of the treatment limits widespread application to the most complex cases but provides powerful proof of principle for the benefits of PR in deep intra‐bony defect.
Background
Furcation involvement and attachment loss are major predictors of tooth loss. The aim of this study was to describe specific designs for papilla preservation flaps (PPFs) and minimally ...invasive surgery to be used in compromised molars and report proof‐of‐principle data with 3 to 16‐year follow‐up in severely compromised molars due to the presence of combined furcation and intrabony defects.
Methods
Forty‐nine subjects with furcated molars and deep intrabony defects were treated with PPFs, application of periodontal regenerative devices. Improvement as a consequence of therapy was defined as tooth retention, reduction in horizontal and vertical furcation involvement, decrease in probing depths, and increases in clinical attachment level. Subjects were maintained with regular supportive periodontal care.
Results
At 1 year, 100% of maxillary and 92% of mandibular molars showed improvements. Improvements were not observed in molars with baseline hypermobility: two mandibular molars with hypermobility were extracted at the 1‐year follow‐up. Improvement in vertical sub‐classification was observed in 87.5% of maxillary and in 84.6% of mandibular molars. One‐year improvements could be maintained over the 3 to 16‐year follow‐up.
Conclusions
PPFs and periodontal regeneration can be applied and provide clinical benefits to severely compromised molars due to the combined presence of furcation involvement and deep intrabony defects. These results were obtained in cases with an interdental peak of bone and gingival margin coronal to the furcation entrance in well‐maintained and compliant subjects. Randomized controlled clinical trials with medium‐ to long‐term follow‐up are needed to confirm these findings.
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