Introduction

The comprehensive oral health assessment of a newly presenting patient includes a periodontal assessment. In patients without a history of periodontal disease, or in whom a clinical inspection does not indicate its presence, periodontal probing is required to confirm periodontal disease or otherwise the absence of it. This will typically involve the use of an established screening tool, the basic periodontal examination (BPE), which will either confirm the absence of periodontal disease, result in a diagnosis of localised or generalised gingivitis, or trigger further clinical and radiographic examinations. The rationale for the application of the BPE is to carefully screen for signs of periodontitis, that is, increased probing depth, while at the same time avoiding the time-consuming process of recording a detailed periodontal chart in patients with no periodontitis. However, in patients with clear evidence of periodontitis based on their history and/or clinical inspection, that is, the presence of interproximal attachment loss; the BPE is essentially redundant, and a full periodontal assessment is indicated.

In this case presentation we report on a patient who presented with a history of treatment for periodontitis. We demonstrate step-by-step how the BSP recommendations for implementation of the 2017 classification system can be applied in practice to reach an appropriate periodontal diagnosis.1,2,3,4

Case report

A 49-year-old female patient, who had recently moved into the area, presented in good general health. Specifically, she had not been diagnosed with diabetes mellitus, was not taking any medications regularly, reported a healthy diet and low stress levels, and was a never smoker. She reported a history of several courses of periodontal treatment by her previous GDP. Clinical examination revealed overt interproximal recession/clinical attachment loss (Fig. 1).

figure 1

Fig. 1 Intraoral view

Given the history of periodontitis provided by the patient, and the clear evidence of interproximal clinical attachment loss due to periodontitis, a detailed pocket chart (DPC) was indicated (Fig. 2). The DPC showed deep pockets (>5 mm) on seven teeth with pocket depths extending to 9 mm, and moderate pockets (4-5 mm) on an additional 11 teeth. Furcation involvement was evident on all molars and both upper first premolars. Periapical radiographs were taken (Fig. 3).

Fig. 2
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Detailed periodontal chart

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Fig. 3
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Periapical radiographs

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The medical and dental history, as well as the clinical and radiographic findings, were consistent with a diagnosis of periodontitis; and staging and grading was performed as the next step. The radiographs showed evidence of bone loss on all teeth with the possible exception of teeth 43, 44, 45, 47 and 36. On teeth 15 and 35, bone loss appeared to extend into the apical third of the root (80% bone loss on 15), resulting in a classification of stage IV periodontitis for this patient. Given that the patient was 49 years old, the disease was classified as grade C periodontitis (80% bone loss divided by age 49 years results in a percentage bone loss/age ratio >1.0, indicating grade C). At least 21 out of 26 teeth exhibited bone loss due to periodontitis, making this a case of generalised periodontitis.

In summary, the definitive diagnosis was 'generalised periodontitis; stage IV, grade C; currently unstable'. The patient concerned will always be a periodontitis patient, with evidence of high disease susceptibility, as indicated by grade C; requiring careful and intensive periodontal maintenance, risk factor control and monitoring.

Discussion and summary

This case report provides an example of how to diagnose a patient with a history of periodontitis according to the 2017 classification of periodontal and peri-implant diseases and conditions, by following the BSP implementation plan.1 Because the patient gave a history of periodontal treatment and presented with clear evidence of generalised interproximal attachment loss due to periodontitis upon inspection, a diagnosis of periodontitis was made without the use of a BPE; the use of a screening test in a patient who is already known to have the disease of interest is not helpful. Instead, a full periodontal assessment was performed immediately.

One of the main new features of the new 2017 classification system is the staging and grading of disease in patients diagnosed with periodontitis. The system represents a major advance as it allows for a clear distinction of disease severity (stage) on one hand, and disease susceptibility (grade) on the other. The disease stage reflects the amount of periodontal tissue loss that has already occurred due to periodontitis, and a higher stage will be associated with higher complexity in terms of periodontal and restorative management of the disease. The disease grade reflects the interplay of all causal factors that have conspired to produce a particular level of tissue destruction in a specific patient over a given period of time.

Grading thus focuses the clinician's mind on the patient's risk of future disease progression and their 'risk factor profile'. For simplicity, the BSP implementation plan proposed to base disease grade on the ratio of radiographic bone loss to age,1 the application of which is demonstrated in this case report. However, there are limitations. Firstly, disease susceptibility may change as risk factors are managed (for example, if a patient quits smoking) or when new risk factors are acquired (for example, a patient may develop diabetes). Secondly, according to the 2017 classification system, the staging and grading of periodontitis are to be performed 'at presentation'.5 Periodontitis is a chronic inflammatory disease that many patients live with for decades, and it is currently unclear if, and if so how often, the staging and/or grading should be repeated.

Furthermore, in patients with a long-standing history of disease, previous periodontal therapy, depending on its effectiveness, will have affected disease progression to varying degrees. The patient presented here reported to have received several courses of therapy. These had not achieved resolution of the signs of disease as she presented with unstable periodontitis (many sites with pocket probing depth (PPD) ≥5 mm and bleeding sites with PPD ≥4 mm). A discussion of the reasons for not reaching a healthy and potentially stable treatment outcome is beyond the scope of this report. However, even if resolution of periodontitis had not been achieved, it is possible that the previous therapy had slowed progression of periodontal tissue loss to some extent. In the present case, this did not affect the grading as the highest possible grade was assigned; however, this may result in an underestimate of disease grade in some patients, in particular in those who have been successfully treated and maintained for many years.