definición y clasificación de la periodontitis - un nuevo paradigma.pdf

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Focus

Dening and classifying periodontitis:

need for a paradigm shift?

Vibeke Baelum, Rodrigo LopezDepartment of Community Oral Health andPediatric Dentistry, Faculty of Health Sciences,University of Aarhus, Aarhus, Denmark

Almost 40 yr ago, S cherp (1) noted that Discussions of periodontal disease commonly begin with the tacitassumption that all participants are considering the sameentity. Since the varieties of periodontal diseases arealmost limitless, depending on one s taste for subclassi-cation, this unqualied usage often leads to fruitless

semantic misunderstandings. This quote epitomizes aproblem that remains prominent in periodontology: thelack of a unied and joint understanding of the diseasesunder study. While some of the disagreements mayreect the adherence to different disease paradigms (2),variation may be discerned even among proponents of the same paradigm. There is thus a great reluctance tospecify the clinical features that document periodontitisany further than this example shows: These [features]include probing pocket depth, gingival recession, pro-bing attachment level, gingival width, furcation involve-ment, tooth mobility, and radiographically determinedbone changes (3). As a result, the literature is charac-terized by the use of a vast array of different criteria forthe diagnosis of periodontitis (2, 4), and this has ham-pered attempts to review the literature and synthesizecurrent knowledge.

Further evidence that S cherp s statement still holdsmay be found in the numerous proposals published forthe classication of periodontitis. Just considering thepast 20 yr, at least 10 different periodontitis classica-tions have been proposed and published (513). Eventhough some of these classications (6, 11) have beenadvocated by scientic societies their survival time has,nevertheless, been quite short.

We submit that the large number of periodontitisclassications proposed and the large variability of the

methods used to record and document periodontitisindicate that the basis for the denition and classicationof periodontitis needs to be carefully reconsidered. Weargue that the problems largely result from the implicitadherence to an essentialistic disease concept (14, 15).We also argue that the driving force underlying the

many periodontitis classications is an unjustiedbelief in the existence of a diagnostic truth for perio-dontitis. We thus submit that a nominalistic approach(14, 15) to the denition of periodontitis and therecognition of periodontitis as a syndromically deneddisease will be helpful in bringing periodontology for-ward towards a unied and common understanding of periodontitis.

Essentialism in periodontitis definitionsAlthough the tacit assumption (1) of a common under-standing of periodontitis has frequently been invoked,explicit disease denitions have been offered. In the mid-1960s, when the gingivitis-periodontitis continuum wascentral to the dominant periodontal disease paradigm(2), Scherp (1) dened the most common form of periodontal disease as an inammatory process affectingone or more of the supporting tissues of the teeth thegingival tissue, the periodontal membrane, and thealveolar bone . In the early 1980s, P age & Schroeder (5)dened periodontitis as an inammatory disease of theperiodontium characterized by the presence of (a) peri-odontal pocket(s) and active bone resorption with acuteinammation . Most recently, the American Academy of Periodontology (AAP) (16) dened chronic periodontitis

Baelum V, Lopez R. Dening and classifying periodontitis: need for a paradigm shift?.Eur J Oral Sci 2003; 111: 26. Eur J Oral Sci, 2003

The past two decades have witnessed a large number of proposals for the classicationof periodontitis. These proposals are all founded in an essentialistic disease concept,according to which periodontitis is a link between the causes and the signs andsymptoms of periodontitis. Essentialistic denitions are necessarily rather impreciseand thereby subject to multiple interpretations. Consequently, it remains unknown towhat extent current knowledge regarding different forms of periodontitis is based onthe same type of patients. However, periodontitis is a syndrome, the clinical mani-festations of which may come in all sizes. Thereby, periodontitis has no diagnostictruth, just as there is no natural basis for a sharp distinction between health anddisease or between different forms of periodontitis. Recognition of these facts andadoption of a nominalistic approach to the denition of periodontitis is needed toprovide a rational framework for the development of a classication system that meetsthe needs of both clinicians and scientists.

Vibeke Baelum, Department of CommunityOral Health and Pediatric Dentistry,Faculty of Health Sciences,University of Aarhus,Vennelyst Boulevard 9, DK ) 8000 Aarhus C,Denmark

Telefax: +4586136550

E-mail: [email protected] words: classification; diagnosis; disease;periodontitis; syndrome

Accepted for publication November 2002

Eur J Oral Sci 2003; 111: 26Printed in UK. All rights reserved

Copyright Eur J Oral Sci 2003

European Journal of Oral Sciences

ISSN 0909-8836


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as an infectious disease resulting in inammation withinthe supporting tissues of the teeth, progressive attach-ment and bone loss characterized by pocket formationand/or recession of the gingiva .

The wording of these disease denitions provides a keyhint to the reasons why none of them have translatedinto uniform and operational criteria for the presence of

periodontal disease/periodontitis/chronic periodontitis.All three denitions reect a disease concept that hasbeen termed essentialistic or demonic because it holdsthat a given disease has an independent existence (14, 15).A denition which begins Periodontitis is an inamma-tory disease of the periodontium implies a priori theexistence of something that can be identied as perio-dontitis. When the denition subsequently states that thedisease results in attachment and bone loss and ischaracterized by the presence of periodontal pockets , itappears as knowledge that periodontitis is an essencethat may produce the symptoms pockets and bone loss.The core theme of the essentialistic disease concept hasbeen summarized by S cadding (15): Essentialist ideasabout disease are implicit in colloquial speech. Diseasesare regarded as causes of illness. The doctor s skill con-sists in identifying the causal disease and then prescribingthe treatment. However, the essentialistic disease con-cept leads to circular reasoning (15): The essentialisthankering after a unied concept of disease as a class of agents causing illness is mistaken and misleading forseveral good reasons: many diseases remain of unknowncause; known causes are of diverse types; causation maybe complex, with interplay of several factors, intrinsicand extrinsic; and, more generally, an effect the disease should not be confused with its own cause .

The essentialistic reasoning is Causes Disease

Signs and Symptoms. The periodontitis denitions pre-viously cited illustrate how an essentialistic belief in theexistence of a disease essence that links the causes andthe signs and symptoms results in non-operational peri-odontitis denitions. Rigid application of the denitionprovided by S cherp (1) will result in everybody beingconsidered a case. The denition provided by P age &Schroeder (5) is non-operational because features suchas active bone resorption and acute inammation haveno practically observable and measurable expressions.Finally, the AAP denition (16) is non-operationalbecause progressive attachment loss has no practicalexpression at a given point in time (assessment of pro-gression necessitates two observations spaced in time),and because very few adults are completely free fromsigns of attachment loss, bone loss, pockets or recession.However, it is precisely the lack of specicity and thehigh level of abstraction inherent in the essentialisticperiodontitis denitions that allow periodontitis to beconstrued as an essential link between the causes and thesigns and symptoms.

Nominalism and periodontitisThe essentialistic disease concept has a counterpart inwhat has been called the nominalistic disease concept

(14, 15, 17). According to this, the term periodontitis is just a term used to label a group of individuals that sharecertain dening characteristics. The name chosen to labelthe group (e.g. periodontitis ) is just a brief statement of the common abnormality by which the particular groupof periodontitis-patients can be identied. Importantly,the disease periodontitis is not restricted to encompass

only those signs and symptoms that are made explicit bythe label (the disease name), but encompasses the wholerange of signs and symptoms that may be observed inperiodontitis-patients . The implications of this are per-haps best understood using an alternative example suchas mitral stenosis , which refers to the complex of symptoms and signs observed in persons with narrowmitral valves and not simply to the narrowed mitralvalve (17). More generally, disease names have beendescribed as no more than a convenient way of statingbriey the endpoint of a diagnostic process that pro-gresses from assessment of symptoms and signs towardsknowledge of causation. They may have gone no fur-ther than recognition of a familiar pattern; they mayhave progressed to detection of underlying disorders of structure or of function; or they may have identiedspecic causes (15).

It is central to the nominalistic disease concept thatdiseases have no existence apart from that of patientswith them (15). The old dictum that there are no dis-eases, only sick people, is thus a core theme. Methodo-logically, nominalistic disease denitions specify diseasebased on observable and measurable phenomena (17)and it is essential to the nominalist disease denition thatthere are norms for these phenomena with which thecharacteristics of the patient can be compared in order toaccept or discard the tentative diagnosis.

The basis for defining diseaseThe use of the term disease in colloquial speech is basedon the comfortable delusion that everyone knows whatit means (17). However, a formal denition is requiredfor use in a scientic context. S cadding (17) has pro-posed the following denition: A disease is the sum of abnormal phenomena displayed by a group of livingorganisms in association with a specied common char-acteristic or set of characteristics by which they differfrom the norm for their species in such a way as to placethem at a biological disadvantage . This denitionnecessitates the establishment of normal standards, andimplies a statistical basis for the assessment of abnor-mality (17), a strategy which is well known from anumber of diagnostic elds (e.g. routine blood tests).Although the term biological disadvantage is necessarilyrather vague, it species that abnormalities may indeedexist which are not disease-related.

Ideally, a nominalistic disease denition describes aset of criteria that are fullled by all persons said to havethe disease, but not fullled by persons that are con-sidered free from the disease (18). This frameworkaccommodates diseases that are anatomically dened,such as breast cancer, diseases that are metabolically or

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physiologically dened, such as arterial hypertension,and diseases that are etiologically dened, such as chol-era (18). However, many disease denitions do not meetthese requirements, and a large number of diseases aredened as syndromes. A simple syndrome is diagnosedwhen a xed combination of clinical signs and symptomsare present simultaneously, while an etiologically or

anatomically dened disease has been excluded as adifferential diagnostic possibility (since syndromes aresubordinate to such diseases) (18). For a composite syn-drome, no single sign or symptom is necessary forthe diagnosis. Well-known examples of composite syn-dromes are rheumatoid arthritis and systemic lupuserythematosus, both of which have explicit dening cri-teria (Table 1). Rheumatoid arthritis is diagnosed whenat least four of seven criteria are simultaneously fullled(19), whereas the diagnosis of systemic lupus erythema-tosus requires the simultaneous presence of at least fourof eleven criteria (Table 1) (20). It follows that twopatients with systemic lupus erythematosus need nothave any signs or symptoms in common, whereas tworheumatoid arthritis patients have a least a single com-mon nding.

Periodontitis is a syndrome that may comein all sizesPeriodontitis is a good example of a syndromicallydened disease (21). Although there is a general agree-ment that the dening characteristics for periodontitisare to be found among the features inamed gingivae,pocket formation, gingival recession, clinical attachmentloss, alveolar bone loss, tooth mobility, and tooth drift

(3, 16), more explicit and commonly accepted deningcriteria for periodontitis have not (as yet) been estab-lished. Moreover, each of these dening characteristicsmay vary considerably between individuals, in terms of both the extent and the severity. M arshall -D ay et al .

(22) noted that signs and symptoms of periodontitis areubiquitous among adults. Beyond the age of 35 yr mostpersons in a population will display signs of periodon-tal destruction (2), and the prevalence of periodontaldestruction in the form of clinical attachment lossapproaches 100% (2). On a population basis, the extent(number of teeth affected) and the severity (degree of

destruction per tooth) increases with increased age,although the distribution of both the extent and theseverity of periodontal signs and symptoms tends to berather skewed in all age-groups (2). These characteristicsnecessarily imply that the idea of a sharp distinctionbetween health and disease is a medical artifact for whichnature, if consulted, provides no support (23). In cor-roboration of this statement, M achtei et al . (24) notedthat none of the attachment or pocket depth levelsconsidered yielded a bi-modal distribution which mightbe compatible with health and disease . Similarly, epi-demiological studies clearly show that the absence orlow severity of clinical attachment loss merges imper-ceptibly into high severity of clinical attachment loss(25).

Essentialism and the clinical problem diagnostic variationAlthough periodontitis appears in all degrees, with lowmerging imperceptibly into high (25), and although noexplicit dening criteria for periodontitis have yet beenestablished, dental practitioners are faced with diagnosticand therapeutic decisions on a daily basis. Diagnosticand therapeutic decisions are yes/no decisions and theclinical management of periodontitis requires unam-

biguous case/non-case labels. While thousands of suchlabels are issued by dental practitioners every day, thereluctance to explicate and formalize the dening criteriafor periodontitis leaves the diagnostic decisions in thehands of the art of dentistry , the likely result of which isdiagnostic variation between practitioners. Such vari-ation is problematic since the diagnosis case/non-case,and hence the decision whether and how to intervene, ismeant to have bearing on the health outcome. Providedthat periodontal therapy is effective, a different diagnosis(e.g. case or non-case) assigned to the same patient willresult in different health outcomes, with the non-casepatient experiencing an inferior health outcome.

In view of the fact that practitioners have to issue case/non-case labels routinely, it should be possible to makeexplicit quantitative statements about the dening char-acteristics for periodontitis. Indeed, the denitions pro-posed by M achtei et al . (24) and by van der Velden(12) represent such explicit quantitative statements,although none of these proposals have gained popu-larity. The continuous nature of periodontitis means thatno matter how carefully chosen, explicit dening criteriawill have elements of arbitrariness (17), just as the de-ning criteria cannot reect some underlying naturaldenition of periodontitis (23), because none exists.However, decisions that are based on a single, commonlyaccepted set of criteria have the potential to be superior

Table 1

Dening criteria for the diagnosis of the composite clinical syndrome rheumatoid arthritis (19) and systemic lupus

erythematosus (20). If four or more symptoms are present,a positive diagnosis may be made

Rheumatoidarthritis

Systemic lupuserythematosus

Morning stiffness Malar rashArthritis of at least

three joint areasDiscoid rash

Arthritis of hand joints PhotosensitivitySymmetric arthritis Oral ulcersRheumatoid nodules ArthritisSerum rheumatoid factor SerositisRadiographic changes Renal symptoms

Neurological symptomsNeurological symptomsImmunological symptomsAntinuclear antibody

All the symptoms are described in more detail in other publi-cations (19, 20).

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definición y clasificación de la periodontitis - un nuevo paradigma.pdf

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