2017 World Workshop on Periodontitis PDF

2017 WORLD WORKSHOP Periodontitis 2017 WORLD WORKSHOP American Academy of Periodontitis (AAP) European Federation of Periodontics (EEP) CHICAGO (U.S.A). 120 EX...

2017 WORLD WORKSHOP Periodontitis 2017 WORLD WORKSHOP American Academy of Periodontitis (AAP) European Federation of Periodontics (EEP) CHICAGO (U.S.A). 120 EXPERTS. 50 members from each association. 20 members from the rest of the world. Papapanou PN, Sanz M, Buduneli N, Dietrich T, Feres M, Fine DH and cols. Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri- Implant Diseases and Conditions. J Periodontol. 2018;89: S173-82.  2017 WORLD WORKSHOP Objective: reaching a consensus with a common structure to clarify and define health and gingival pathologies, periodontal and periiimplant diseases and conditions. 1st: Worldwide experts were identified 2nd: prepare 16 groundworks that would summarize the scientific evidence accumulated in the last 20 years. 3rd: create a Workshop where they would reach a consensus and elaborate a new classification. Four workgroups were arranged: Periodontal Health, Other Conditions Peri-Implant Gingival Diseases Periodontitis Affecting the Diseases and Conditions Periodontium and Conditions 2017 WORLD WORKSHOP Periodontal Classification 2017 2017 WORLD WORKSHOP Periodontal Classification 2017  2017 WORLD WORKSHOP Past Classification and Relevant Changes Armitage, 1999 1. Chronic Periodontitis: forms of destructive periodontal disease, generally characterized by slow progression. 2. Aggressive periodontitis: diverse group of highly destructive forms of periodontitis affecting primarily young individuals. 3. Periodontitis as a manifestation of a systemic disease: heterogeneous group of systemic pathological conditions that include periodontitis as a manifestation. 4. Necrotizing Periodontal Diseases: group of conditions that share a characteristic phenotype where necrosis of the gingival or periodontal tissues is a prominent feature. 5. Periodontal Abscess: clinical entity with distinct diagnostic features and treatment requirements. 6. Periodontitis associated to endodontic lesions 7. Periodontal deformities and conditions Papapanou PN, Sanz M, Buduneli N, Dietrich T, Feres M, Fine DH and cols. Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri- Implant Diseases and Conditions. J Periodontol. 2018;89: S173-82.  2017 WORLD WORKSHOP Past Classification and Relevant Changes Armitage, 1999 1. Chronic Periodontitis: forms of destructive periodontal disease, generally characterized by slow progression. SHORTCOMINGS: 2. Aggressive periodontitis: diverse group of highly destructive forms of periodontitis affecting primarily young individuals. - Lack of 3. Periodontitis asclear pathobiology-based a manifestation of a systemicdistinction between the group of disease: heterogeneous systemic pathological conditions that include periodontitis as a manifestation. stipulated 4. Necrotizing Periodontal Diseases: categories. group of conditions that share a characteristic phenotype where necrosis of the gingival or periodontal tissues is a prominent feature. - Diagnostic imprecision. 5. Periodontal Abscess: clinical entity with distinct diagnostic features and treatment requirements. - Implementation difficulties. 6. Periodontitis associated to endodontic lesions 7. Periodontal deformities and conditions Papapanou PN, Sanz M, Buduneli N, Dietrich T, Feres M, Fine DH and cols. Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal  2017 WORLD WORKSHOP Conclusions of the 5 Positioning Papers Papapanou PN y Sanz M (Workgroup 2) Objective: revisit the current classification system of periodontitis, incorporate new knowledge relevant to its epidemiology, etiology and pathogenesis and propose a new classification framework along with case definitions. Five papers were created: 1. Classification and diagnosis of aggressive periodontitis (Fine et al. 2018). 2. Age-dependent distribution of clinical attachment loss in two population-representative, cross sectional studies (Billings et al. 2018). 3. Progression data from clinical attachment loss from existing prospective, longitudinal studies (Needleman et al. 2018). 4. Diagnosis, pathobiology and clinical presentation of acute periodontal lesions (Herrera et al. 2018). 5. Periodontitis case definitions (Tonetti et al. 2018). 2017 WORLD WORKSHOP Conclusions of the 5 Positioning Papers Papapanou PN y Sanz M (Workgroup 2) 1. Current evidence does not support the distinction between chronic and aggressive periodontitis as two different diseases. 2. There is evidence of multiple factors and interactions between both pathologies that influence the phenotype of the disease. 3. Longitudinal mean annual attachment level change was considerably wide within the world population. 4. Geographic localization was associated with different clinical attachment level change. 5. A classification exclusively based in the severity of the disease does NOT take in account the individual characteristics: Complexity of the treatment Risk factors that define the prognosis Level of knowledge for designing the treatment plan 2017 WORLD WORKSHOP Conclusions of the Conclusions Papapanou PN y Sanz M (Workgroup 2) Chronic and aggressive periodontitis are not two distinct diseases. A new classification of periodontitis is created based in a simple matrix that describes the stage and grade of the disease.  2017 WORLD WORKSHOP How would we define a “periodontitis case”? 1. Interdental CAL is detectable at ≥ 2 non-adjacent teeth. OR 2. Buccal or oral CAL ≥ 3mm with pocketing > 3mm is detectable at ≥ 2 non-adjacent teeth, but the observed CAL cannot be ascribed to non-periodontitis-related causes such as: Gingival recession of traumatic origin. Dental caries extending in the cervical area of the tooth. Presence of CAL on the distal aspect of a second molar and associated with malposition or extraction of a third molar. Endodontic lesion draining through the marginal periodontium. Ocurrence of a vertical root fracture. Papapanou PN, Sanz M, Buduneli N, Dietrich T, Feres M, Fine DH and cols. Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Cl assification of Periodontal and Peri- Implant Diseases and Conditions. J Periodontol. 2018;89: S173-82.  2017 WORLD WORKSHOP Which different forms of periodontitis are recognized in the present revised classification system? a. Necrotizing Periodontitis b. Periodontitis as a direct manifestation of systemic diseases c. Periodontitis Differential diagnosis is based on history and the specific signs and symptoms of necrotizing periodontitis, or the presence or absence of an uncommon systemic disease that alters the host immune response. The remaining clinical cases of periodontitis should be diagnosed as “periodontitis” and be further characterized using a staging and grading system that describes clinical presentation as well as other elements that affect clinical management, prognosis, and potentially broader influences on both oral and systemic health. Papapanou PN, Sanz M, Buduneli N, Dietrich T, Feres M, Fine DH and cols. Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Cl assification of Periodontal and Peri- Implant Diseases and Conditions. J Periodontol. 2018;89: S173-82.  2017 WORLD WORKSHOP Which different forms of periodontitis are recognized in the present revised classification system? Periodontal abscess and endo-periodontal lesions must include the presence of a preexistent periodontitis as a main feature in order to differentiate it from other pathologies. Periodontal abscesses, lesions from necrotizing periodontal diseases and acute presentations of endo-periodontal lesions, share the following features that differentiate them from periodontitis lesions: (1) rapid-onset, (2) rapid destruction of periodontal tissues, underscoring the importance of prompt treatment, and (3) pain or discomfort, prompting patients to seek urgent care. 2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES Stage describes: The severity of the diseases at presentation. The anticipated complexity of disease management (risk factors). The extent and distribution of the disease in the dentition. Primary Goals of Staging a Periodontitis Patient - Classify Severity and Extent of an individual based on currently measurable extent of destroyed and damaged tissue attributable to periodontitis. - Assess complexity: assess specific factors that may determine complexity of controlling current disease and managing long-term function and esthetics of the patient’s dentition. Factors such as probing depths, type of bone loss (vertical and/or horizontal), furcation status, tooth mobility, missing teeth, bite collapse, and residual ridge defect size increase treatment complexity and need to be considered and should ultimately influence diagnostic classification. Tonetti MS et al. Staging and grading of periodontitis: Framework and proposal of a new classification and new definition. J Clin Periodontal. 2018;45(20): S149-161 2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES Grade describes: Biological features of the disease: includes analysis of the rate of periodontitis progression. Assessment of the risk for further progression. Analysis of possible poor outcomes of treatment. Assessment of the risk that the disease or its treatment may negatively affect the general health of the patient. Tonetti MS et al. Staging and grading of periodontitis: Framework and proposal of a new classification and new definition. J Clin Periodontal. 2018;45(20): S149-161 2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES EACH STAGE IS A UNIQUE DISEASE PRESENTATION. An individual case may be defined by a simple matrix of stage at presentation (severity and complexity of management) and grade (evidence of risk of progression and potential risk of systemic impact of the patient’s periodontitis). Tonetti MS et al. Staging and grading of periodontitis: Framework and proposal of a new classification and new definition. J Clin Periodontal. 2018;45(20): S149-161  2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES STAGE I PERIODONTITIS Borderland between gingivitis and periodontitis. Early stages of attachment loss. Is the result of a persistent gingival inflammation and biofilm dysbiosis. The age can inform us of the patient’s susceptibility. Periodontal probing to estimate early clinical attachment loss (current gold standard for defining periodontitis) may be inaccurate. Assessment of salivary biomarkers may increase early detection of stage I. Tonetti MS et al. Staging and grading of periodontitis: Framework and proposal of a new classification and new definition. J Clin Periodontal. 2018;45(20): S149-161  2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES STAGE I PERIODONTITIS TREATMENT: INTIAL PHASE THERAPY Guiding behaviour change by motivating the patient to undertake successful removal of supragingival dental biofilm and risk factor control. This may include the following interventions: Supragingival dental biofilm control: mechanical or chemical means. Mechanical means: manual or powered toothbrushes or supplemental interdental cleaning (dental floss, interdental brushes, oral irrigators. Chemical means: antiseptic agents. Oral hygiene instructions (OHI) Adjunctive therapies for gingival inflammation: probiotics, anti-inflammatory agents, and antioxidant micronutrients. Professional mechanical plaque removal Risk factor control: smoking cessation, diabetes control, stress reduction, dietary counseling, weight loss. Sanz M et al. Treatment of stage I-III periodontitis- The EFP S3 level clinical practice guideline. J Clin Periodontol. 2020;47:4-60  2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES STAGE I PERIODONTITIS TREATMENT: Guiding behaviour change by motivating the patient to undertake successful removal of supragingival dental biofilm and risk factor control. This first step should be implemented in all periodontitis patients, irrespective of the stage of their disease, and should be reevaluated in order to continue building motivation and adherence, and for developing skills in dental biofilm removal. Sanz M et al. Treatment of stage I-III periodontitis- The EFP S3 level clinical practice guideline. J Clin Periodontol. 2020;47:4-60  2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES STAGE I PERIODONTITIS TREATMENT: Guiding behaviour change by motivating the patient to undertake successful removal of supragingival dental biofilm and risk factor control. Cause-related therapy: aimed at controlling the subginigval biofilm and calculus. Ultrasonics + SRP (biomechanic elimination of biofilm). In addition to this, the following interventions were analyzed for inclusion: Use of adjunctive physical or chemical agents: laser (insufficient evidence to recommend adjunctive application of lasers to subgingival instrumentation). Use of adjunctive host-modulating agents (local or systemic): local statins: it is not posible to draw definitive conclusions. Use of adjunctive subgingival local delivered antimicrobials: sub-antimicrobial dose doxycycline offered conflictive results. Use of adjunctive systemic antimicrobials: use of systemic local non-steroidal anti-inflammatory drugs: long-term use of systemic NSAID’s carries a well-known risk of unwanted side effects, which raises concerns over their use as adjuncts to subgingival instrumentation. Sanz M et al. Treatment of stage I-III periodontitis- The EFP S3 level clinical practice guideline. J Clin Periodontol. 2020;47:4-60  2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES STAGE I PERIODONTITIS TREATMENT: Guiding behaviour change by motivating the patient to undertake successful removal of supragingival dental biofilm and risk factor control. Cause-related therapy Reevaluation: the individual response to the 2nd step of therapy (cause-related therapy) should be assessed once the periodontal tissues have healed (4-6 weeks after). If the endpoints of therapy (no periodontal pockets > 4 mm with BoP or no deep periodontal pockets ≥ 6 mm have not been achieved, the third step (surgical management, although this step wouldn’t be part of the Stage I patient) of therapy should be considered. Sanz M et al. Treatment of stage I-III periodontitis- The EFP S3 level clinical practice guideline. J Clin Periodontol. 2020;47:4-60  2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES STAGE I PERIODONTITIS TREATMENT: Reevaluation: If the treatment has been successful in achieving endpoints of therapy, patients should be placed in a supportive periodontal care programme. Supportive periodontal care visits: aimed at maintaining periodontal stability in all treated patients combining preventive and therapeutic interventions. This step should be rendered at regular interval according to the patients needs. Any patient may need re-treatment if recurrent disease is detected. In any of the steps of the therapy, tooth extraction may be considered if the affected teeth are considered with a hopeless prognosis. Sanz M et al. Treatment of stage I-III periodontitis- The EFP S3 level clinical practice guideline. J Clin Periodontol. 2020;47:4-60 2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES STAGE I, II & III PERIODONTITIS 2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES In order to calculate interproximal CAL at site of greatest loss: If PD is greater than 3 mm: = (PROBING DEPTH – 3mm) + GINGIVAL RECESSION If PD is less tan or equal to 3 mm: = GINGIVAL RECESSION  2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES STAGE II PERIODONTITIS Represents an established periodontitis. Management remains simple and monitoring is expected to arrest disease progression. Case grade + treatment response may guide more intensive management for specific patients. Tonetti MS et al. Staging and grading of periodontitis: Framework and proposal of a new classification and new definition. J Clin Periodontal. 2018;45(20): S149-161  2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES STAGE II PERIODONTITIS TREATMENT Guiding behaviour change by motivating the patient to undertake successful removal of supragingival dental biofilm and risk factor control. Cause-related therapy Reevaluation Surgical management of local residual inflammation Supportive periodontal care visits. Tonetti MS et al. Staging and grading of periodontitis: Framework and proposal of a new classification and new definition. J Clin Periodontal. 2018;45(20): S149-161 2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES STAGE I, II & III PERIODONTITIS  2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES STAGE III PERIODONTITIS Periodontitis has produced significant damage to the attachment apparatus and in the absence of advanced treatment, tooth loss may occur. Presence of deep periodontal pockets that extend in the middle portion of the root and whose management is complicated by the presence of deep intrabony defects, furcation involvement, history of periodontal tooth loss/exfoliation, and presence of localized ridge defects that complicate implant tooth replacement. Masticatory function is preserved and treatment of periodontitis does not require complex rehabilitation of the function. Tonetti MS et al. Staging and grading of periodontitis: Framework and proposal of a new classification and new definition. J Clin Periodontal. 2018;45(20): S149-161  2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES STAGE III PERIODONTITIS TREATMENT STAGE II THERAPY + Broad range of surgical skills (repeated subgingival instrumentation with or without adjunctive therapies, access flap periodontal surgery, resective periodontal surgery, regenerative periodontal surgery). Prepare for restorative therapy and implant placement if necessary. Depending on the situation, interdisciplinary treatment may be appropriate. Tonetti MS et al. Staging and grading of periodontitis: Framework and proposal of a new classification and new definition. J Clin Periodontal. 2018;45(20): S149-161 2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES STAGE I, II & III PERIODONTITIS  2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES STAGE IV PERIODONTITIS Periodontitis causes considerable damage to the periodontal support and may cause significant tooth loss = LOSS OF MASTICATORY FUNCTION. Presence of deep periodontal pocket that extends to the apical portion of the root and history of multiple tooth loss. Frequently complicated by tooth hypermobility due to secondary occlusal trauma and the sequelae of tooth loss: posterior bite collapsing and drifting. Case management requires stabilization/restoration of masticatory function. Tonetti MS et al. Staging and grading of periodontitis: Framework and proposal of a new classification and new definition. J Clin Periodontal. 2018;45(20): S149-161  2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES STAGE IV PERIODONTITIS TREATMENT STAGE II THERAPY + Managed by clinicians with a broad range of surgical skills (surgical access, osseous surgery, regenerative procedures, ridge augmentation, mucogingival surgery) as well as experience in restoring oral function (interdisciplinary care). Tonetti MS et al. Staging and grading of periodontitis: Framework and proposal of a new classification and new definition. J Clin Periodontal. 2018;45(20): S149-161 2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES STAGE I, II, III, IV PERIODONTITIS 2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES STAGE I, II, III, IV PERIODONTITIS 2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES STAGE I, II, III, IV PERIODONTITIS The initial stage should be determined using CAL; if not available then radiographic bone loss (RBL) should be used. Information on tooth loss that can be attributed primarily to periodontitis – if available may modify stage definition. Complexity factors may shift the stage to a higher level, Not all, complexity factors may be present, however, in general it only takes one complexity factor to shift the diagnosis to a higher stage. 2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES STAGE I, II, III, IV PERIODONTITIS Determination of localized and generalized form should be based on the teeth with greatest severity that define the specific Stage. Missing teeth whose loss can be attributed to periodontitis should be factored into the definition of localized or generalized disease. In terms of extent description, the number of teeth fulfilling the most severe Stage criteria is utilized - after adding the number of missing teeth attributable primarily to periodontitis – to calculate the percentage of affected teeth at the identified Stage. Wisdom teeth are not used in the calculation. 30% of affected teeth will continue to be the threshold to identify localized from generalized cases. 2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES Staging relies on the standard dimension of severity and complexity: Severity is mainly based in the interproximal clinical attachment loss (CAL), measured in the most affected teeth. Periodontal teeth must only be used. Complexity is based in local factors, considering the need of eliminating or modifying them: Vertical defects Furcation involvement Dental hypermobility 1. Determine CAL (periodontogram and full-mouth rx) Dental absence 2. Detect complexity factors Alveolar ridge defects Masticatory function 2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES GRADES 2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES GRADES PRIMARY CRITERIA Allows rate of progression to be considered. Direct evidence: based on longitudinal observation (example: older diagnostic quality radiographs). Indirect evidence: based on the assessment of bone loss at the worst affected tooth in the dentition as a function of aged (measured in radiographic bone loss in percentage of root length divided by the age of the subject) Periodontitis grade can then be modified by RISK FACTORS the presence of risk factors. 2017 WORLD WORKSHOP CLASSIFICATION OF PERIODONTITIS BASED IN STAGES AND GRADES RISK OF SYSTEMIC IMPACT OF PERIODONTITIS GRADES FOR THE FUTURE… Consider how periodontal inflammation will act as an inflammatory comorbidity in some patients and contribute to other systemic diseases/conditions. Elevated systemic inflammation may also indicate that uncontrolled, and possibly unidentified, systemic inflammatory diseases may influence periodontitis outcomes. Baseline assessment of systemic inflammatory status provides objective assessment of whether the patient is at increased risk for major chronic diseases because of elevated systemic inflammation of which the patient’s periodontitis may be a contributor. Example: Obesity, that raise levels of systemic inflammation, negatively impact outcomes to standard periodontal therapy. 2017 WORLD WORKSHOP DECISION-MAKING ALGORITHM FOR CLINICAL PRACTICE AND EDUCATION STEP 1. NEW PATIENT 1st QUESTION: availability of full-mouth rx YES: assess clinical marginal bone loss in any area of the dentition. YES: Bone loss is detectable. Suspect presence of periodontitis and move forward to STEP 2. Tonetti MS, Sanz M. Implementation of the new classification of periodontal diseases: Decision‐making algorithms for clinical practice and education. J Clin Periodontal. 2019;46: 398- 405.  2017 WORLD WORKSHOP DECISION-MAKING ALGORITHM FOR CLINICAL PRACTICE AND EDUCATION STEP 1. NEW PATIENT 1st QUESTION: availability of full-mouth rx NO: no rx available or no bone loss is detectable IMPERATIVE: clinician assesses the whole dentition for the presence of interdental CAL (visible CEJ or stopping of the tip of the periodontal probe on the root surface in inter- dental space. If interdental CAL is detectable: suspect presence of periodontitis. If interdental CAL is not detectable evaluate presence of oral recessions with PPD > 3 mm. Tonetti MS, Sanz M. Implementation of the new classification of periodontal diseases: Decision‐making algorithms for clinical practice and education. J Clin Periodontal. 2019;46: 398- 405.  2017 WORLD WORKSHOP DECISION-MAKING ALGORITHM FOR CLINICAL PRACTICE AND EDUCATION STEP 1. NEW PATIENT If presence of oral recessions with PPD > 3 mm is NOT detectable perform a full mouth BOP. If present in > 10% of the sites: gingivitis If present in < 10% of the sites: periodontal health Tonetti MS, Sanz M. Implementation of the new classification of periodontal diseases: Decision‐making algorithms for clinical practice and education. J Clin Periodontal. 2019;46: 398- 405. 2017 WORLD WORKSHOP DECISION-MAKING ALGORITHM FOR CLINICAL PRACTICE AND EDUCATION STEP 2. SUSPECT PERIODONTITIS DIAGNOSIS POTENTIAL PERIODONTITIS CASE: ascertain wether this CAL is no due to local factors (endo-perio lesion, vertical root fractures, caries or restorations, impacted wisdom tooth). If it is due to local factors: clinician needs to go back to STEP 1 and assess gingival health for the remaining dentition. Tonetti MS, Sanz M. Implementation of the new classification of periodontal diseases: Decision‐making algorithms for clinical practice and education. J Clin Periodontal. 2019;46: 398-405. 2017 WORLD WORKSHOP DECISION-MAKING ALGORITHM FOR CLINICAL PRACTICE AND EDUCATION STEP 2. SUSPECT PERIODONTITIS DIAGNOSIS POTENTIAL PERIODONTITIS CASE: ascertain wether this CAL is no due to local factors (endo-perio lesions, vertical root fractures, caries or restorations, impacted third molars). It’s not due to local factors: ascertain that the inter-dental CAL is present in more than one non-adjacent tooth. If CAL involves two or more non-adjacent teeth: clinician makes a diagnosis of periodontitis patient and need of a comprehensive periodontal assessment: periodontogram and periapical full-mouth serie. Tonetti MS, Sanz M. Implementation of the new classification of periodontal diseases: Decision‐making algorithms for clinical practice and education. J Clin Periodontal. 2019;46: 398-405.  2017 WORLD WORKSHOP DECISION-MAKING ALGORITHM FOR CLINICAL PRACTICE AND EDUCATION STEP 2. SUSPECT PERIODONTITIS DIAGNOSIS Comprehensive periodontal assessment and periodontal charting does not reveal PPD of 4 mm or more then clinician needs to evaluate the full mouth BOP. Higher than or equal to 10%: Diagnosis is gingival inflammation in a periodontitis patient. Less than or equal to 10%: Diagnosis is Reduced but healthy periodontist. Comprehensive periodontal assessment and periodontal charting reveals PPD of 4 mm or more then PERIODONTITIS CASE NEEDS TO BE FURTHER ASSESSED (STAGING AND GRADING) Tonetti MS, Sanz M. Implementation of the new classification of periodontal diseases: Decision‐making algorithms for clinical practice and education. J Clin Periodontal. 2019;46: 398-405.  2017 WORLD WORKSHOP DECISION-MAKING ALGORITHM FOR CLINICAL PRACTICE AND EDUCATION STEP 3A. PATIENT IS A PERIODONTITIS CASE THAT NEEDS TO BE STAGED. For staging a periodontitis case, the following information is needed: full- mouth radiographs, a periodontogram and a periodontal history of tooth loss. (PTL) Based on the information the clinician shall assess the extent of the disease by determining whether the CAL/BL affects < 30% of the teeth (localized) or greater or equal of 30% (generalized). Then the clinician must assess the stage of the disease by assessing severity through CAL, BL and PTL and complexity by assessing PPD, furcation and intrabony lesions, tooth hyper mobility, secondary occlusal trauma, bite collapse, flaring or having < 10 occluding pairs. Tonetti MS, Sanz M. Implementation of the new classification of periodontal diseases: Decision‐making algorithms for clinical practice and education. J Clin Periodontal. 2019;46: 398-405.  2017 WORLD WORKSHOP DECISION-MAKING ALGORITHM FOR CLINICAL PRACTICE AND EDUCATION STEP 3B. STAGING III AND IV VERSUS I AND II. When CAL > 5 mm or if BL affects the middle third of the root or beyond, the diagnosis is STAGE III or IV. If CAL < 5 mm, the clinician should look for the presence of class II or III furcation involvements. If present the diagnosis is either STAGE III or IV. If no furcation involvement is present, the clinician should check the PPD. If PPD is > 5 mm, then the diagnosis is either STAGE III or IV. If PPD is > 5 mm, in the presence of pseudopockets, the periodontitis case should stay in STAGE II. If PPD are between 3 and 5 mm, then If there is a history of PTL the diagnosis is either assess the history of PTL. STAGE III or IV. If not, then the diagnosis is I or II.  2017 WORLD WORKSHOP DECISION-MAKING ALGORITHM FOR CLINICAL PRACTICE AND EDUCATION STEP 3C. DIAGNOSIS OF STAGE I, II, III OR IV Staging for I and II will be based upon the level of CAL and BL. When BL is < 15% and CAL is between 1-2mm: STAGE I When BL is between 15%-33% and CAL is between 3-4 mm: STAGE I When BL affects middle third of the root or beyond and CAL is ≥ 5 mm, if PTL is > 4 teeth and in the absence of 10 occluding pairs, or bite collapse, drifting, flairing or a severe ridge defect: STAGE IV Once the correct stage is determined, the clinicians should proceed to determine the grade. Tonetti MS, Sanz M. Implementation of the new classification of periodontal diseases: Decision‐making algorithms for clinical practice and education. J Clin Periodontal. 2019;46: 398-405.  2017 WORLD WORKSHOP DECISION-MAKING ALGORITHM FOR CLINICAL PRACTICE AND EDUCATION STEP 4A. GRADING WHEN THERE ARE EXISTING PREVIOUS RECORDS. If progression is < 2 mm in the previous 5 years, the diagnosis is GRADE B. If there has been NO progression In the previous 5 years, the diagnosis is GRADE A. When the progression has been ≥ 2 mm in the previous 5 years, the diagnosis is GRADE C. Grade A and B can be upgraded to a higher grade in the presence of recognized risk factors (smoking or diabetes). Smoker ≥10 or more cigarettes/day: upgraded to Grade C. Smoker