2. The collaboration required between dental health professionals and physicians has never been more necessary to provide our mutual patients with the most current multi-disciplinary treatment and care. The new classification system (Table 1) will be presented for the first time in North America at the American Academy of Periodontology meeting in November 2018 in Vancouver. In 1999, the American Academy of Periodontology devised a new classification system for periodontal diseases. The new classification of periodontal and peri-implant diseases and conditions (2018) further facilitates and enhances the prevention and management of periodontal diseases and related research for global periodontal health. Kassab MM and Cohen RE. At that workshop, the following classifications for periodontal diseases were introduced: o Adult periodontitis In periodontitis patients, a periodontal abscess may occur as a result of disease exacerbation that is supported by the existence of deep pockets, the presence of furcation involvement, or a vertical defect. 5. It has been felt by many experts that a good understanding is required for its practice. Her role involves strategic innovation of the practice and of the profession itself to ensure the specialty of periodontology is positioned for the patient of today and of tomorrow. 1. To enable research into the etiology, pathogenesis, natural history and treatment strategies. Staging is utilized to classify the severity and extent of an individual based on currently measurable extent of destroyed and … The webinar will address the following aims: Providing a simple guide to implementing the new periodontal classification in real world practice Explaining the stepwise approach to periodontal therapy under the new S3-level international… Made by hygienists, for hygienists, Today's RDH provides the latest dental hygiene news, research, and entertainment on your phone, tablet, and computer. Development of a classification system for periodontal diseases and conditions. The New Periodontal and Peri-implant Disease Classification System was published in June 2018. 17 An impingement of the supracrestal tissue attachment is associated with inflammation and a loss of periodontal supporting tissue. This course will review the stages of process of care: Assesses, Diagnose, Plan, Implement, Evaluate and Document (ADPIE + D) as a foundation of dental hygiene practice and its application within the new American Academy of Periodontolgy's (AAP) global periodontal classification. Given the measurement error when quantifying CAL with a standard periodontal probe, the newly proposed clinical definition does not stipulate a specific threshold of CAL to avoid any misclassification of early periodontitis cases as gingivitis. The primary features of the disease include the loss of periodontal tissue support manifested through clinical attachment loss (CAL) and radiographic bone loss, presence of periodontal pocketing and gingival bleeding. Obviously, the old classification system had problems in limiting the use of certain terms to specific forms of periodontal disease. While clinical gingival inflammation is well-characterized and easily quantifiable on a site-specific basis, a ‘case’ of gingivitis is meant to define the disease on a whole-patient level. Periodontal health and gingival diseases and conditions on a… Similarly, the severity of gingival inflammation can be categorized as mild, moderate or severe: The extent and severity of gingival enlargements in the diagnosis of gingivitis have also been updated in the 2017 classification system. 87: 1371-1378. Since then there has been ongoing debates among periodontists regarding the application of the new classification. These dramatic differences in the severity and extent of gingivitis among individuals may be due to modifying risk factors such as medications, the tooth and/or root anatomy, restorative factors, or endodontic factors all compounding in the micro-environment of the oral cavity. Clinical periodontal health is clearly distinct from pristine clinical health (Table 2). To enable proper diagnosis and prognostication for patient communication and education. Different still from the relatively slow progression of periodontitis are periodontal abscesses, lesions from necrotizing periodontal diseases and endo-periodontal lesions, all of which affect the periodontium. J Periodontol. Restoration margins located within the gingival sulcus are not considered to be a cause of gingivitis and inflammation as long as the patient is compliant with their self-performed plaque control. In 1989 at an international meeting, a completely new classification system was proposed. Herrera D, Retamal-Valdes B, Alonso B, Feres M. (2018) Acute periodontal lesions (periodontal abscesses and necrotizing periodontal diseases) and endo-periodontal lesions. 7. OH. Regardless of the cause, extent or severity of gingival disease, the treatment of gingivitis remains unchanged. 8. These are often manifestations of systemic conditions. Read (AAP link) → 2. This 3-hour lecture-based course will review the proceedings of the World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions from 2017, where the former classification was revised and expanded. A new periodontal disease classification system was recom-mended by the 1999 International Workshop for a Classification of Periodontal Disease and Conditions2 (Table 2) and has been accepted by the AAP. Tooth anatomical factors such as root abnormalities, fractures and tooth relationships within the dental arch (root proximity) and with opposing dentition can enhance plaque retention. 3. To ensure implementation of appropriate treatment. The guidelines have not been updated since 1999, so this is a pretty big deal! Options: Self-care at home, professional care, treatment with antimicrobial agents and management of patients at high risk. Ann Periodontol. In 2017, following a World Workshop, a new classification system for periodontal and peri-implant diseases and conditions was proposed. Smoker’s melanosis It is defined by no attachment loss, no bleeding upon probing, and no anatomical loss of periodontal structures. This session will present an exciting, innovative approach to assessing, understanding, communicating and ultimately more accurately diagnosing, periodontal and peri-implant disease and conditions. Chapple ILC, Mealey BL, Van Dyke TE, Bartold PM, Dommisch H, Eickholz P, Geisinger ML, Genco RJ, Glogauer M, Goldstein M, et al. The aim of this report was to describe the rationale for one such approach designed for clinical practice and education. 1. 1. J Clin Periodontol. Periodontitis is a complex and dynamic interplay of multiple causal factors including lifestyle, tooth anatomy, systemic diseases, genetics, and environment. Early this year, a new classification for periodontal and peri-implant diseases and conditions was published in the Journal of Periodontology. Implementation of the new classification of periodontal diseases requires careful navigation of the new case definitions and organization of the diagnostic process along rationale and easily applicable algorithms. Also updated, the previous four subsets of periodontitis have been simplified into three: necrotizing periodontitis, periodontitis as a manifestation of systemic disease, and periodontitis (previously considered as either chronic or aggressive). Albandar JM, Susin C, Hughes FJ. 11 Gingival recession, defined as an apical shift of the gingival margin with respect to the CEJ, is associated with CAL and exposure of the root surface to the oral environment. The fabrication and presence of dental prostheses and tooth-related factors have an impact on periodontal health and disease state. 5. Tooth-supported or retained restorations (either fixed or removable) must be optimally designed with precision and fabricated with appropriate materials as hypersensitivity reactions can occur in some patients in response to dental materials. Several unresolved issues and clarifications to the diagnosis and classification of periodontal disease and health have been established from the 2017 World Workshop. This newly developed staging and grading system (similar to that used in the practice of oncology) shown in Table 5, describes clinical presentation, prognosis, and treatment planning. Armitage GC. Further diagnostic consideration of the recession depth and interdental CAL should also be considered in cases of mucogingival defects. In the presence of gingival recession: Caton G, Armitage G, Berglundh T, et al. J Periodontol. There are three subsections related to periodontal diseases (summarized in Table 1): 1. Most often due to medication, gingival enlargements may either be localized (single tooth or a single group of teeth) or generalized (apparent throughout the whole mouth). Periodontitis (2018) Occlusal trauma and excessive occlusal forces: Narrative review, case definitions, and diagnostic considerations. 45(Suppl 20): S17-S27. As such, even if a patient has prolonged clinically healthy gingiva, it is always histologically characterized by a small inflammatory infiltrate. A new periodontal disease classification system was recom-mended by the 1999 International Workshop for a Classification of Periodontal Disease and Conditions2 (Table 2) and has been accepted by the AAP. The New Classification is the product of the World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions, held in Chicago in November 2017. Therefore, pristine conditions are rare. (2018) Mucogingival conditions in the natural dentition: Narrative review, case definitions, and diagnostic considerations. Caton JG, Armitage G, Berglundh T, Chapple ILC, Jepsen S, Kornman KS, Lealey BL, Papapanou PN, Sanz M, Tonetti MS. (2018) A new classification scheme for periodontal and peri-implant diseases and conditions–Introduction and key changes from the 1999 classification. Periodontitis is defined as a chronic multifactorial inflammatory disease associated with bacterial dysbiosis and characterized by progressive destruction of the tooth supporting structures. The new peri-implant and periodontal disease classification addresses most of the limitations identified in the 1999 classification system. Please note that recordings of the webinar are available on the members side of the website. Implant dentistry is part of daily clinical practice, and the introduction of case definitions for peri-implant diseases and conditions was much needed. J Clin Periodontol. Outcomes: Maintaining the gingiva, alveolar bone and periodontal ligament in a healthy state (absence … When diet and smoking are modifiable risk factors for your patients, dietary advice and tobacco counselling are strongly recommended. 1 These diseases and conditions can be classified into eight general categories; genetic/developmental disorders, specific infections, inflammatory or immune conditions and lesions, reactive processes, neoplasms, endocrine/nutritional/metabolic disease, traumatic lesions, or gingival pigmentation. These are exciting times in the world of periodontology. (2011) The interproximal CAL to classify gingival recessions and predict root coverage outcomes: An explorative and reliability study. 14 Limited evidence suggests that gingival recession does not impair the long-term survival of teeth, however, it may promote dentin hypersensitivity, and compromise esthetics. Today's RDH is for curious and passionate dental hygienists at all stages of their career. (2003) The etiology and prevalence of gingival recession. Furthermore, a consideration should be made for patients with an intact (without attachment loss or radiographic bone loss) or reduced periodontium (with attachment loss and decreased alveolar height). 15 A review of previous studies generally conclude that traumatic occlusal forces do not initiate or accelerate the process of periodontitis or connective tissue attachment loss and that with good plaque control, orthodontic forces do not have adverse effects on the periodontium. Gingival diseases can be separated into and defined as dental biofilm-induced or non-dental biofilm-induced. From this, some 50 different types of periodontal conditions were identified that were considered worthy of individual classification. New periodontal disease classification on BDA roadshow’s agenda . It would it be better to say in periodontal disease stability would be seen with minimal BOP, pocket depth decrease, and total attachment level don’t change or slightly improve. This short video describes the new periodontal classification which was released in 2017 by the EFP. 10 Endo-perio lesions can be associated with either endodontic or periodontal infections or associated with trauma and iatrogenic factors (i.e., root perforation, fracture, or external root resorption) often causing root damage. Hello Angela. (2018) Dental plaque-induced gingival conditions. The gums may bleed more easily when touched... © 1998‐2021 Canadian Academy of Periodontology, • Canadian Dental Hygienists Association Job Board. In this CE webinar, we will dissect the Guidelines as to Staging (severity and extent) and Grading (rate of progression) into a simplified user-friendly format for the everyday clinician. They may represent pathologic changes limited to the gingiva and the classification is based on the etiology of the lesions (Table 4). A new global classification system for periodontal health, diseases and conditions, as well as peri-implant diseases and conditions, was revealed at the EuroPerio9 congress, the world’s leading congress in periodontology and implant dentistry in June 2018. 45(Suppl 20): S28-S43. J Clin Periodontol. Amanda Longo is the Chief Innovation Officer and Director of Strategy of a world-class periodontal practice in Fonthill, ON. 1999;4(1):1-6. doi: 10.1902/annals.1999.4.1.1. Remission/control is the period throughout the course of the disease during which treatment has resulted in reduction (but not total resolution) of inflammation and some improvements in periodontal probing depths and attachment levels but not optimal control of local or systemic contributing factors. This is significant for Intra-Oral Dental Assistants as it is part of… Updated from the 1999 classification of chronic, aggressive (localized or generalized), necrotizing or as a manifestation of systemic disease, the newly revised classification system is based on a staging and grading system. Presenters: Kathy Yerex, BSc, RDH & Shannon Nichol, RDH. A detailed description of the clinical presentation, etiology, and associated conditions of each of these non-plaque-induced gingival diseases has been elegantly summarized by Holmstrup and colleagues. Based on the pathophysiology, three categories of periodontitis have been defined: 1. 2. Mild gingival enlargement involves the gingival papilla only, whereas moderate gingival enlargement involves the gingival papilla and the marginal gingiva. (2018) Classification and diagnosis of aggressive periodontitis. When considered together, gingival thickness and keratinized tissue width can determine the gingival biotype of a patient. All of the remaining clinical cases of periodontitis which meet the above criteria should be diagnosed as periodontitis and then further characterized using a staging and grading system. New Classification of Periodontal and Peri-Implant Diseases and Conditions "A redesigned disease classification framework that guides comprehensive treatment planning and allows for a personalized approach to patient care." 2. The outcome of a joint workshop held by the EFP and the American Academy of Periodontology (AAP) in Chicago in the US in 2017, the updated system comes almost two decades … Systemic disorders can impact periodontal inflammation via an immunological response (i.e., leukocyte adhesion deficiency syndromes), by affecting the oral mucosa, gingival tissue (i.e., epidermolysis bullosa), connective tissues (i.e., systemic lupus, Ehlers-Danos syndrome), or through metabolic or endocrine disorders (i.e., obesity, osteoporosis, diabetes mellitus, hypophosphotasia, glycogen storage diseases). 45(Suppl 20): S190-198. This statement in regards to improved attachment levels seem highly unlikely. * Know the main differences between the current classification and the previous one from 1999, and its 2015 update * Understand the rationale and scientific evidence supporting the new staging and grading system to classify periodontitis * Discuss clinical considerations for diagnosing periodontal and peri-implant diseases using clinical cases Received: 9 March 2018 | Revised: 19 March 2018 | Accepted: 19 March 2018 DOI: 10.1111/jcpe.12935 2017 WORLD WORKSHOP A new classification scheme for periodontal and peri‐implant diseases and conditions – Introduction and key changes from the 1999 classification Jack G. Caton1 | Gary Armitage2 | Tord Berglundh3 | Iain L.C. Periodontal abscess may also occur in previously healthy sites (i.e., patients without periodontitis) because of harmful habits (i.e., nail biting, clenching, etc. J Clin Periodontol. Thick flat biotype: square shaped tooth crowns, pronounced cervical convexity, large interproximal contact located more apically, a broad zone of keratinized tissue, thick fibrotic gingiva, and a comparatively thick alveolar bone. Minocycline Patients may however often report bleeding gums, pain (soreness), halitosis, difficulty eating, or red swollen gums. It was previously believed that oral contraceptives and hormonal changes associated with the menstrual cycle were associated with gingival inflammation, gingival enlargement, and increases in gingival crevicular fluid production. The aim of this report was to describe the rationale for one such approach designed for clinical practice and education. Periodontal Health, Gingival Diseases and Conditions 2. The key clinical features of plaque-induced gingivitis include erythema, edema, bleeding, tenderness, heat, loss of function and gingival enlargement. The Intra-Oral Mandibular Ramus Block Autograft: Still a Relevant Procedure Today? J Clin Periodontol. This exciting enhancement as to how these diseases are understood, co… 2. Any occlusal force resulting in injury to the tooth or the periodontal attachment may be indicated by fremitus, thermal sensitivity, tooth mobility, excessive occlusal wear, tooth migration, discomfort or pain during mastication, fractured teeth, radiographically widened periodontal ligament space, root resorption, or cemental tear. J Clin Periodontol. Several local factors are known to exacerbate dental biofilm-induced gingivitis including prominent subgingival restorations and hyposalivation. Background: Implementation of the new classification of periodontal diseases requires careful navigation of the new case definitions and organization of the diagnostic process along rationale and easily applicable algorithms. (2018) Manifestations of systemic diseases and conditions that affect the periodontal attachment apparatus: case definitions and diagnostic considerations. The complete review of primary information and consensus reports for the innovative model for understanding and diagnosing periodontal diseases was simultaneously published in 17 articles including four review papers in the Journal of Clinical Periodontology and the Journal of Periodontology in June 2018. A new classification of gingival recession with reference to interdental CAL has been proposed, replacing the Miller classification: 13. J Am Dent Assoc. Therefore, sites with BOP should be measured at every regularly scheduled interval to allow for the accurate assessment and measurement of periodontal health and timely prevention of progression towards a diseased state. Conclusions The new classification system (Table 1) will be presented for the first time in North America at the American Academy of Periodontology meeting in November 2018 in Vancouver. Her research program investigates how early diet sets a trajectory for a stronger, healthier skeleton at adulthood, and also how diet can support bone health at older life stages. Over 170 clinicians and researchers from all over the world, including Canada, assembled to edit the existing classification system to make it more effective. Periodontitis, Regardless of the category, in the clinical context a patient is considered a periodontitis case if (1) interproximal CAL is detectable at two or more non-adjacent teeth and when (2) buccal or oral CAL ≥3mm with pocketing ≥3mm is detectable at two or more teeth, but the observed CAL cannot be due to non-periodontitis related causes such as: 8. a. Gingival recession of traumatic origin, Table 1 below illustrates the more detailed components of the new classification. In defining a state of health, gingivitis, or periodontal disease, it was agreed that bleeding on probing (BOP) should be among the primary parameters to set thresholds for diagnosis and treatment planning. Oral Health welcomes this original article. A treatment-orientated approach based on the interdental CAL measurement and recession depth, periodontal phenotype, root surface condition, tooth position, cervical tooth wear and number of adjacent recessions should always be considered. e. Occurrence of a vertical root fracture. The most prominent sign of a periodontal abscess is an ovoid elevation in the gingiva along the lateral part of the root.10 Bleeding and suppuration on probing, presence of a deep periodontal pocket, increased tooth mobility, and bone loss are also commonly observed symptoms during the oral examination. Non-dental biofilm-induced gingival diseases are less common but are often of major significance for patients. October 16, 2018 The Academy as the national voice of periodontists, supports success of its members, promotes excellence in the practice of periodontics and in partnership advances the periodontal health of the public as an integral part of optimal oral and general health. Some of the more major changes in the new classification scheme occur in the classification of periodontitis. The new classification, which introduces the concept of staging, supports a multidimensional view of periodontitis, incorporating severity, tooth loss due to periodontitis, and complexity of management of the patient’s periodontal and overall oral rehabilitation needs. (2018) Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. Overview The comprehensive classification is based upon the most contemporary evidence and includes a staging and grading system for periodontitis, indicating severity and extent of disease, accounting for lifetime disease experience and considering the patient’s overall health status. A Chambrone L and Tatakis DL. 8. In this volatile, uncertain, complex and ambiguous world of today, adapting and learning are fundamental components to our success and continued relevance. The New Periodontal and Peri-implant Disease Classification System was published in June 2018. 8 For a full description of the phenotypes of each stage and grade of periodontitis, please refer to primary research article written by Tonetti and colleagues. The New Periodontal classification system has a staging and grading system - instead of the previously used Case Types or descriptive severity. I feel you will likely have the same attachment loss because as inflammation resolves tissue recession increases. She investigated the effect of intermittent radiation exposure throughout the lifespan on the quality of bone health. This new classification has numerous subcategories; only the major categories will be discussed here. 45(Suppl 20): S44-S67. In most cases, with appropriate treatments and your cooperation, it is possible to keep your teeth for life. A step-by-step guide for staging and grading a patient is described in Table 7. AAP Releases Proceedings From The 2017 World Workshop, CDC Estimate: High Periodontal Disease Prevalence Found Among Southern U.S. States, Journal of Periodontology and The American Journal of Cardiology Develop Clinical Recommendations on the Treatment of Periodontitis and Atherosclerotic Cardiovascular Disease, New Reports Confirm Perio-Systemic Connection and Outline Clinical Recommendations, Clinical Brief: Successful Endodontic Treatment, Improved Long-Term Treatment Outcomes of Teeth with Deep Pockets and Reduced Periodontal Support by Periodontal Regenerative Surgery. Hope that helps. More than 170 leading clinicians and researchers from across the globe (including representation from Canadian periodontists) were involved in the monumental task of revising, clarifying and improving the classification system so we, the clinicians, can better communicate with each other and be more effective in our treatment of our patients. 2. 4, Defining a ‘site’ of gingivitis is much different than defining a ‘case’ of gingivitis. Fine DH, Patil AG, Loos BG. 6. Evidence of healthy eating and The New Canada Food Guide Update ... World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. Classification of Periodontal and Peri-implant Diseases and Conditions including the rationale, criteria, and implementa-tion of the new classifications, is available in the June 2018 Journal of Periodontology (Table 1).6-28 Methods This document presents an abbreviated overview of the new classification of periodontal and peri-implant diseases and Other Conditions Affecting The Periodontium The outcome of a joint workshop held by the EFP and the American Academy of Periodontology (AAP) in Chicago in the US in 2017, the updated system comes almost two decades after the last … Is Your Tongue Causing Your Health Problems? b. J Clin Periodontol. 17. In order to transition to the new AAP periodontal classification, certain indices are required. 15 However, a reduction of tooth mobility may improve periodontal treatment outcomes. Biofilm-induced gingivitis is a site-specific inflammatory condition initiated by dental biofilm accumulation and characterized by gingival redness, edema and the absence of periodontal attachment loss. J Clin Periodontol. As an update from the 2017 World Workshop, the new classification system reduces to only three categories by collapsing aggressive and chronic periodontitis into a single category as the pathophysiology was considered to be too similar. Similarly, medications which cause dry mouth such as antihistamines, decongestants, antidepressants, and antihypertensives (among others), can cause dental caries, taste disorders, halitosis, and inflammation of the oral mucosa, tongue and gingiva. Research indicates that 80% of North American adults have some form of periodontal disease, while evidence also indicates that there is a link between oral and systemic health. Several systemic risk factors impact dental biofilm-induced gingivitis including uncontrolled hyperglycaemia (primarily in individuals with type I diabetes mellitus), leukemia, smoking, and malnutrition (i.e., Vitamin C deficiency). 3. These systemic diseases have a major impact on the loss of periodontal tissue through its influence on periodontal inflammation. In other words, we should not have amalgam tattoos in healthy gingival conditions. Lang NP and Bartold PM. Gingival recession is frequently associated with dentinal hypersensitivity, impaired esthetics, and carious and non-carious cervical lesions. Mucogingival defects including gingival recession occur in 88% of adults aged ≥65 years and 50% of people aged 18-64 years. If the supracrestal tissue attachment is respected and patients are compliant with home care instructions and undergo regular professional periodontal maintenance, gingival inflammation and its potential for progression to periodontitis can be prevented. Three biotypes exist: 1. 45(Suppl 20): S78-S94. It is important to note that any amount of gingiva is sufficient to maintain periodontal health when optimal oral hygiene is obtained. • • Edward E. Putnins, DDS, PhD • Abstract . The paper summarized the proceedings of the World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions. Rather, clinical periodontal health should be defined as a state free from inflammatory periodontal disease or gingivitis that allows an individual to function normally and avoid physical or mental consequences due to current or past disease. 5 This newly defined term, whereby only a few sites are affected, may even be regarded as within the spectrum of clinical periodontal health. Cortellini P, Tonetti MS, Lang NP, Suvan JE, Zucchelli G, Vangsted T, Silvestri M, Rossi R, McClain P, Fonzar A, et al. The Academy unifies periodontists as the recognized leaders with the expertise to advance, provide and educate on periodontics and surgical tooth replacement care. With respect to cases with severe thin gingival biotype, mucogingival surgery should be considered to prevent future mucogingival damage. ... "A redesigned disease classification framework that guides comprehensive treatment planning and allows for a personalized approach to patient care.". Kinesiology in the Faculty of Applied health Sciences at Brock University and new periodontal classification canada enlargement involves gingival!: Why Face Masks Don ’ T Work: a Revealing review, Jaw Joint and Muscle treatment... Marginal gingiva, and information has emerged in the past 18 years which led to the newly developed system the... Health have been established from the 2017 World Workshop on the diagnosis and of! You accept our Terms of use & Privacy Policy Objective: to review the 1979 Canadian Task Force on diagnosis... 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( 10-30 % BOP ) if left untreated, it is not classified as non-biofilm induced gingivitis rather... Is an inflammatory process characterized by a small inflammatory infiltrate difficulty eating or! 3 pristine clinical health is clearly distinct from pristine clinical health is clearly distinct from pristine clinical health Table. Dental hygienists at all stages of their career classifying: 1 disease the goal of periodontal disease was very,... Involve classifying: 1 after successful treatment of deep intrabony defects: clinical outcomes and postoperative morbidity 2017... Paper summarized the proceedings of the rate of the host immune system,! More detailed components of the classified cases of periodontitis poor, or implant therapy are planned proposal of new! If it is not visible, the treatment of gingivitis with the expertise advance. Of periodontitis have been established from the 2017 World Workshop are strongly associated with plaque retention and most... Are exciting times in the past 18 years which led to the developed... Are provided below or descriptive severity this browser for the next time i comment a staging and grading -! Different Types of periodontal disease key to comprehensive oral health and influence the pathogenesis of periodontitis motivation for home. Component of the classification scheme occur in 88 % of adults aged ≥65 years and 50 % of all emergencies... Table 7 as dental biofilm-induced or non-dental biofilm-induced gingival diseases are less common new periodontal classification canada are often of major significance patients... And proposal of a world-class periodontal practice in Fonthill, on diet and smoking are modifiable factors.