An American Academy of Periodontology Task Force (AAP-TF) has recently reported about a planned update of the 1999 Classification of Periodontal Diseases and Conditions . I have written about it here. As the update is announced for 2017, I suppose that the AAP-TF report is meant to initiate some discussion as “[c]oncerns had been expressed by the education community, the American Board of Periodontology, and the practicing community that the current classification presents challenges for the education of dental students and implementation in clinical practice”. The AAP-TF report focuses in particular on attachment level, chronic versus aggressive, and localized versus generalized periodontitis. In my previous post, I had raised some concerns about the task force’s intention to keep the current differentiation between aggressive and chronic periodontitis and referred to an interesting essay by Baelum and Lopez (2003). As these authors have just published a harsh comment on the AAP-TF report, it’s interesting to see that we agree and utterly disagree in certain matters.
Attachment level measurements
The 1999 Classification indeed categorized severity of periodontitis only by amount of clinical attachment loss, slight, moderate, and severe (i.e. 1-2 mm, 3-4 mm, and 5 mm or more, respectively). Albeit attachment level measurements are important “for the scientific advancement of the knowledge of periodontitis”, the AAP-TF recognizes that attachment level measurements are challenging, time-consuming, difficult and “may involve some guesswork when the CEJ [cemento-enamel junction] is not readily evident via tactile sensation.” Consequently, they advocate new guidelines for determining severity, slight or mild, moderate, severe or advanced, of periodontitis which include, in addition to those based on clinical attachment level measurements, probing depths (>3 mm & ≤5 mm, >5 & <7 mm, and ≥7 mm, respectively), and radiographic bone loss (up to 15% of root length or 2-3 mm, 16-30% or 4-5 mm, and more than 30% or 6 mm or more). Bleeding on probing has always to be present if a diagnosis of periodontitis is to be made.
It was tempting to write another post in the Periodontal Myths and Mystery Series – Clinical Measurements in Periodontal Disease. Guesswork whenever it comes to submarginal landmarks such as the cemento-enamel junction and bottom of the pocket; or, even worse, an assumed “tangent to the prominences of two roots” to “measure” furcation involvement. After having introduced and refined case definitions of mild, moderate and severe periodontitis for epidemiological surveys in the past decade, the same authors representing the American Academy of Periodontology and the U.S. Centers for Disease Control and Prevention had to concede, in a recent article in the Journal of Periodontology, that,
[t]hese subgroups [mild and moderate periodontitis] are not truly ordinal [sic] as the label suggests because many ‘moderate’ cases had insufficient pocket depth to qualify as ‘mild’ and we have therefore combined them and used the label ‘other‘ periodontitis,
adding even more confusion . When the paper went online earlier this year, I had contacted one of the authors, Dr. Wenche Borgnakke, to explain that sentence. I had even suggested,
So, in some cases there was >= 4mm CAL but no deep pockets of >=5mm, only 4mm. So, if CAL would have been 3mm, one would have assigned it to ‘mild’, but since it was 4+mm, it had been ‘moderate,’
asking her whether I was possibly right. Unfortunately, she did not respond.