Clinical Cases in Periodontics. Группа авторов

etiologic or pathologic process for each of the former [3,9,10]. Such distinctions now are helped by the use of the grading system and among other features aim to find aggressive manifestations, i.e. those that show a faster rate of tissue loss and a greater risk for further progression. However, clinicians rarely have the opportunity to measure rates of disease progression, and therefore indirect measures may assist in this understanding, especially using the percentage bone loss/age formula incorporated in the grading. Although periodontitis can affect individuals of any age, chronological age remains an essential component of the natural progression of periodontitis if left untreated. If a younger individual presents with advanced attachment and bone loss, it is concluded that these subjects are presenting a faster rate of progression.

      Although the description of a specific disease called “aggressive periodontitis” is no longer adopted, the classical presentation of several clinical features that made it easily distinguishable, such as age of onset, primarily incisors and firsts molars affected by the disease (including a tendency to manifest infrabony angular defects around these molars), and an overall lack of clinical signs of inflammation and minimal amounts of gross plaque and calculus accumulation despite severe bone loss around the affected teeth is accounted for by the new grading system, especially the grade C pattern.

The treatment of periodontitis as discussed in later chapters depends on the ability of the clinician to remove plaque and calculus from the root surfaces, allowing for proper healing of the gingival tissues, and on the capacity of the patient to perform proper plaque control. These are the cornerstones of periodontal therapy. Although the focus of this case is the diagnosis, but not treatment, of periodontitis, it is important to emphasize that the results obtained with anti‐infective periodontal therapy will determine the long‐term prognosis of the case and the need for additional treatment. Therefore, it is essential that clinicians examine the outcome of the initial therapy before any additional decisions regarding the case can be made, and this reevaluation could be considered part of the diagnostic process.

      Studies examining the prognostic ability of periodontal clinical parameters have demonstrated that the presence of plaque, BOP, and suppuration have very low positive predictive values but very high negative predictive values [11,12]. This indicates that sites without clinical signs of inflammation are at very low risk for disease progression and might not require additional therapy. In addition, the accumulation of information regarding the clinical parameters for a given site over time increases the prognostic value of these parameters. Sites with constant BOP have a much higher chance of progression than sites that bleed sporadically [12]. These findings support the notion that any site cleared of periodontitis, but still presenting with PD ≥4 mm and BOP should be carefully monitored during the maintenance phase [7]. It is also well established that the prognosis of periodontitis directly depends on the patient’s ability to control plaque accumulation. A longer follow‐up will afford the clinician a better assessment of the patient’s oral hygiene skills.

      The presence of residual pockets after initial therapy, rather than the presence of deep pockets at the initial examination, is associated with an increased risk of future attachment loss [13]. This information is readily available to periodontists and can add great insights into the long‐term prognosis of the case. When clinicians are trying to assess the outcome of their initial periodontal therapy, another key piece of information is how much improvement one can anticipate. In other words, what should be the realistic expectation of a therapist regarding the treatment outcome? This clearly will depend on the severity and extent of the periodontal condition at the beginning of treatment, also understood by the given staging and grading of the case. A few clinical end points for the active phase of periodontal treatment have been recently suggested, such as the presence of at most four sites with PD ≥5 mm [14], absence of sites with PD ≥4 mm and bleeding on probing and <10% of sites with BOP in the mouth [7], and absence of sites with PD ≥5 mm with BOP and no sites with PD ≥6 mm [15]. All these authors have suggested that successful anti‐infective treatment should lead to a minimal number of deep pockets and of sites with BOP in the mouth after treatment.

      In addition, several longitudinal studies have been conducted, and guidelines regarding the amount of pocket depth reduction and clinical attachment gains for each initial pocket depth are available and should be used to keep the outcome of treatment in perspective [16,17]. It is unrealistic, for instance, to expect a 9‐mm pocket to convert to a 3‐mm sulcus after SRP. The staging of the case may therefore allow a better understanding of what to expect of the case and what course of action a clinician should take. For example, a case described as periodontitis stage I/II will need anti‐infective therapies, but likely will not need any further treatment if this initial phase is successful. A periodontitis stage III is one where the patient may expect some teeth loss following long‐term care, but is likely to maintain most of the dentition, if not all, if proper anti‐infective treatment and good home care are maintained. However, because of the multiple complexities of such cases, they may benefit from a consultation with a periodontist, and may need adjunctive antimicrobials and periodontal surgery, especially those with a generalized extent. A periodontitis stage IV is one where the patient may expect complete loss of the dentition if appropriate treatment is not timely rendered, or if successful outcomes are not established. These cases would significantly benefit from multidisciplinary treatment, especially a team of professionals with advanced restorative/prosthodontic and periodontal skills. If part of the dentition remains, these cases may also benefit from adjunctive antimicrobials and periodontal surgery. The grading of the case may also help establish expectations and course of action. Especially in cases that have modifiers affecting the grade, such as diabetes and smoking, an integrative approach involving the medical care team in the management of the case would be of benefit to the outcomes of periodontal treatment and the overall health of the patient. Cases without known systemic conditions, but presenting with grade C features, may also benefit from a more careful analysis by such an integrated healthcare team, or at least may need more attention and special care from the dental providers.

      Self-Study Questions

      1 What are the clinical features that differentiate incidental loss of attachment resulting from mechanical trauma from periodontitis-induced loss of attachment?

      2 If a clinician is unsure about the diagnosis of the case based on the presence of some aggressive characteristics (i.e. periodontitis as a manifestation of systemic disease or generalized periodontitis), how should he or she proceed?

      3 What are the possible therapeutic consequences of a differential diagnosis between periodontitis of different gradings or of other potentially aggressive manifestations?

      4 If the initial outcome of a periodontal anti-infective therapy is below the standards indicated by the literature, what should the therapist suspect and how should he or she proceed?

      5 How should the periodontist proceed if, by the reexamination, the case has several residual pockets?

      Answers located at the end of the chapter.

References

      1 1. Caton JG, Armitage G, Berglundh T, et al. A new classification scheme for periodontal and peri‐implant diseases and conditions: introduction and key changes from the 1999 classification. J Clin Periodontol 2018; 45(Suppl 20):S1–S8.

      2 2. Page RC, Eke PI. Case definitions for use in population‐based surveillance of periodontitis. J Periodontol 2007; 78:1387–1399.

      3 3. Papapanou PN, Sanz M, Buduneli N, et al. Periodontitis: consensus report on workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions. J Clin Periodontol 2018; 45(Suppl 20):S162–S170.

      4 4. Sanz M, Papapanou PN, Tonetti MS, et al. Guest Editorial: clarifications on the use of the new classification of periodontitis. J Clin Periodontol 2020; 47(6):658–659.

      5 5. Ravidà A, Troiano G, Qazi M, et al. Development of a nomogram for the prediction of periodontal tooth loss using the staging and grading system: a long‐term cohort study. J Clin Periodontol 2020; 47(11):1362–1370.

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