Impact of Periodontal Classification on Treatment Planning

In its simplest form, the 2018 revised classification of periodontal diseases created by the American Academy of Periodontology and the European Federation of Periodontology can be summarized as Stage I being the earliest manifestation of periodontal disease and then graduating up through Stage II and III to Stage IV, which is the most severe manifestation of periodontal disease. The speed of periodontal disease progression is described as Grade A through C, with Grade A representing slow progression and Grade C indicating rapid progression.

The grade of a case is extremely important in determining the long-term prognosis of a patient, but it requires more than a single evaluation of the patient. When periodontal patients are initially classified, they are graded as B until the passage of time permits a more accurate estimate of periodontal progression. If it is determined that a patient has rapidly progressing periodontal disease (Grade C), prompt referral to a periodontist is recommended.

Classification of Periodontitis and Treatment

Gingivitis. Gingivitis is not classified as a periodontal disease but as gingival inflammation. Pocket depth is not appreciably increased in gingivitis. The treatment for gingivitis is patient education and oral prophylaxis. Scaling and root planing (SRP) is not appropriate care for gingivitis. Studies have shown that SRP in shallow pockets can actually cause an increase of clinical attachment loss (CAL).¹

Stage I Periodontitis. This stage of periodontitis is characterized by pocket depth of ≤ 4 mm, clinical attachment loss of 1 mm to 2 mm, and/or radiographic bone loss of < 15%. Stage I treatment is usually performed by the primary practitioner following a nonsurgical protocol. Treatment usually consists of oral hygiene instruction, oral prophylaxis of pockets of 3 mm or less, SRP performed in deeper pockets, site-by-site reevaluation and recording of responses to treatment ideally at 6 weeks post-treatment, and, assuming adequate response to therapy, placement of the patient on a periodontal maintenance plan that may start at every 3 months with a goal of every 6 months. Complete periodontal reevaluation is necessary at each maintenance visit. If active disease recurs or progression of anatomic damage is noted, the patient should be returned to active therapy at the stage of periodontal disease presented at the time of reevaluation.

Stage II Periodontitis. This stage is characterized by pocket depth of ≤ 5 mm, CAL of 3 mm to 4 mm, and/or radiographic mostly horizontal bone loss of between 15% and 33%. Limited furcation (class I) involvement may be noted.

Stage II treatment may be carried out by the primary practitioner or the patient may be referred to a periodontist. The decision for referral will be based on a thorough evaluation of the patient’s periodontal condition and the skill level of the practitioner. Stage II treatment usually consists of oral hygiene instruction, oral prophylaxis of pockets of 3 mm or less, SRP performed in 4 mm to 5 mm periodontal pockets, and reevaluation of response to treatment ideally at 6 weeks post-treatment.

Assuming the response to therapy is adequate, the patient should be placed on a periodontal maintenance schedule. It should be noted that adequate response to closed SRP is less likely to occur in some Stage II cases compared with Stage I cases. Many factors may be responsible, but the most frequent cause is the inadequate removal of all subgingival calculus and roughness using blind SRP. If the patient has not returned to periodontal health at the time of reevaluation, he or she should not be placed on a periodontal maintenance schedule, but active therapy should continue—modified to better address the unique nature of the circumstances. This might consist of further closed SRP but advanced care is almost always indicated.

On the other hand, if the patient displays periodontal health, he or she should be placed on a periodontal maintenance schedule of every 3 months with reevaluation at each maintenance visit. If signs of active disease recur or progression of disease is noted, the patient should be returned to active therapy at the stage of periodontal disease presented at the time of reevaluations.

Stage III Periodontitis. This is an advanced stage of the disease and will usually not fully respond to nonsurgical (SRP) therapy. Based on this, initial referral to a periodontist for advanced care should be considered. Stage III periodontitis is characterized by pocket depth of ≥ 6 mm, CAL ≥ 5 mm, radiographic bone loss of 33 % or more, multiple class I to class III furcation involvements, and/or loss of one tooth to three teeth due to periodontal disease.

Stage III treatment will almost always necessitate the use of advanced periodontal therapy. Stage III treatment will usually consist of oral hygiene instruction; exhaustive evaluation of risk factors such as anatomic concerns or systemic medical concerns; SRP performed usually on all teeth; reevaluation of response to initial treatment (SRP) at 6 weeks; treatment planning for advanced therapy including a prosthetic treatment plans if indicated; performing advanced therapy, which will frequently be surgical in nature and may include therapy aimed at sculpting remaining tissue and/or aimed at regenerating lost tissue (bone and/or soft tissue); and placement on a periodontal maintenance and reevaluation schedule of a minimum of every 3 months depending on the response to therapy. More frequent maintenance visits may be indicated in some situations with the goal being to increase the time between maintenance intervals if patient response permits. As in all cases, if active disease returns or progression of disease is noted, the patient should be returned to active therapy at the stage of periodontal disease presented at the time of re-evaluation.

Stage IV Periodontitis. This stage is characterized by periodontal tissue degeneration greater than would be expected based on existing etiologic factors such as the amount of plaque, calculus accumulation, age, and other risk factors. There may also be evidence of past rapidly occurring episodes of bone and attachment loss. Stage IV periodontitis will also frequently present as multiple lost teeth and extensive prosthetic needs due to bite collapse and other factors. The periodontal conditions for Stage IV, such as pocket depth, CAL, furcation involvement, and other factors, are the same as in Stage III. The difference between the two stages is the extent of damage and the loss of greater than three teeth to periodontal disease.

Treatment of Stage IV periodontitis will require a team effort. Because of tooth loss and occlusal changes, prosthetic planning will always be part of therapy. Additionally, other disciplines will likely be needed, including orthodontics, endodontics, and physician consultation.  The treatment of Stage IV periodontitis is usually best performed under the supervision of a periodontist. Advanced care is necessary for treatment of Stage IV cases and will vary with each patient. A specific description of therapy for Stage IV periodontitis is beyond the scope of this paper.

Bottom Line

Several studies report that many “hopeless” periodontal teeth are salvageable for extended periods of time with appropriate and timely periodontal therapy.^2–5 The treatment recommendations presented here are based on our many years of private practice, academic, and public health experience. Treatment should always be individualized for each patient, so no single treatment approach is correct for all patients or even for the same patient at different times. In early cases of periodontal disease (Stage I and possibly Stage II), basic treatments, such as oral hygiene instruction and SRP, may be adequate, but, in many cases, these treatments will be inadequate. This can only be determined by meticulous and frequent reevaluations that hopefully lead to appropriate modulations of subsequent care. Moreover, if periodontitis is not controlled by the treatment rendered, the patient must be informed of the need for and the availability of advanced care. In closing, the repeated use of basic therapies—such as closed (blind) SRP that fail to control periodontitis—is neither adequate nor ethical.

References

1. Cobb CM. Nonsurgical periodontal therapy: mechanical. Annals Periodontol. 1996;1:443-490.
2. Cobb CM, Sottosanti JS. A re-evaluation of scaling and root planing. J Periodontol. 2021;92:1370–1378.
3. De Beule F, Alsaadi G, Peric M, Brecx M. Periodontal treatment and maintenance of molars affected with severe periodontitis (DPSI =4): an up to 27-year retrospective study in a private practice. Quintessence Int. 2017;48:391–405.
4. Díaz-Faes L, Guerrero A, Magán-Fernández A, Bravo M, Mesa F. Tooth loss and alveolar bone crest loss during supportive periodontal therapy in patients with generalized aggressive periodontitis: Retrospective study with follow-up of 8 to 15 years. J Clin Periodontol. 2016;43:1109–1115.
5. Graetz C, Dörfer CE, Kahl M, et al. Retention of questionable and hopeless teeth in compliant patients treated for aggressive periodontitis. J Clin Periodontol. 2011;38:707–714.

This information originally appeared in Harrel SK, Rethman MP, Cobb CM, Sheldon LN, Sottosanti JS. Clinical decision points as guidelines for periodontal therapy. Dimensions of Dental Hygiene. 2022;20(6)28–33.