of life, with the potential to negatively affect multiple systemic conditions. Early diagnosis and treatment has been shown to improve considerably the oral health of patients, and also biomarkers associated with their overall well‐being. This disease is diagnosed based on the clinical signs of inflammation and clinical evidence of periodontal tissue destruction. Radiographs also help to determine the extent of bone loss. According to the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions (https://www.perio.org/2017wwdc) [1], periodontitis has been identified in three distinct forms: periodontitis; periodontitis as a direct manifestation of systemic diseases; and necrotizing periodontitis. This case has focused on periodontitis, since this is the most prevalent form of this disease, and corresponds to what has been previously classified as either chronic or aggressive periodontitis.
Periodontitis is distinguished from gingivitis primarily on the basis of the presence of loss of attachment and resorption of alveolar bone. Therefore, in addition to common signs found in gingivitis, such as redness, swelling, bleeding tendency, and possibly suppuration, the diagnosis of periodontitis requires the presence of periodontal pockets associated with clinical loss of attachment. Alveolar bone loss is also a hallmark of the pathology and can be detected radiographically. It is not uncommon to detect extensive accumulation of dental plaque and calculus, although this can also be found in gingivitis [2]. According to the 2017 World Workshop, the severity and complexity of periodontitis can be categorized into a staging system that ranges from stage I to IV, from the least to the most complex conditions. The distinctions between these stages are clearly provided in the published proceeding of the 2017 World Workshop, and consider parameters such as interdental CAL, bone loss, tooth loss due to periodontitis, PD, furcation involvement, ridge defects, and masticatory dysfunctions. The stage can also be described in terms of its extent and distribution as localized (<30% of teeth involved) or generalized (≥30%), and/or molar/incisor pattern [3]. The extension should be assessed after the stage has been determined, and it should refer to the stage that captures the overall severity and complexity of the case [4]. This classification system also categorizes the case in a grade system based on historical disease progression and risk for potential continuation, including the factors that modify progression of the disease such as diabetes and smoking burden (grade modifiers). In this way the provider and the patient can have a clearer idea of the aggressiveness of the manifestation of periodontal disease, the likelihood of successful outcomes with most modalities of treatment, and the impact of the disease on systemic health. Other than the grade modifiers (smoking and diabetes), the primary factors considered in establishing the grade include direct and indirect evidence of progression, such as longitudinal bone loss or CAL, percentage bone loss/age, and case phenotype (level of destruction proportional to magnitude of local factors, such as biofilm and calculus). The grades are described as A, B or C, in which grade A represents the lowest risk of progression and grade C the highest risk.
Figure 1.6.5 Periodontal chart three months after therapy.
Source: courtesy of Dr. Eduardo Sampaio and Dr. Marcelo Faveri.
Figure 1.6.6 Clinical presentation of the case one year after therapy.
Source: courtesy of Dr. Eduardo Sampaio and Dr. Marcelo Faveri.
Based on the criteria established by this current classification, the present case would be diagnosed as periodontitis stage III, localized, grade C. A brief discussion of this diagnosis follows.
Periodontitis case: periodontitis was defined based on the presence of two or more nonadjacent teeth with CAL >2 mm, associated with bone loss and periodontal pockets. The case is not associated with necrosis of gingival tissues or with rare forms of systemic disease that severely affect periodontal tissues.
Stage III: most of the teeth present with bone loss extending to the middle of the root, CAL is more than 5 mm for multiple teeth, and more than one site presents with PD >6 mm. However, there is no tooth loss due to periodontitis, neither is any tooth expected to be extracted because of it, and apparently there is no significant need of complex rehabilitation.
Localized extension: less than 30% of teeth were affected at the stage III level, as the chart and radiographs show. Of the 28 teeth present, eight (28.5%) had CAL >5 mm.Figure 1.6.7 Periodontal chart one year after periodontal therapy.Source: courtesy of Dr. Eduardo Sampaio and Dr. Marcelo Faveri.
Grade C (rapid rate of progression): percentage bone loss/age was more than 1.0 (50%/43 years).
Although the diagnosis of periodontitis for cases such as the one presented here is straightforward, the determination of cases at the beginning of the disease process and the distinction between severe generalized cases and more aggressive forms of periodontitis is not always easy. The new classification system presents numerous tools to help clarify such distinctions. Such understanding is very valuable in determining prognosis and establishing a treatment plan and guiding the follow‐up on these cases. Although this classification is fairly new, some recent longitudinal data has validated its staging and grading parameters for long‐term prognosis and outcomes following treatment of periodontal patients [5,6]. However, clinical technical issues still exist, especially in the distinction between early signs of periodontitis and more advanced forms of gingivitis, complicated by difficulties in determining initial clinical attachment loss in the absence of clear radiographic evidence of alveolar bone loss, mainly in areas where severe gingival inflammation causes hyperplasia of the gingival margin.
Clinicians should also be careful while distinguishing between patients with periodontitis and those presenting with areas of incidental attachment loss not caused by the bacterial‐induced inflammation characteristic of periodontitis – what is currently described as “reduced periodontium in non‐periodontitis patient” [7]. For instance, isolated sites of gingival recession caused by toothbrush trauma should not be confused as a sign of periodontitis. These lesions are easily distinguishable from recession of the gingival margin as a consequence of periodontitis on the basis of their clinical features. They involve primarily the buccal surface of teeth, with no loss of adjacent interproximal tissue, and are primarily associated with teeth with thin buccal soft tissues such as maxillary canines and premolars – what is described as “periodontal phenotype.” The presence of these isolated lesions is not sufficient for the diagnosis of periodontitis, even though they are associated with attachment and alveolar bone loss. However, if lesions such as these present with CAL ≥3 mm and PD >3 mm in two or more teeth, especially in the context of plaque and gingival inflammation, then the diagnosis of periodontitis would be more likely and therefore recommended [8].
Other common examples of incidental attachment loss lesions include the bone loss associated with restorations invading the biologic width and defects on the distal aspect of second molars caused by the malposition of unerupted or partially erupted third molars. The mesial tipping of teeth can also lead to a clinically deepened sulcus and a radiographic image suggestive of a vertical bone loss. This appearance is the consequence of the apical displacement of the mesial CEJ and should not lead to the erroneous diagnosis of periodontitis. It should be noted, however, that a condition such as this may predispose the site to greater accumulation of plaque, and therefore greater risk of development of any form of periodontal disease. As one can see, there are several circumstances where the early diagnosis of periodontitis can be complicated.
The distinction among more aggressive manifestations of periodontitis, what previously was differentiated as chronic and aggressive periodontitis, can also be difficult. These two conditions have since been understood as one single disease –