Journal of Indian Society of Periodontology

EDITORIAL
Year
: 2019  |  Volume : 23  |  Issue : 3  |  Page : 185--186

Generalized periodontitis; Stage IV, Grade C; currently stable. 1. Current smoker >12 cigarettes per day 2. Optimally controlled diabetes.


Ashish Kumar 
 Editor, Journal of Indian Society of Periodontology, Professor, Department of Periodontology, Institute of Dental Studies and Technologies, Kadrabad, Modinagar, Ghaziabad - 201 201, Uttar Pradesh, India

Correspondence Address:
Ashish Kumar
Editor, Journal of Indian Society of Periodontology, Professor, Department of Periodontology, Institute of Dental Studies and Technologies, Kadrabad, Modinagar, Ghaziabad - 201 201, Uttar Pradesh
India




How to cite this article:
Kumar A. Generalized periodontitis; Stage IV, Grade C; currently stable. 1. Current smoker >12 cigarettes per day 2. Optimally controlled diabetes. J Indian Soc Periodontol 2019;23:185-186


How to cite this URL:
Kumar A. Generalized periodontitis; Stage IV, Grade C; currently stable. 1. Current smoker >12 cigarettes per day 2. Optimally controlled diabetes. J Indian Soc Periodontol [serial online] 2019 [cited 2019 May 22 ];23:185-186
Available from: http://www.jisponline.com/text.asp?2019/23/3/185/257342


Full Text



[AUTHOR:1]

Wondering what is the title all about? The title tells you how the diagnosis needs to be mentioned as per the new classification system (according to my understanding). The new 2018 classification system has brought with it new intricacies when compared to the 1999 classification. The overview of the new classification makes it look far easier and simpler than 1999 classification. The “overview” can be deceptive and may not be the accurate view. An in-depth reading of the 320-page document, published in the two leading journals of Periodontology, shall give the readers, a precise view of what the new classification is all about and it is up to each individual to decide on its own, the merits and de-merits of new classification.

I shall also mention here that the experts who had participated in creating this document have has worked in detail on few aspects of 1999 classification to bring in changes. Many areas of older classification have just been extended by adding new diseases in the already long list, making it almost impossible for anyone to remember the subclassifications and diseases included in the list. The subclassification of “Periodontitis as a manifestation of systemic disease” will substantiate this point. Similarly the subclassifications of all other categories have been made extensive, making it much more difficult for anyone to recollect all subcategories. The time will be the best judge to evaluate and confirm the effect of these widespread and exhaustive subclassifictions on formulating correct diagnosis.

The experts have worked in detail and tried to resolve one of the most controversial aspect of 1999 classification- chronic vs aggressive debate and localized aggressive vs generalized aggressive periodontitis debate. Ultimately the experts have come to conclusion that its “periodontitis.” I had mentioned this in my earlier editorial[1] before this classification was introduced. The features of aggressive or chronic periodontitis almost remain the same and it was very difficult to apply the 1999 classification in a clinical scenario. The pertinent question which arose was, if there is not much difference in treating chronic or aggressive periodontitis, then why spent time on differentiating between them. Dr Armitage (man behind 1999 classification) in publications accepted this. While in 2004, he was advocating strict application and differentiation between chronic and aggressive periodontitis,[2] by 2011 he had reconciled to the fact that this difference is futile for a clinical treatment scenario.[3]

Few of the changes made are for good and introduction of new concept of staging and grading (mimicking oncology) may have made diagnosis very exhaustive (as you can see in the title of this editorial), I feel it will do good for the practice of Periodontology.

Earlier, a case of periodontitis would be diagnosed as mild, moderate or severe chronic periodontitis or localized aggressive periodontitis or generalized aggressive periodontitis. These diagnoses were not able to have an impact on the patient as well as dentist, especially non-periodontists, about the severity and complexity of disease, and the kind of expertise required to provide optimal treatment to the patient. The new system of mentioning stage and grade will change this. As a common man knows what does a Stage IV cancer means, a time will come when the non-periodontist dentists as well as common men will start realizing what does a Stage IV, grade C periodontitis mean. They would understand the severity of condition, urgency of consulting the dentist for treatment and that involvement of periodontist in treatment is necessary.

Although the application of this staging and grading has its own perils, and will require sound clinical judgment to arrive at the most appropriate clinical diagnosis. There are problematic areas. To use grading, patient should have radiographs for last 5 years. This may not be an ideal and practical situation in our country. The alternative given for this is to use percentage of bone loss/age. This aspect is also very controversial. Let me explain how the application of this criteria (in absence of radiographs) can mislead in grading. A 50-year patient reports with 4 mm bone loss and 10 mm root of worst affected tooth and does not have previous radiographs. To grade, we use the percentage of bone loss/age criteria. The percentage of bone loss is 40% and when divided by age it come to 0.8, i.e., Grade B. Now by default, you have considered that the loss has occurred over 50 years. If we realistically see, we will have teeth from 6 years of age. So 50 years is as such not the right age to be used, and what if the disease started at the age of 47 and this 4 mm bone loss has occurred in last 3 years. So the grading can be very misleading.

Another good thing has been the introduction of concept of defining periodontal health. This is important from a preventive aspect as well as is a therapeutic endpoint to use. So the treating dentist clearly knows what is health. Earlier even one or two gingival bleeding sites were considered to be gingivitis. But now they are considered with in the realm of normalcy and are considered a part of health.

No classification is complete and everlasting in Periodontology. As the history suggests, the periodontists have special affinity toward revisiting classification systems every 15-20 years, even much earlier, sometimes. We had a classification introduced in 1989, 1993 and 1999. 1989 classification had a major flaw of missing out on gingival diseases component. If the legends of Periodontology who have defined the subject of Periodontology with their research and who devised the 1989 classification can go wrong at such a basic level, then any classification can be a fault. Already voices of dissent have started appearing in journals regarding the exhaustiveness and inapplicability of 2018 classification in clinical scenarios. People have also suggested that persons exclusively in private practices should mandatorily be part of such groups which device classifications so that we not only have research and theoretical aspects coming from eminent academicians but more practical aspect also is given due importance in devising a classification system.

I foresee a new version of classification of periodontal diseases in next few years considering the difficulties of applicability (1999 classification also had its own issues of applicability).

My humble submission is that we should not change the name of disease. Periodontitis is periodontitis. Now, with internet savvy public, who googles about each disease to seek information before going to a dentist, multitude of names of same disease creates confusion. A disease called as juvenile periodontitis before 1999, becomes localized aggressive periodontitis after 1999 and again becomes periodontitis after 2018… must be difficult for a common man to understand. We are only not researching and so should change names. Much more research is going on in cardiology or diabetes. Diabetes has remained diabetes for the longest period of time and name has not changed.[1] Myocardial Infarction is MI. Common people can relate to these names and have a basic idea of what this disease is all about.

Is it the appropriate time that ISP can work on this and present a new practically oriented classification for the world to follow… How long will we keep following what is fed to us by American Academy of Periodontology and European Federation of Periodontology.

Happy Classifying…

References

1Kumar A. What's there in a name…? J Indian Soc Periodontol 2018;22:285.
2Armitage GC. Periodontal diagnoses and classification of periodontal diseases. Periodontol 2000 2004;34:9-21.
3Armitage GC, Cullinan MP. Comparison of the clinical features of chronic and aggressive periodontitis. Periodontol 2000 2010;53:12-27.