Discussion
tooth mobility, periodontitis, dentitions, bone loss
BONE LOSS, PERIODONTITIS, DISEASE, DIABETES MELLITUS, MINOR, SECONDARY, PERIODONTAL DISEASE, REGRESSION
The implementation of a new classification often poses a great challenge not only for clinical practice but also in education, especially if the previous classification has been valid for almost two decades [Several research groups have already investigated the diagnostic accuracy of differently experienced clinicians using the current classification. Regarding consistency and accuracy among periodontal experts, general dentists, and undergraduate students, Marini et al. showed moderate consistency of the differently experienced examiners to the gold standard, while accuracy was almost perfect for staging and moderate for grading [Therefore, the objective of this four-arm randomized controlled study was to evaluate the influence of these algorithms on diagnostic accuracy in differently experienced undergraduate dental students.In general, the presented results provide evidence for the positive influence of these decision-making algorithms on the diagnostic quality and accuracy of differently experienced students showing highly significant differences especially in terms of staging and grading. In addition, subjective perceptions regarding helpfulness, understanding, and desire for implementation into the existing dental curriculum were overwhelmingly positive.Comparison of less experienced students with more experienced showed significant differences in diagnostic accuracy considering staging and grading. This clearly verifies a difference between the two groups with regard to their experience and their basic knowledge of periodontal diagnostics, confirming the adequacy of the chosen cohorts.Besides significant and highly significant differences between study groups and controls in both more and less experienced students, proving the advantages of the algorithms and their effectiveness alike, logistic regression analysis revealed a four times higher probability of a correct staging and an even 30 times higher chance for a correct grading when using the algorithms.Concerning these results and the aforementioned under- and overestimation in staging compared to the sample diagnoses, an evaluation of the criteria of staging as proposed by the current classification seems reasonable. Herein, CAL is considered the primary criteria for staging. RBL on the other hand is recommended only secondary in the absence of measurable CAL or in mixed dentitions where detection of CAL is impaired [Besides these anatomical limitations regarding the reference point of CAL measurement, misdiagnosis might occur in subjects previously treated for periodontitis. It is commonly accepted that following successful conventional therapy of periodontal lesions, a long junctional epithelium is formed along the root surface leading to reduction of probing depths [Therefore, the sole use of CAL to describe severity of periodontal destruction may be misleading, resulting in under-estimation of actual loss of periodontal attachment in previously treated patients when using the current classification of periodontal disease.These shortcomings of the solely use of CAL to determine periodontal stage may have led to the poorer results in accuracy of the control groups in the present study, considering that the matrix published within the classification primary recommends CAL to stage. Hence, especially the under-estimation of C1 that presented with low levels of CAL and at the same time high levels of RBL may be explained. On the other hand, the algorithms used by the study groups emphasize the primary use of RBL when initially classify a periodontitis case (step 1 [Furthermore, besides CAL or RBL, the role and relative importance of complexity of disease for the process of staging determined by probing depths, furcation status, tooth mobility, type of bone loss, extent of ridge defect, masticatory (dys)-function, and missing teeth or number of opposing pairs as proposed by the classification is not clarified by the staging matrix.In contrast, the influence of complexity is embedded in the sequential structure of the decision-making algorithms, which might have facilitated the staging process in the study groups, bearing in mind that the cases differed considerably in complexity despite being diagnosed with the same stage.Concerning grading, the results revealed an even higher spread when comparing diagnostic accuracy of the study groups and their controls. Again, the sequential structure of the algorithms seems to play a crucial role, since a weighting of the primary criteria as described in the classification cannot be withdrawn from the matrix, but from the algorithms. None of the clinical cases presented with a history of smoking or diabetes mellitus; therefore, grade modifiers were not applicable. Nevertheless, it has to be stated that following the algorithms clearly facilitates the process weighting the different criteria of grading.Besides the advantages resulting from the use of the algorithms, it has to be highlighted that the significant differences in grading might also be explained by the fact that, compared to the former classification, grading is a completely new diagnostic modality, including thresholds of progression. While the severity of periodontal disease has already been described in the 1999 classification [On the other hand, the decision-making algorithms seemed to have no influence on the users’ choice regarding the extent of periodontal disease. This finding is most likely to be justified by the fact that unlike the newly developed staging and grading system in terms of extent, only minor changes have been made to the 1999 classification.Having compared the diagnostic accuracy of only two representative cases can be considered a limitation of this study, also because it examines the influence of the decision-making algorithms exclusively on the diagnosis of periodontitis, not including the other possible diagnoses of the current classification. A statement on the impact of the decision-making algorithms on the accuracy in detecting periodontal and peri-implant health [Further research in lager scales and of differently experienced clinicians including general and specialized dentist is necessary to evaluate the decision-making algorithms as an everyday tool in periodontal patients.