Periodontology CLINICAL

A clinical periodontal assessment pro forma

incorporating the new periodontal classification
Peter Galgut1

Key points
The new periodontal classification is difficult and
time-consuming to administer in clinical practice.
This paper describes a quick and easy system to
administer the classification in clinical practice.
In addition to administering the classification for
diagnosing periodontal diseases, this system can
be used for identifying poor prognosis cases and/
or teeth, facilitating more efficient and effective
treatment planning for restorative dentistry and
long-term maintenance of oral health.

Abstract
The new periodontal classification is a huge step forward in the effective management of periodontal diseases in
clinical practice. However, despite the production of numerous flowcharts and tables to streamline its clinical use,
dental professionals have found its application time-consuming and difficult to administer in clinical practice due to its
complexity. As a practising clinician, the aim of this paper was to explore ways to streamline the application of the new
periodontal classification system for clinicians to save clinical time and improve the provision of effective periodontal
diagnoses and treatments for their patients. This paper describes and illustrates a simplified clinical system for the
application of the periodontal classification system in clinical practice, to enable practitioners to quickly and easily
derive a diagnosis and treatment plan for their periodontal patients using the new classification system.

Introduction
Much has been written in the British Dental
Journal (January 2019)1,2 and elsewhere3,4 about
the new 2017/2018 periodontal classification.
A number of organisations, such as the British
Society of Periodontology and the American
Dental Association, produced flow diagrams
and other aids regarding how to apply
this classification clinically. However, the
classification is complex, confusing and time-
consuming to apply in clinical practice.
As a clinical periodontist, I have devised a
simplified assessment form that is easy and
quick to apply clinically, which I thought
would be useful for fellow clinicians to apply
in their own practices. It must be emphasised
that, because it is a simplified version of the
classification, there are aspects that I have left
1
Clinical Periodontist, London, N11 A11, UK.
Correspondence to: Peter Galgut
Email address: periofeedback@periodontal.co.uk
Refereed Paper.
Accepted 7 April 2020
https://doi.org/10.1038/s41415-020-1753-x
out. There are other aspects of this assessment
form that I have used clinically for many years
before the advent of this new classification,
which I have incorporated into the assessment
document. It must also be emphasised that this
is very much a ‘work in progress’ and I would
be delighted to receive feedback, suggestions
for improvement and also criticism of the
document, in the hope of evolving a clinically
applicable system of effective and efficient
management of our periodontal patients.
Many dental professionals have questioned
the need for such a complex periodontal
classification. It is important to appreciate
that our knowledge of the aetiology and
pathogenesis of periodontal diseases has
drastically changed in recent years, and this
classification is designed to address our current
understanding of these conditions and their
clinical management.
Essentially, the old paradigm was that plaque
causes dental diseases such as dental decay and
gingivitis, then sooner or later gingivitis would
progress to periodontitis, with bone loss and
ultimately tooth loss; this is no longer valid.
As clinicians, many of us have noticed that
there are some people who don’t clean their
teeth very well (if at all) and never develop
periodontal disease – there are some who
develop gingivitis, but it never progresses to
periodontal disease – just as there are those
who seem to try very hard and clean their teeth
very well, but can never eliminate it. Also, while
gingivitis tends to be generalised, periodontitis
tends to be localised, with some teeth suffering
deep pockets and bone loss and others only
minimal or no periodontal pocketing at all.
In the new classification, it is now recognised
that there are different periodontal diseases:
periodontitis (generalised, localised and
molar/incisor), necrotising periodontal disease
and periodontitis associated with systemic
disease.
In recognition of this complexity, and of
the fact that the aetiology and progression
of periodontal diseases are determined by
multifactorial influences rather than simply
due to dental plaque, this new classification has
been established, which reflects the complexity
of our current understanding.
The system that I have developed to
clinically assess this hugely complex condition

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 CLINICAL
is reproduced below. It is aimed at gathering
the relevant data with minimal text entry and,
wherever possible, tick boxes (or digital click
boxes) to save time and effort, in order to
gather as much data as possible with minimum
effort and clinical time. The assessment system
is in two parts. Part one is designed as an initial
screening overview of the clinical condition
and, in cases where clinical assessment
parameters are raised, identifies the need for a
full periodontal assessment (part two), which
is mandatory if the initial screening assessment
(part one) identifies the presence of significant
active periodontal disease being present.
Notes on completing part one
The notes that follow are all annotated where
they are applicable in the sample pro forma in
Appendix 1.
1. Note that for intraoral and extraoral
examination, a list is provided to be ticked
or annotated if there are any abnormalities,
as an aide-memoire and a record that these
assessments have been done
2. This assessment is used by many clinicians
to provide an overall assessment of the
gingivae. Quite clearly, the management
of atrophic gingivitis, hyperaemic and/
or hypertrophic gingivitis may require
different clinical strategies in management
independently of the amount of bleeding
present or not. The third item identifying
the consistency of the gingivae is important
because thin and friable gingivae are often
associated with very thin alveolar bone,
making the dentition more susceptible to
recession rather than periodontal pocketing.
If the gingivae are thick and fibrous, it is
implied that there is more alveolar bone
and therefore the tissues are resistant to
recession, but have a greater tendency to
develop periodontal pockets. This factor is
described in some older textbooks as ‘the
washboard test’ and the relevance of the
consistency of the supporting tissues is
referred to in the new classification. Once
again, the clinical management of patients
susceptible to recession may be different
to those less susceptible to recession, both
from a periodontal point of view and a
restorative dentistry point of view, where
restorations with subgingival margins may
be planned for cosmetic and other reasons
3. This is taken from the new classification
and can be determined by routine clinical
observation of oral hygiene and gingival
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Periodontology
bleeding status to enable a decision to
be made as to whether a full periodontal
assessment is necessary. The form in part
one identifies the need for only oral hygiene
instruction (OHI) programmes, scaling or
some subgingival debridement, as opposed
to more complex forms of treatment
appropriate for full-blown periodontal
diseases
4. This is taken directly from the new
classification and, from a clinical point
of view, it indicates that those individuals
who are assessed as being ‘healthy’ may
be monitored less frequently (for example,
every six months as part of a regular dental
check-up/review appointment), as opposed
to those individuals who are described as
‘stable’, which implies that the condition can
return at any time; these patients need to be
monitored more frequently (for example,
every three months) to ensure that, if the
condition returns, it is rapidly brought
under control before it is able to progress
further. It is also to be noted that the new
classification recognises that there are
different types of gingivitis; that is, localised
(which may be due to local factors such as
defective restorations) and generalised,
with the implication being that these two
types of gingivitis may need to be managed
differently in clinical practice
5. It is now mandatory to take ‘appropriate’
diagnostic radiographs to assess the
interdental alveolar bone status at regular
intervals. Appropriate radiographs for the
purposes of assessing alveolar bone are not
standard bitewings. Full-mouth periapical
radiographs are ideal, but modern digital
panoral radiographs have improved to such
an extent that these are now acceptable for
this purpose. It is also now mandatory to
report on these radiographs when they are
taken and to annotate these findings in the
clinical notes. In individuals who have active
ongoing periodontal disease these need to be
taken more frequently, whereas in pateints
who do not have active disease they may be
taken less frequently. The frequency is not
specified in the classification because it is at
the discretion of the clinician assessing the
degree of inflammation present at review
appointments. As a guideline, it is essential
to take appropriate diagnostic radiographs at
baseline (that is, the first appointment) and
then possibly annually or even less frequently
thereafter in patients whose periodontal
condition has been stabilised after treatment.
Those individuals with more active ongoing
destructive periodontal disease with bone
loss may require these radiographs more
frequently. It is important that the findings
from the radiographs, taken for both dental
and periodontal diagnostic purposes, are
fully annotated in the clinical notes
6. This is a standard basic periodontal
examination (BPE) assessment, which is
currently extensively used clinically and
therefore needs no further explanation
7. It is well known that other dental factors
play a significant role in the progression
of periodontal diseases, particularly
the localised forms of gingivitis and
periodontitis. In this paragraph, a list of
potential dental co-factors in the aetiology
of gingival inflammation is provided as
an aide-memoire to be checked as part of
the assessment process. This is followed
by a further list of items that are known
to have significant effects in the initiation
and progression of gingival/periodontal
inflammation, for example class II and
class III malocclusions and local defective
restorations
8. Drawing up a treatment plan in the context
of this more basic evaluation would
obviously be confined to those patients
assessed as having only low readings in
the assessment sequences described above.
It must be emphasised that a treatment
plan, drawn up particularly in respect of
periodontal problems, needs to be formally
re-evaluated after treatment to determine
its efficacy and to modify it as necessary
where results of the treatment provided do
not achieve periodontal health. A modified
treatment plan must then be drawn up,
which may include progression to the full
periodontal assessment (part two) and/or
the provision of different treatments (such
as topical pharmacological adjunctive
agents or surgical intervention) or referral
to specialist care, and these modifications
to the treatment strategy need to be fully
annotated in the clinical records.
Notes on completing part two
The notes that follow are all annotated in the
sample pro forma in Appendix 2, in order to
enable easy cross-referencing of the assessment
document with the notes that follow.
1. This is a fairly standard periodontal
charting, but it should be noted that it only
annotates four readings per tooth rather

than the six readings per tooth required
by the UK NHS regulations. A four-point
charting system is used by many authorities
and clinicians for clinical assessments based
on the deepest reading on each surface as
opposed to multiple readings on each tooth
surface. This method of assessment is used
here to save time in obtaining clinically
relevant data efficiently and effectively.
From a clinical point of view, noting
only the deepest periodontal defects on
each surface identifies the problem areas
that need treatment rather than the more
comprehensive six-point chartings that are
used extensively for research purposes
2. It is now also mandatory to take
appropriate diagnostic radiographs at
regular intervals and to report on them,
and the new periodontal classification
requires that interproximal bone levels are
annotated throughout the mouth. Bone
loss is measured from the cementoenamel
junction (CEJ) to the alveolar bone. This
is often difficult to do in practice because
measuring distances on radiographs is not
easy, so some practitioners have simply
adopted a policy of approximation based on
mild (less than 2 mm), moderate (4–6 mm)
or severe (greater than 6 mm) and annotate
the grid accordingly as ‘Mi’, ‘Mo’ or ‘S’. Note
that the ‘8s’ are included as there are often
significant bony defects distal to them and
it is important to annotate these sites as well
if the 8s are present
3. With regards to gingivitis and periodontal
diseases, it is important to note that both
of these conditions are now recognised as
distinctly different categories, presenting
clinically as gingival and/or periodontal
inflammation (as separate clinical entities).
It is also to be noted that the recognition
of gingival health is different to gingival
stability in that, with the former, the
patient has never suffered any gingival or
periodontal inflammation, whereas with
the latter, the implication is that they may
be healthy at any given moment in time,
but there is clinical evidence that they have
suffered periodontal inflammation in the
past so they are susceptible to recurrences.
Therefore, these patients have to be more
closely and frequently monitored, even
when they appear to have no gingival
inflammation present compared to those
who have never suffered any gingival/
periodontal inflammation in the past.
Also important is the recognition in the
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Periodontology
new classification that there are forms of
gingival/periodontal inflammation which
are not solely dependent on the presence of
biofilm, and that there may be other factors
that need to be addressed in addition to
normal OHI and scaling/debridement to
achieve stability and health in the oral tissues
4. It has also, at last, been recognised that
gingival/periodontal inflammation may
be localised or generalised, and that in
some individuals it affects their incisors
predominantly, whereas in others it may
affect only the molars. This is important
because the management of these patients,
particularly from a restorative and/or
orthodontic point of view, may be very
different and the outcomes of periodontal
treatment may vary in different parts of the
mouth or, by inference, some parts of the
mouth may need more intensive treatment
and monitoring than others. This, and
the other new concepts that follow, can
be used not only to diagnose, classify and
treat periodontal diseases, but also for
prognostication and restorative treatment
planning and long-term management of
patients with periodontal disease, which
has not been possible up until now
5. Staging is another very important and
valuable help to the clinician in determining
the most appropriate treatment plan for
individual patients, as well as prognosticating
the potential for future tooth loss and
providing appropriate restorative dentistry
in relation to the likely future progression
of the periodontal condition. In its most
simple form, the prognosis of stage I is likely
to heal well, whereas stage II will probably
resolve with treatment, but will need more
than average ongoing maintenance care to
prevent progression into the more severe
forms with time. Stage III indicates that
more extensive periodontal destruction
has occurred and, although treatable with
more complex and vigorous treatment and
post-treatment maintenance therapy, it is
unlikely that full resolution of the condition
will occur. The object of treatment in these
cases may be to preserve as many teeth
as possible in the long term. In stage IV,
periodontal destruction of the supporting
periodontal tissues is very advanced and,
even with the most vigorous treatment
and long-term clinical management, some
tooth loss will almost certainly occur, which
needs to be taken into account in treatment
planning and when advising individual
CLINICAL
patients as to the best treatment options that
may be available to them. Often, advanced
restorative options (including implants) are
contraindicated; if embarked upon, patients
need to be advised of the high risk of failure
of the proposed treatment
6. Grading is another very important and
valuable aid in predicting long-term
treatment outcomes and management
of periodontal patients. An easy way of
understanding this is to consider a patient
with moderate generalised bone loss who
has lost a couple of teeth due to periodontal
disease. If this patient is 65 years old, the
condition has been progressing slowly
over many years and therefore the chances
of further tooth loss are minimal (that is,
grade 1), whereas exactly the same clinical
picture in someone only 25  years old
implies that the condition is progressing
very quickly. Management of this condition
will be more difficult and complex, and the
likelihood of achieving periodontal health/
stability without tooth loss in the long term
is unlikely (grade 3). Similarly, restorative
treatment plans may need to be modified –
and fully informed consent by the patient
for high-risk treatment options clearly
explained and obtained in writing – or
avoided altogether
7. So now, with this new classification, instead
of simply being able to annotate in the notes
that this is early onset, aggressive or chronic
periodontitis, we are now able to derive a
far more sophisticated and meaningful
diagnosis and prognosis from management
of gingival/periodontal diseases clinically.
We are also able to advise our patients as to
the nature of the condition, what treatment
options are available and what are the
likely long-term future for their dentitions.
By comparison to the unsophisticated
and rudimentary nature of the previous
classifications, clinicians can achieve
better diagnosis with indicators of the most
appropriate treatment and management,
with indications of probable long-term
prognosis and successful restorative
treatment outcomes for their patients.
For instance, using these assessment
documents, an example of the information
gathered may be something like: gingivitis
with more than 10% bleeding, and localised
molar periodontitis and moderate bone loss
in the upper molars (stage II), but progressing
slowly (grade 1).
 CLINICAL Periodontology

Benefits of using an assessment Appendix 1 – part one: initial screening document

system based on the new
periodontal classification in clinical
practice

From a patient perspective, this assessment

summarises that there has been some bone
loss, but that it is not in one of its more severe
forms and is not complicated by other factors
such as genetics or medication etc, so it is likely
that treatment will probably be successful in
the long term. Although it may not be arrested
completely and therefore regular maintenance
will be necessary indefinitely.
Similarly, restorations are likely to be more
successful in the long term as it is likely that
stability of the tissues is probably going to be
achieved.
By way of illustration, a completed assessment
has been provided (see online supplementary
information). It should be noted that important
information and items for action are annotated
in red to highlight them as opposed to general
information that appears in blue.
Using the new periodontal classification
may look hugely intimidating initially.
However, using it as described in this paper is
a very effective way to help decide on the most
appropriate frequencies of recalls, intensity
and extent of initial treatment, or whether to
refer to a specialist unit, as well as being able
to advise patients on their condition and its
long-term likely progression. Furthermore,
it offers significant potential to provide our
periodontal patients with better treatment
outcomes, treatment planning and long-term
management of their dental requirements in
clinical practice.

References
1. Dietrich T, Ower P, Tank M et al. Periodontal diagnosis
in the context of the 2017 classification system of
periodontal diseases and conditions – implementation
in clinical practice. Br Dent J 2019; 226: 16–22.
2. Walter C, Chapple I L C, Ower P et al. Periodontal
diagnosis in the context of the BSP implementation
plan for the 2017 classification system of periodontal
diseases and conditions: presentation of a pair of young
siblings with periodontitis. Br Dent J 2019; 226: 23–26.
3. Tonetti M S, Greenwell H, Kornman K S. Staging and
grading of periodontitis: Framework and proposal of
a new classification and case definition. J Periodontol
2018; DOI: 10.1002/JPER.18-0006.
4. Caton J G, Armitage G, Berglundh T et al. A new
classification scheme for periodontal and peri-implant
diseases and conditionsintroductions and key changes
from the 1999 classification. J Clin Periodontol 2018;
DOI: 10.1111/jcpe.12935.

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Appendix 2 – part two: full periodontal evaluation (cont. on page 120)

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Appendix 2 – part two: full periodontal evaluation (cont. from page 119)

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Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.