Occurrence of periodontal diseases according to the ACES 2018 Classification Framework and the CDC/AAP definition: A cross-sectional study in a major Brazilian city.

AIM: The occurrence of periodontal diseases is still to be determined in large samples of major Brazilian cities. This study aimed to assess the periodontal status of adults from Curitiba, Paraná, Brazil, using periodontitis definitions by the Centers for Disease Control and Prevention and the American Academy of Periodontology (CDC/AAP) and the recently published ACES 2018 Classification Framework. MATERIALS AND METHODS: A multi-stage probability sampling technique was applied to draw individuals aged 18 or older. A total of 566 individuals underwent a full-mouth periodontal examination. Periodontitis cases were defined according to the CDC/AAP and the ACES 2018 Classification Framework. Non-periodontitis cases were classified as healthy or gingivitis. The agreement between the two definitions was calculated. RESULTS: Periodontal health was present in 33.6% and 13.8% of individuals, and gingivitis was found in 11.7% and 7.5%, according to CDC/AAP and ACES, respectively. Mild, moderate and severe periodontitis (CDC/AAP) were present in 2.1%, 33.4% and 19.1% of individuals, respectively. Using ACES, 34.3% had Stages I/II and 43.3% had Stages III/IV. The occurrence of periodontitis was higher when a subgroup of individuals aged 30+ were analysed, ranging from 69.6% (CDC/AAP) to 90.1% (ACES). CDC/AAP and ACES agreement for health, gingivitis and periodontitis accounted for 68.8% of the observations. CONCLUSIONS: Periodontal diseases affect more than 66% of the population aged 18+ years. Classic definition by the CDC/AAP and the recently published ACES Framework yielded moderate agreement.

The burden of diagnostic error in dentistry: A study on periodontal disease misclassification.

BACKGROUND: Periodontal disease constitutes a widely prevalent category of non-communicable diseases and ranks among the top 10 causes of disability worldwide. Little however is known about diagnostic errors in dentistry. In this work, by retrospectively deploying an electronic health record (EHR)-based trigger tool, followed by gold standard manual review, we provide epidemiological estimates on the rate of diagnostic misclassification in dentistry through a periodontal use case. METHODS: An EHR-based trigger tool (a retrospective record review instrument that uses a list of triggers (or clues), i.e., data elements within the health record, to alert reviewers to the potential presence of a wrong diagnosis) was developed, tested and run against the EHR at the two participating sites to flag all cases having a potential misdiagnosis. All cases flagged as potentially misdiagnosed underwent extensive manual reviews by two calibrated domain experts. A subset of the non-flagged cases was also manually reviewed. RESULTS: A total of 2,262 patient charts met the study's inclusion criteria. Of these, the algorithm flagged 1,124 cases as potentially misclassified and 1,138 cases as potentially correctly diagnosed. When the algorithm identified a case as potentially misclassified, compared to the diagnosis assigned by the gold standard, the kappa statistic was 0.01. However, for cases the algorithm marked as potentially correctly diagnosed, the review against the gold standard showed a kappa statistic of 0.9, indicating near perfect agreement. The observed proportion of diagnostic misclassification was 32 %. There was no significant difference by clinic or provider characteristics. CONCLUSION: Our work revealed that about a third of periodontal cases are misclassified. Diagnostic errors have been reported to happen more frequently than other types of errors, and to be more preventable. Benchmarking diagnostic quality is a first step. Subsequent research endeavor will delve into comprehending the factors that contribute to diagnostic errors in dentistry and instituting measures to prevent them. CLINICAL SIGNIFICANCE: This study sheds light on the significance of diagnostic excellence in the delivery of dental care, and highlights the potential role of technology in aiding diagnostic decision-making at the point of care.

Periodontal grading-estimation of responsiveness to therapy and progression of disease.

OBJECTIVE: To investigate the capability of periodontal grading to estimate the progression of periodontal disease and the responsiveness to therapy. MATERIALS AND METHODS: Eighty-four patients who underwent non-surgical therapy (NST) were included. Direct and indirect evidence of progression were determined according to the current classification. Responsiveness to therapy was examined using mean pocket probing depths reduction (PPDRed), reduction of bleeding on probing (BOPRed), and the rate of pocket closure (%PC) after six months. RESULTS: Statistical analysis revealed no agreement between direct and indirect evidence in grading periodontitis (κ = 0.070). The actual rate of progression as determined by longitudinal data was underestimated in 13% (n = 11), overestimated in 51% (n = 43) and correctly estimated in 30% (n = 36) by indirect evidence. No significant differences in responsiveness to therapy were observed in patients graded according to direct evidence. Using indirect evidence, patients assigned grade C showed more PPDRed but less BOPRed and lower %PC compared to grade B. CONCLUSION: The present data indicate that indirect evidence may lead to inaccuracies compared to direct evidence regarding the estimation of periodontal progression. However, indirect evidence seems to be more suitable in the estimation of responsiveness to therapy than direct evidence, helping to identify cases that are more likely to require additional therapies such as re-instrumentation or periodontal surgery. CLINICAL RELEVANCE: Regarding the estimation of disease progression and responsiveness to periodontal therapy, accuracy and reliability of both direct and indirect evidence are limited when grading periodontitis.

Ease and practicability of the 2017 classification of periodontal diseases and conditions: a study of dental electronic health records.

BACKGROUND: A new classification for Periodontal and Peri-implant Diseases and Conditions was introduced in the 2017 World Workshop. In the past the 1999 Armitage Classification was commonly used in practice. This study aimed to assess the ease and practicability of retroactively diagnosing a subset of patients formerly diagnosed using the 1999 AAP/CDC classification with the 2017 AAP/EFP disease classification. METHODS: A random subset of 10% of all patients referred over a 7-year period (2011-2018) to the Post-Doctoral Periodontics Clinic at Columbia University College of Dental Medicine were reviewed by accessing the Electronic Health Records (EHRs) on axiUm. Patients diagnosed with periodontal disease based on the 1999 AAP/CDC classification (including chronic and aggressive Periodontitis) were reclassified using the 2017 classification (stage: I, II, III and grade: A, B, C). RESULTS: A sample of 336 patient records were examined. 132 were diagnosed with gingivitis, and 204 with periodontitis. Of these 204 patients, 68 (33.3%) were diagnosed with aggressive and 136 (66.7%) with chronic periodontitis. Patients diagnosed with aggressive periodontitis, 10% were reclassified as stage II, 47% as stage III, and 43% as stage IV periodontitis, and 100% were reclassified as grade C. Among patients with chronic periodontitis, 7% were reclassified as stage I, 65% as stage II, 21% as stage III, and 7% as stage IV; 11% of these were reclassified as grade A, 63% grade B, and 26% grade C. CONCLUSIONS: The majority of those originally diagnosed with aggressive (90%) and chronic (80%) periodontitis were reclassified as either molar/incisor pattern stage III grade C or stage IV grade C periodontitis, and stage II or III periodontitis, respectively. The study demonstrated that it is practical to retroactively reassign a diagnosis according to the new 2017 classification using available information included in dental EHRs.

Revisão crítica da nova classificação das periodontites / Critical review of periodontitis classification

Para o correto diagnóstico e tratamento da doença periodontal precisamos usar as classificações da doença periodontal. A mais recente foi proposta pela Academia Americana de Periodontia em conjunto com a Federação Europeia de Periodontia. Para a assimilação dos conceitos estabelecidos precisamos avaliar criticamente as informações que foram trazidas pelo consenso realizado há quase 6 anos. O objetivo do presente estudo é revisar o tópico periodontite da classificação, de forma a colaborar para o entendimento dessa doença pelos estudantes de graduação.

The periodontal diseases classifications are important for the correct diagnosis and treatment of periodontal diseases. The most recent classification was proposed by the American Academy of Periodontology in a consensus with the European Federation of Periodontology. For the assimilation of the established concepts, a critical evaluation of the information that was brought by the consensus almost 6 years ago, must be performed. The objective of the present study is to review the periodontitis topic of the new classification, in order to contribute to the understanding of this disease by undergraduate students.

Periodontal Classification Revisited: The Classification System in the Test of Time.

At the EuroPerio conference held in Amsterdam in 2018, an update to the previous classification of periodontal diseases was presented. The update was a joint effort of the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP). On the face of it, the new classification system for diagnosing periodontal diseases and conditions is merely an update of previous definitions from 1999. However, upon close examination, it is much more than another semantic change of old definitions. The new classification rocks the ground upon which generations of pre- and post-graduate students and specialists in the field have stood. It is a perceptual change in the way clinicians describe, diagnose, and ultimately treat periodontal patients.

Periodontal disease and its impact on general health in Latin America. Section IV: Diagnosis.

The art of diagnosis is of great importance in the management of any disease. This includes preventive and therapeutic strategies. To make an accurate and effective diagnosis, knowledge about the health-disease process is fundamental. This paper reviews the important aspects for periodontal diagnosis in a contemporary approach, and endeavors to establish challenges for improving periodontal diagnosis, especially in Latin America. Considering that contemporary periodontal diagnosis should be based on knowledge of the etiopathogenesis of periodontal diseases, this paper highlights that the recently proposed classification system for periodontal diseases and conditions was based on the best available evidence. This system was conceived for individual diagnosis, therefore, its use in research and epidemiological settings might be limited. The system leads to a practical implication that stresses the importance of interviewing the patient, thorough periodontal charting, and requesting any imaging and other complementary tests necessary. An important observation is that partial periodontal data recordings usable for screening are not diagnostic methods and might underestimate disease. The goals of utmost importance for Latin America are to increase the awareness of both the population and the profession and to prioritize correct periodontal diagnosis. In addition, learning how to use the new classification system will help with diagnosing periodontal diseases.

Tooth loss in adults: factors associated with the position and number of lost teeth.

OBJECTIVE: To evaluate the factors associated with tooth loss in adults from the position and number of teeth lost in the dental arches. METHODS: This is a cross-sectional, population-based study with adults participating in the epidemiological survey of oral health of São Paulo in 2015. The outcome of the study was tooth loss, assessed by the proposed classification, namely: I) lost up to 12 back teeth; II) lost up to 12 teeth (including front teeth); and III) lost more than 12 teeth. A four-block analysis was conducted, supported by a conceptual theoretical model adapted for tooth loss. For the multinomial logistic regression, "individuals who did not lose teeth due to caries or periodontal disease" was used as reference (p < 0.05). RESULTS: Of 6,051 adults evaluated, 25.3% (n = 1,530) were classified in category I, 32.7% (n = 1,977) in II, 9.4% (n = 568) in III, and 1.9% (n = 117) were edentulous. Lower income and schooling, the perception of need for treatment and the last appointment motivated by routine, pain or extraction were associated with tooth loss, regardless of the classification. The negative evaluation of the dental service was associated with individuals who lost up to 12 teeth, both front and back. The presence of women and periodontal pocket were associated with tooth loss of up to 12 teeth, including front, and more than 12 teeth. Caries were associated with adults who lost up to 12 teeth, including front teeth. CONCLUSION: The proposed classification allowed the identification of differences between the associated factors. Thus, the need to consider such classification in future studies is evident.

[2018 world new classification of periodontal and peri-implant diseases and conditions].

World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions was held in Chicago on November 9 to 11, 2017. More than one hundred experts from all over the world attended the conference and updated the 1999 classification of periodontal diseases and conditions, and developed a similar scheme for peri-implant diseases and conditions. The case definitions and diagnostic criteria were also established to aid clinicians in the use of the new classification. Nineteen review papers and four consensus reports covering relevant areas in periodontology and implant dentistry were simultaneously published in special issue of Journal of Periodontology and Journal of Clinical Periodontology in June 2018. This paper summarizes the new classification of periodontal and peri-implant diseases and conditions, and briefly introduce the changes made to the 1999 classification.

Variations in Periodontal Diagnosis Among Clinicians: dental hygienists' experiences and perceived barriers.

Purpose: Research indicates clinicians face barriers when attempting to utilize evidence-based protocols for periodontal disease and periodontal disease diagnosis often varies between dental providers. The purpose of this study was to identify and better understand dental hygienists' perceived barriers and experiences during the process of diagnosing periodontal disease in clinical practice.Methods: This study used a qualitative design and a purposive sample of dental hygienists (n=20). Utilizing a virtual video-conferencing platform, participants logged into focus group sessions to discuss their experiences with diagnosing periodontal disease in clinical practice. Focus group sessions were recorded and transcribed. Thematic analysis involved the use of inductive coding to draw themes from the data.Results: Dental hygienists reported being responsible for periodontal disease diagnosis, and that they utilized similar classification systems, and agreed with colleagues' periodontal disease diagnoses. However, participants reported the lack of a standardized periodontal classification system was confusing when communicating outside of their dental practice and described both intrinsic and extrinsic barriers to diagnosing disease. A common theme expressed by participants was that patients' lack of acceptance of their periodontal disease status and inability to fund treatment interfered with providing an evidence-based diagnosis and treatment plan. Newly licensed dental hygienists felt somewhat prepared to diagnose periodontal disease upon completion of their education but reported increased confidence in their skills and knowledge with years of practice and continuing education.Conclusion: Study data indicates dental hygienists feel the lack of a standardized periodontal classification system causes confusion and inconsistencies when communicating with other oral health care providers outside of their clinical practice setting, and dental hygienists face barriers when diagnosing periodontal disease. These findings may be instrumental in assisting educators in preparing students for clinical practice.

Distribution of biopsied non plaque-induced gingival lesions in a Chilean population according to the classification of periodontal diseases.

BACKGROUND: Many gingival lesions are not induced by plaque. The aim of this study was to analyze the frequency of biopsied non-plaque-induced gingival lesions (NPIGL) in a Chilean population. METHODS: One thousand twelve cases of biopsied gingival lesions with confirmed anatomopathologic diagnosis were included, from the records of the Oral Pathology Referral Institute (OPRI), Faculty of Dentistry, University of Chile, between years 1990 and 2009. RESULTS: The most frequent non plaque-induced gingival lesions categories from biopsied cases included hyperplastic lesions, malignancies and benign neoplasms. The most frequent diagnoses in each category were fibrous hyperplasia (35.47%), squamous cell carcinoma (3.85%) and giant cell fibroma (2.08%), respectively. From all lesions, only 8.3% fitted in the specified categories of the current classification of periodontal diseases. CONCLUSIONS: The most frequent biopsied NPIGL were hyperplastic lesions and neoplasms. These categories represent relevant lesions to be included in a future periodontal classification system to improve the care needs of the patients, as well as early diagnosis and treatment.

Socioeconomic status and self-reported periodontal symptoms in community-dwelling individuals: data from the Korea Community Health Surveys of 2011 and 2013.

OBJECTIVES: This study aimed to evaluate the association between socioeconomic status and self-reported periodontal symptoms. MATERIALS AND METHODS: In this cross-sectional study, data were used from the 2011 and 2013 Community Health Surveys. The 210,432 (weighted n = 36,294,413) and 220,396 (weighted n = 39,067,134) subjects, respectively, were aged 19 years or older. Proportional and systematic sampling was performed. Surveys were conducted by trained interviewers using computer-assisted personal interviewing. The proportions of subjects with tooth mobility, gingival swelling, calculus and gingival bleeding were calculated. Independent variables included sex, age and socioeconomic status measures (education, occupation and income). Differences in the self-reported periodontal symptoms rates according to socioeconomic status were determined using independent t-tests and one-way analysis of variance. Logistic regression analysis was used to identify the association of periodontal symptoms with socioeconomic status. RESULTS: Approximately 30% of the subjects reported at least one symptom of periodontal disease; 11.3% and 9.6% reported gingival bleeding and gingival swelling, respectively, while 5.6% and 3.5% reported dental calculus and tooth mobility, respectively. There were significant associations with self-reported periodontal symptoms according to occupation, education and income (P < 0.01). CONCLUSIONS: The severity of self-reported periodontal symptoms differed according to socioeconomic status. Subjects with lower socioeconomic status reported more advanced periodontal disease symptoms, such as gingival swelling, while those with higher socioeconomic status reported more incipient periodontal symptoms, such as gingival bleeding. Socioeconomic status remains a factor affecting self-reported periodontal symptoms in community-dwelling individuals in Korea.

Evaluating periodontal disease misclassification mechanisms under partial-mouth recording protocols.

AIM: To evaluate the assumptions underlying the use of partial-mouth recording (PMR) protocols and the associated mechanisms of potential misclassification of periodontal disease. METHODS: Using data from 640 participants in the VA Dental Longitudinal Study, we compared tooth-specific and site-specific clinical measures and calculated sensitivity and specificity of different PMR protocols by applying the Centers for Disease Control and Prevention in collaboration with the American Academy of Periodontology definitions for periodontitis as the full-mouth reference standard. Additionally, we evaluated alternative case definitions for PMR protocols that accounted for the reduction in numbers of teeth under observation. RESULTS: In this cohort, periodontitis presented as a generalized condition in that measures of clinical severity did not differ meaningfully according to site measured, oral quadrant or jaw. Sensitivity of disease classification under PMR protocols was a function of the number of teeth and sites under observation and the case definition applied. Sensitivity increased when case definitions were modified to account for the smaller number of teeth under observation with PMR protocols. However, specificity was reduced. CONCLUSIONS: Misclassification of periodontal disease by PMR protocols is not random, even if sites under observation are randomly selected. PMR protocols can be selected/modified to maximize sensitivity, but they do so at the expense of bias in mean measures of severity.

Efeitos terapêuticos do uso de produtos derivados da romã (punica granatum) como coadjuvante no tratamento das doenças periodontais: uma revisão de literatura / Therapeutic effects of the use of pomegranate products (Punica granatum) as adjuvant in the treatment of periodontal diseases: a review of the literature

A romã (Punica granatum) possui uma vasta história médica conhecida por sua ação antibacteriana, antioxidante e anti-inflamatória. A presente revisão teve como objetivo verificar os potenciais efeitos terapêuticos do uso de produtos derivados da P. granatum como coadjuvante no tratamento das doenças periodontais. Descritores em inglês e português dos termos: "romã", "doença periodontal", "gengivite", "periodontite" e "punica granatum", foram utilizados para consulta nas bases de dados Pubmed, Lilacs e Scielo. Para avaliação dos efeitos anti-inflamatórios, antimicrobianos e clínicos da romã foram incluídos trabalhos clínicos e pré-clínicos, sem restrições de data. Os diferentes estudos selecionados avaliaram P. granatum em diferentes formulações, incluindo bochechos, géis, infusão, dentifrícios, e chips biodegradáveis. Os resultados demostraram que os componentes fitoquímicos de P. granatum, como polifenóis flavonoides, punicalaginas, ácido punícico e antocinas apresentam propriedades relevantes pró-saúde periodontal, que incluem efeitos anti-inflamatórios, antioxidantes, hemostáticos e imunoregulatórios. Estudos in vivo utilizando diferentes formulações da romã em participantes acometidos por gengivite ou periodontite apresentaram reduções nos índices de placa, sangramento gengival e profundidade de sondagem em graus variados. Conclui-se que P. granatum pode ser uma promissora alternativa à terapia antimicrobiana padrão, para auxílio do controle mecânico de placa, com melhora dos sinais clínicos das doenças periodontais. Contudo, mais estudos clínicos ainda são necessários. (AU)

The pomegranade (Punica granatum) has a vast medical history know by its antibacterial, antioxidant and antiinflammatory action. The presente review aimed at verifying the potential therapeutic effects of products derived from P. granatum as adjuvant in the treatment of periodontal diseases. English and Portugueses descriptors of the terms "pomegranate", "periodontal disease", "gingivitis", "periodontitis" and "Punica granatum" were used for search in Pubmed, Lilacs and Scielo databases. To assess the anti-inflammatory, antimicrobial and clinical effects of pomegranate, clinical and preclinical were included, with no date restrictions. The different studies evaluated P. granatum in different formulations, including mouthwash, gels, infusion, dentifrices, and biodegradable chips. Results showed that the phytochemical components of P. granatum, such as polyphenois flavonoids, punicalagins, punicic acid and antocines, demonstrated relevant periodontal prohealth properties, including anti-inflammatory, antioxidant, hemostatic and immunoregulatory effects. In vivo studies, using different pomegranade formulations in individuals affected by gingivitis or periodontitis, showed reductions in plaque index, gingival bleeding and probing depth in different levels. It was concluded that P. granatum could be a promising alternative to the standard antimicrobial therapy in order to aid the mechanical control of plaque, with improvement of clinical signs of periodontal diseases. However, more clinical studies are still necessary. (AU)

Dental and periodontal health, and microbiological and salivary conditions in patients with or without diabetes undergoing haemodialysis.

OBJECTIVE: The aim of this cross-sectional study was to evaluate the dental and periodontal health, as well as the microbiological and salivary conditions, of patients with and without diabetes mellitus (DM) who are receiving haemodialysis. METHODS: One-hundred and fifty-nine haemodialysis patients were included and divided into groups according to the pre-existing diabetes status: DM or no DM. The oral examination included dental findings and assessment of the periodontal situation. The periodontal condition was classified as healthy/mild, moderate or severe periodontitis. Subgingival biofilm samples were analysed using the polymerase chain reaction. The salivary diagnostics included measurement of unstimulated and stimulated salivary flow, pH and buffer capacity. Statistical analyses used Fisher's test, the t-test and the Mann-Whitney U-test (α = 5%). RESULTS: The dental findings showed no significant difference between patients with and without DM (P = 0.44). The prevalence of periodontitis was high (96% in patients with DM and 97% in patients who did not have DM) and there was no significant difference between the groups (P = 0.71). There was a higher prevalence of Porphyromonas gingivalis, Parvimonas micros, Eubacterium nucleatum and Capnocytophaga spp. in patients without DM (P < 0.05). The salivary pH was significantly higher in patients without DM (P < 0.01). CONCLUSION: While differences in the prevalence of periodontal pathogenic bacteria and in the salivary pH were detected between the groups, the dental and periodontal status was comparable between patients with and without DM. Accordingly, DM appears to have no decisive influence on the oral health in patients treated with haemodialysis who have well-controlled diabetes.