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2021, Number 4

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Rev Odont Mex 2021; 25 (4)

Classification of periodontal and peri-implant diseases and conditions 2018. Second part

Yáñez Ocampo, Beatriz Raquel1; Vargas Casillas, Ana Patricia2

Language: English/Spanish [Versión en español]
References: 17
Page: 376-392
PDF size: 538.47 Kb.


ABSTRACT

The 1999 classification of periodontal diseases was in force for 18 years. In 2017 a world workshop was performed, where periodontal experts from all over the world, with the co-sponsorship of the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP), met to update and present a new classification as evidence based on scientific research has expanded. They were divided into four working groups: I periodontal health, diseases, and gingival conditions. II Forms of periodontitis. III Periodontal manifestations of systemic diseases and developmental and acquired conditions. IV Peri-implant diseases and conditions. This second part will address the main definitions and parameters of group III (Periodontal manifestations of systemic diseases and developmental and acquired conditions), which includes systemic diseases that cause direct damage to healthy periodontal tissues, periodontal abscesses, and endodontic-periodontal lesions, classifying them according to whether or not periodontitis exists. It also considers the change of the term biotype by periodontal phenotype and a new classification of gingival recessions, which evaluates their severity from the interproximal attachment loss. Finally, group IV (Peri-implant diseases and conditions) is also reviewed, describing peri-implant health, peri-implant mucositis and peri-implantitis, and hard and soft tissue deficiencies.



INTRODUCTION

In 2017 the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) brought together 120 experts, 50 from each association and 20 from the rest of the world, to update and present a new classification supported by solid scientific evidence available in the periodontology and implantology area. However, that of a lower level and the experts' opinions were included in case enough research data were unavailable.1

The experts participated in one of the four working groups: I periodontal health and gingival diseases and conditions. II Forms of periodontitis. III Periodontal manifestations of systemic diseases and developmental and acquired conditions. IV Peri-implant diseases and conditions.1

Definitions, parameters of systemic diseases, subclassifications of periodontal conditions of Group III, definitions of peri-implant health and peri-implant diseases, as well as deficiencies before and after the placement of an implant will be presented in this second part (Table 1).



III. PERIODONTAL MANIFESTATIONS OF SYSTEMIC DISEASES AND DEVELOPMENTAL AND ACQUIRED CONDITIONS

In this part of the new classification, an update is presented on 1) systemic diseases that affect the healthy periodontal attachment apparatus and 2) other periodontal conditions such as abscesses in periodontitis and non-periodontitis patients and the endodontic-periodontal lesions with and without root damage.

Among the deformities and mucogingival conditions around the teeth, the following are grouped: periodontal phenotype, gingival recessions, lack of shallow vestibule, aberrant frenum, gingival excess, abnormal color, and condition of the exposed root surface.

Other manifestations in periodontal tissues are traumatic occlusal forces, represented by primary and secondary occlusal trauma and orthodontic forces; finally, dental and prosthetic factors predisposing to periodontal disease are considered (Figure 1).

1. Systemic diseases affecting the periodontal attachment apparatus

Systemic diseases damage periodontal tissues without any periodontal disease being present.2 They include diseases that cause defects or produce metabolic changes in the gingiva or periodontal connective tissue and neoplastic diseases such as squamous cell carcinoma and odontogenic tumors or Langerhans cell histiocytosis, among others; may appear as clinical manifestations of periodontitis. (Table 2).2,3

2. Other periodontal conditions

Some conditions or lesions may affect the periodontal attachment apparatus, whether or not they are involved with periodontitis, such as periodontal abscesses and endodontic-periodontal lesions, among others. These lesions are of clinical relevance, because they require immediate management since they usually cause pain and rapid destruction of periodontal tissues during their course.4

  • a. Periodontal abscesses. The periodontal abscess is defined as the localized accumulation of pus within the gingival wall of the periodontal pocket, with clear periodontal breakdown and easily detectable clinical symptoms, occurring for a limited time. Its classification was made according to the etiological factors involved because it may occur in sites with periodontitis or healthy areas.4

    • i. Periodontal abscess in periodontitis patients: in periodontitis patients, periodontal abscess represents the disease exacerbation at a specific site, favored by deep tortuous pockets, furcation lesion, or a vertical defect. Marginal closure of the pocket can cause greater mobility and spread the infection to surrounding periodontal tissues. In addition, it has been observed that changes in the composition of the subgingival microbiota produce an increase in bacterial virulence and that decrease in the host defense mechanisms could result in a reduced ability to drain suppuration (Figure 2A and B).
    • A periodontal abscess may present as the acute event of untreated periodontitis or after scaling and root planning due to the administration of antimicrobial medications without periodontal treatment or during the maintenance time.
    • ii. Periodontal abscesses in non-periodontitis patients: a periodontal abscess can also occur in previously healthy sites. It may be due to foreign body impaction, orthodontic factors, gingival enlargement, or alterations of the root surface, such as fractures or external root resorption.4
    • Table 3 shows the classification for periodontal abscesses according to the etiological factors involved.

  • b. Endodontic-periodontal lesions. Endodontic-periodontal lesions are clinical conditions involving dental pulp and periodontal tissues and may occur in acute or chronic forms.4

The most common signs and symptoms associated with a tooth affected by an endo-periodontal lesion are deep periodontal pocket reaching or is close to the apex, and negative or altered response to vitality tests; bone resorption in the apical or furcation region, spontaneous pain or on palpation and percussion, purulent exudate, tooth mobility, sinuous tract, crown, and gingival color alterations can also present.

To diagnose an endodontic-periodontal lesion is crucial to know the patient's history concerning the damage to identify the occurrence of trauma during the canal treatment or during/after an intra-radicular-post placement. If one or more of these events are identified, the clinical and radiographic examination should seek perforations (Figure 3A), root fractures (Figure 3B), cracking, or external root resorption. In case of not detecting perforations or fractures, the examination should be carried out in search of a periodontal pocket close to the apex (Figure 3C).4

The classification of endo-periodontal lesions is based on their condition status as soon as it is detected, as it directly impacts prognosis and treatment. Therefore, the new classification divides them into two large groups: endo-periodontal lesions with root damage and endo-periodontal lesion without root damage (Table 4).4

3. Mucogingival deformities and conditions around the teeth

Deformities or mucogingival conditions are defects caused by periodontal disease or trauma that modify soft tissues and/or the bone, diverting the normal anatomical relationship between the gingival margin and the mucogingival line.5

  • a. Periodontal phenotype. The phenotype arises from the relationship of a genotype with the environment, and it can be physical, physiological, biochemical, or behavioral, so it may change through time, depending upon environmental factors and clinical intervention to which it is subjected, and could be site-specific.3

The biotype is the typical animal or plant form considered as a model of its species, variety, or breed and cannot be modified through life.6

Based on the aforementioned definitions, the new classification adopted the term periodontal phenotype to describe what was considered gingival biotype, to recognize its multifactorial determinants, including both genetic and acquired environmental factors, as well as the therapeutic intervention outcome.3

Periodontal phenotype is based upon anatomic characteristics of components of the masticatory complex.7

  • • Gingival phenotype (gingival thickness and keratinized tissue width).
  • • Bone morphotype (buccal bone cortical thickness).
  • • Tooth dimension.

Three different periodontal phenotypes have been defined using these parameters.7


  • i. The thin scalloped phenotype in which there is a more significant association with a slender triangular crown with a slight cervical convexity, interproximal contacts close to the incisal border, a narrow area of keratinized tissue, fine, thin, translucent gingiva, and a relatively slender alveolar bone (Figure 4A).
  • ii. Thick flat phenotype showing a more square-shaped crown, marked cervical convexity, significant apically localized interproximal contact, a broad area of keratinized tissue, thick fibrotic gingiva, and a comparatively thick alveolar bone (Figure 4B).
  • iii. Thick scalloped phenotype featured by a thick fibrotic gingiva, slender teeth, narrow area of keratinized tissue, with marked gingival scalloping, and a comparatively thick alveolar bone (Figure 4C).

  • b. Gingival or soft tissue recession. Gingival recession is an apical shift of the gingival margin caused by different conditions or pathologies; it is associated with non-periodontitis attachment loss and may occur to any tooth surface (buccal, lingual, interproximal).3
  • The consensus report replaced Miller's proposed classification of gingival recession8 with Cairo's, which takes as references the interproximal attachment level.9

    • i. Recession type 1 (RT1): gingival recession with no loss of interproximal attachment. Interproximal cementum-enamel-junction (CEJ) is clinically not detectable at both distal and mesial aspects of the tooth (Figure 5A).
    • ii. Recession type 2 (RT2): gingival recession associated with loss of interproximal attachment. The interproximal attachment loss is less than or similar to the vestibular attachment loss (Figure 5B).
    • iii. Recession type 3 (RT3): gingival recession associated with loss of interproximal attachment. The amount of interproximal attachment loss is higher than the vestibular attachment loss (Figure 5C).

  • c. Lack of gingiva and shallow vestibule. Lack of gingiva or keratinized tissue and the presence of a shallow vestibule are not conditions associated with the development of gingival recessions or periodontal disease. They can maintain periodontal health if patients performs appropriate buccal hygiene measures and attends professional maintenance.7
  • d. Aberrant frenum. Clinically, frenum with attachment to the interdental and palatine papilla are considered aberrant and are associated with interdental papilla loss, gingival recession, diastema, inappropriate tooth brushing, and tooth malposition.10
  • e. Gingival excess. It is considered a gingival excess to the pseudo-pockets, inconsistent gingival margin, excessive gingival display, and gingival enlargement.7
  • f. Abnormal color. The abnormal color presented in the gingiva can be caused by the smoker's melanosis and tattoo by metal carving inside the oral cavity.
  • g. Condition of the exposed root surface. In addition to determining the gingival recession type, a list of factors affecting the therapeutic outcome is suggested, such as gingival thickness, the keratinized tissue width, presence/absence of non-carious cervical lesions (Figure 6A), and presence/absence of the CEJ or step on the root surface (Figure 6B).7

4. Traumatic occlusal forces

The traumatic occlusal forces exceed the adaptive capacity of the periodontium and/or teeth. Lesion caused by traumatic occlusal forces is called occlusal trauma and is clinically detected by excessive wear or fractured teeth.3

Although occlusal trauma is a histological term that refers to a lesion in the periodontal ligament, cementum, and adjacent bone, its clinical diagnosis may be made in the presence of one or more of the following signs: progressive tooth mobility (fremitus), adaptive tooth mobility (fremitus), radiographical widened periodontal ligament space, tooth migration, discomfort or pain on chewing and root resorption.3

Classification of occlusal trauma:

  • a. Primary occlusal trauma. It is a damage that causes tissue changes from traumatic occlusal forces applied to a tooth or teeth with average periodontal support. It manifests itself clinically with adaptive mobility and is not progressive.3
  • b. Secondary occlusal trauma. Secondary occlusal trauma is a tissues affectation from standard or traumatic occlusal forces to a tooth or teeth with reduced support. Teeth with progressive mobility may present migration and pain on function.3
  • c. Orthodontic forces. Evidence in animal models suggests that some orthodontic forces may adversely affect the periodontium and cause root resorption, pulpal disorders, gingival recessions, and alveolar bone loss.9 However, observational studies indicate that with a regular dental biofilm control, orthodontic movement can be achieved in teeth with healthy but reduced periodontium not compromising periodontal support.11

5. Factors related to the tooth and dental prosthesis that modify or predispose to gingival diseases induced by dental biofilm and/or periodontitis

The periodontal status could be considerably affected by tooth-related factors and dental prostheses. The extent to which these conditions contribute to the disease process depends on each patient's susceptibility.3,12

  • a. Localized tooth-related factors. Tooth anatomical factors are cervical enamel projections, enamel pearls, developmental grooves, root proximity, abnormalities, fractures, and dental relationships within the arcade. These factors are related to dental biofilm inflammation and loss of periodontal supporting tissues.3
  • Passive eruption: the altered passive tooth eruption is a developmental condition characterized by the gingival margin (and sometimes the bony crest) at a more coronal level. This condition may be clinically associated with forming pseudo-pockets and aesthetic affectations.3
  • b. Localized factors related to dental prosthesis.
  • Supracrestal tissue attachment: the term biologic width has been used to describe the apical-coronal dimensions of the supracrestal soft tissue in tooth; histologically, it is made up of the junctional epithelium and the supracrestal connective tissue attachment. In the new classification the term biologic width was replaced by supracrestal tissue attachment to highlight its histological nature.3

The restorations' margins that invade the supracrestal tissue attachment are associated with inflammation, apical shift of the junctional epithelium, and attachment loss. However, not enough studies have been conducted to determine whether these clinical features are caused by dental biofilm, trauma during tooth preparation, or in the fabrication, placement, type of material, or a combination of these factors.3

According to the available evidence, plaque control by the patient and compliance with periodontal maintenance procedure is of enormous importance to maintaining the periodontium health when subgingival restorations' margins or crowns that support a fixed prosthesis are placed. The subgingival margins of prosthetic crowns can cause permanent changes in the periodontium, such as a gingival recession. However, the gingival recession seems to be associated more with the trauma on the periodontium during prosthetic preparation by the instruments and materials used to place and record the margins in a subgingival position than with the margin position itself.3

Adverse reactions to dental materials: dental materials may be associated with hypersensitivity reactions, clinically detectable as a localized inflammation which does not respond to adequate measures of plaque control.

Some in vitro evidence suggest that some dental materials ions may affect cell viability and function.3



IV. PERI-IMPLANT DISEASES AND CONDITIONS

Peri-implant tissues are those that form around an osseointegrated dental implant. They are divided into the soft tissue or peri-implant mucosa and hard tissue made up of the bone in intimate contact with the implant's surface (osseointegration). Figure 7 shows the diseases and conditions around dental implants.

1. Peri-implant health

Peri-implant health is characterized by the absence of erythema, bleeding on probing, swelling, and suppuration in the peri-implant mucosa and may present a slight bone loss (not exceeding 2 mm) in the osseointegrated implant.13

Since probing depth variations may differ depending on soft tissue's height concerning the implant's location, it is not possible to define a range of probing depths compatible with health (Figure 8A). This means that peri-implant health can also exist around implants with reduced bone support.13

2. Peri-implant mucositis

Peri-implant mucositis is an inflammatory lesion of the soft tissues surrounding an endosseous implant without supporting bone loss. The leading cause is the accumulation of bacterial biofilm on the surface of the osseointegrated implants causing an inflammatory response.14

The main feature of peri-implant mucositis is the bleeding on probing; erythema, inflammation, and suppuration may also be present, and there may be an increase in probing depth caused by inflammation or decreased resistance to probing (Figure 8B).15

Peri-implant mucositis may be present for extensive periods without progression to peri-implantitis. However, sites with peri-implant mucositis should be considered at increased risk for developing peri-implantitis.14

3. Peri-implantitis

Peri-implantitis is a biofilm-associated pathological condition occurring in tissues surrounding dental implants, characterized by inflammation of the peri-implant mucosa with subsequent progressive loss of the supporting bone.13

The peri-implantitis sites show signs of inflammation, bleeding on probing and/or suppuration, increased probing depth (compared to measurements obtained during suprastructure placement), and/or recession of the peri-implant mucosal margin, in addition to radiographic bone loss and compared with previous examinations (Figure 8C y D).13

In the absence of radiographs and initial probing depth measurements, radiographic evidence of bone levels ≥ 3 mm and/or probing depths ≥ 6 mm, together with profuse bleeding, are considered representative signs of peri-implantitis.13

There is confident evidence of increased risk of peri-implantitis in patients with a history of periodontitis, poor plaque control, and no regular maintenance care after implant therapy.16

4. Peri-implant hard and soft tissue deficiencies

Deficiencies at implant sites may result from multiple factors before or after dental implant placement. They can cause complications or compromise implant survival (Table 5).17

Local factors that these deficiencies can cause include loss of supporting bone caused by periodontitis, periapical infections, root fractures, slender cortical bone resorption, or trauma from tooth extraction; in addition to the maxillary sinus pneumatization and systemic diseases and conditions, such as the intake of medication that cause decreasing of natural bone formation. In most cases, these deficiencies are presented by combining several of the above factors.17

Soft tissue deficiencies include recession or dehiscence of the peri-implant mucosa, lack of keratinized mucosa, and papilla height.17



CONCLUSIONS

The American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) workshop undertook a comprehensive literature review to categorize periodontal and peri-implant diseases and conditions and periodontal and peri-implant health.

The new classification defines periodontal and peri-implant health and diseases mainly based on their clinical characteristics of presence/absence of bleeding on probing sites and clinical signs of inflammation or destruction of tissues.

In the first article, the categorizations of periodontal health in different situations and biofilm-induced gingivitis were presented, the latter subclassified according to its degree of severity and extension, to provide the clinician and the researcher with a reliable parameter to differentiate the health of the biofilm-induced gingivitis; the periodontitis using stages and degrees, as well as the numerous systemic diseases and conditions that initiate or aggravate periodontitis, also presented. All of this impacts the patient's prognosis, treatment planning, and periodontal maintenance.

This second part covered periodontal conditions, the new way of classifying periodontal abscesses and endo-periodontal lesions according to their etiology, and whether or not there is periodontitis to establish criteria for accurate diagnoses and timely treatments. The new classification changes the terms of gingival biotype by periodontal phenotype and biologic width by supracrestal tissue attachment to adapt them to the correct terminology. It also considers the surface condition of gingival recessions to obtain greater predictability in their treatment. The inclusion in this classification of health, diseases, conditions, and peri-implant deficiencies, makes them part of periodontology and not a distinct branch of dentistry.

Dentists and periodontists should start using the new classification in daily practice, as it facilitates timely periodontal treatment intervention, which can positively impact the improvement of the patient's health and well-being.

The new system also seeks to implement these definitions within the inclusion criteria of future periodontal and peri-implant research.

For further information about the new classification, we suggest the articles published on this topic by the American Academy of Periodontology and the European Federation of Periodontology.



ACKNOWLEDGEMENTS

We are grateful for the images provided by the students of Periodontics and Implantology of the Graduate Studies and Research Division of the Faculty of Dentistry of the National Autonomous University of Mexico.


REFERENCES

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

  2. Albandar JM, Susin C, Hughes FJ. Manifestations of systemic diseases and conditions that affect the periodontal attachment apparatus: case definitions and diagnostic considerations. J Clin Periodontol. 2018; 45 (Suppl 20): S171-S189.

  3. Jepsen S, Caton JG, Albandar JM et al. Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report of workgroup 3 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Clin Periodontol. 2018; 45 (Suppl 20): S219-S229.

  4. Herrera D, Retamal-Valdes B, Alonso B, Feres M. Acute periodontal lesions (periodontal abscesses and necrotizing periodontal diseases) and endo-periodontal lesions. J Clin Periodontol. 2018; 45 (Suppl 20): S78-S94.

  5. Parameter on mucogingival conditions. American Academy of Periodontology. J Periodontol. 2000; 71 (5 Suppl): 861-862.

  6. Real Academia Española. Diccionario de la lengua española. 2019. [Consultado el 14 de marzo de 2020] Disponible en: https://dle.rae.es/

  7. Cortellini P, Bissada NF. Mucogingival conditions in the natural dentition: Narrative review, case definitions, and diagnostic considerations. J Clin Periodontol. 2018; 45 (Suppl 20): S190-S198.

  8. Miller PD. A classification of marginal tissue recession. Int J Periodont Rest Dent. 1985; 5 (2): 8-13.

  9. Cairo F, Nieri M, Cincinelli S, Mervelt J, Pagliaro U. The interproximal clinical attachment level to classify gingival recessions and predict root coverage outcomes: explorative and reliability study. J Clin Periodontol. 2011; 38: 661-666.

  10. Newman MG, Takei HH, Klokkevold PR, Carranza FA, editors. Newman and Carranza's clinical periodontology. Cap. 65. 13th ed. Philadelphia: Elsevier; 2019. pp. 660-663.

  11. Boyd RL, Leggott PJ, Quinn RS, Eakle WS, Chambers D. Periodontal implications of orthodontic treatment in adults with reduced or normal periodontal tissues versus those of adolescents. Am J Orthod Dentofacial Orthop. 1989; 96: 191-198.

  12. Ercoli C, Caton JG. Dental prostheses and tooth-related factors. J Clin Periodontol. 2018; 45 (Suppl 20): S207-S218.

  13. Berglundh T, Armitage G, Araujo MG et al. Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Clin Periodontol. 2018; 45 (Suppl 20): S286-S291.

  14. Heitz-Mayfield LJA, Salvi GE. Peri-implant mucositis. J Clin Periodontol. 2018; 45 (Suppl 20): S237-S245.

  15. Renvert S, Persson GR, Pirih FQ, Camargo PM. Peri-implant health, peri-implant mucositis, and peri-implantitis: Case definitions and diagnostic considerations. J Clin Periodontol. 2018; 45 (Suppl 20): S278-S285.

  16. Schwarz F, Derks J, Monje A, Wang HL. Peri-implantitis. J Clin Periodontol. 2018; 45 (Suppl 20): S246-S266.

  17. Hämmerle CHF, Tarnow D. The etiology of hard- and soft-tissue deficiencies at dental implants: A narrative review. J Clin Periodontol. 2018; 45 (Suppl 20): S267-S277.



AFFILIATIONS

1 Cirujano Dentista. Doctorado en Ciencias de la Educación. Profesora en la Especialidad de Periodoncia e Implantología y Coordinadora del área de Periodontología. División de Estudios de Posgrado e Investigación de la Facultad de Odontología de la Universidad Nacional Autónoma de México. México.

2 Cirujano Dentista. Maestría en Periodoncia. Profesora y Coordinadora de la Especialidad de Periodoncia e Implantología. División de Estudios de Posgrado e Investigación de la Facultad de Odontología de la Universidad Nacional Autónoma de México. México.



CORRESPONDENCE

Beatriz Raquel Yáñez Ocampo. E-mail: raquel.yaez@gmail.com




Received: Marzo 2020. Accepted: Junio 2020.

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