Received: 3 February 2022 Revised: 23 April 2022 Accepted: 12 May 2022

DOI: 10.1002/jdd.12964

ORIGINAL ARTICLE

Diagnosis and treatment planning using the 2017

classification of periodontal diseases among
three dental schools
Kaveri K. Gandhi BDS, MDS1 Diksha Katwal DDS, MSD2
Jennifer Chang DDS, MSD3 Steven Blanchard DDS, MS1
Daniel Shin DDS, MSD1 Gerardo Maupome DDS, MSc, PhD4
George J. Eckert MAS5 Vanchit John DDS, MSD1

1 Department of Periodontology, Indiana

University School of Dentistry, Abstract
Indianapolis, Indiana, USA Objectives: The American Academy of Periodontology and the European Fed-
2 Department of Periodontology, eration of Periodontology developed a new classification system for periodontal
University of Louisville School of
Dentistry, Louisville, Kentucky, USA diseases in 2017. The next step in its widespread implementation involves train-
3 Department of Periodontology, ing dental students to improve consistency in clinical decisions. This study
University of Texas School of Dentistry at conducted in 2020–2021 aimed to evaluate knowledge in periodontal diagno-
Houston, Houston, Texas, USA
sis and treatment planning using the new classification, among first, second,
4 Department of Social and Behavioral
Sciences, Richard M. Fairbanks School of
third- and fourth-year dental students at Indiana University School of Den-
Public Health, Indianapolis, Indiana, USA tistry (IUSD), University of Texas School of Dentistry at Houston (UTSD), and
University of Louisville School of Dentistry (ULSD).
5 Department of Biostatistics, Indiana
Methods: A minimum of 20 dental students per class year from each of the three
University School of Dentistry,
Indianapolis, Indiana, USA schools participated. Ten HIPPA de-identified case records and a questionnaire
with a fixed list of answer options, comprising two demographic questions and
Correspondence
two questions on diagnosis and treatment planning of each case, were presented
Vanchit John, DDS, MSD, Department of
Periodontology, Indiana University School to the participants. A group of three board-certified periodontists established the
of Dentistry, 1121 W Michigan St, answers for all cases which were used to score the appropriateness of diagnosis
Indianapolis, IN 46202, USA.
Email: [email protected]
and treatment planning among the participants.
Results: A total of 263 students participated. Overall, 22.6% of IUSD responses,
Funding information 25.2% of UTSD, and 27.6% of ULSD responses were correct for diagnosis (no statis-
the Indiana University School of Dentistry
Graduate Student Research Fund tically significant differences). For the treatment plan, 64.9% of IUSD responses,
66.2% of UTSD, and 68.9% of ULSD responses were correct (no statistically
significant differences).
Conclusion: Based on the findings from our study, we suggest that additional
training be considered to improve the understanding of the 2017 classification of
periodontal and peri-implant diseases among dental students.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2022 The Authors. Journal of Dental Education published by Wiley Periodicals LLC on behalf of American Dental Education Association.

J Dent Educ. 2022;86:1521–1528. wileyonlinelibrary.com/journal/jdd 1521

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1522 GANDHI et al.

KEYWORDS
classification, dental education, diagnosis, periodontal disease, treatment plan

1 INTRODUCTION odontology webinars. These webinars aimed at explaining

the contents of the four working groups that drew up the
A classification scheme is necessary for clinicians and design of the new classification system for UK dentists and
scientists to diagnose and treat patients and investigate dental hygienists on the new classification.5 This type of
the etiology, pathogenesis, and treatment of periodontal effort is commendable because the integration of informa-
diseases.1 Common classification systems also provide a tion for determining the stage and grade of periodontitis
common language for clear communication between clin- may appear challenging in the beginning. Additionally, as
icians, patients, and researchers.2 The classification of there are several subjective factors that go into formulat-
periodontal disease has been revised four times (1977, 1986, ing a periodontal diagnosis and treatment plan; there is a
1999, and 2017) since it was first proposed at the 1966 World high chance of variability in clinical decision making, espe-
Workshop of Periodontics.2 The American Academy of cially with the many changes from the 1999 classification.
Periodontology (AAP) and the European Federation of The next important step in the widespread implementation
Periodontology (EFP) 2017 used several review papers and of the new classification system should therefore involve
consensus reports to develop a new classification system educational plans and training of dental students. Con-
for periodontal diseases. The extensive discussion between sistency in clinical decision-making is necessary for both
reviewers and workgroups led to the release of an introduc- teaching effectiveness and reliable assessment of student
tory paper in June 2018 presenting the new classification performance.7
system.1 This new classification is a dynamic system that Such consistency has been a key point of interest at
incorporates emerging advances in clinical and biological Indiana University School of Dentistry (IUSD) in the
knowledge, such as tissue and chemical biomarkers, to Department of Periodontology. The department holds
diagnose periodontitis.3 monthly consensus training meetings for periodontics res-
The 1999 classification classified periodontitis into four idents and faculty members to help maintain consistency
types: 1) chronic periodontitis, 2) aggressive periodontitis, while teaching pre-doctoral students.8 This attention to
3) necrotizing ulcerative periodontitis, and 4) periodontitis calibration started in 2013 when John et al. measured vari-
as a manifestation of systemic disease.3 The 2017 classifica- ations in periodontal diagnosis and treatment planning
tion eliminated aggressive periodontitis and introduced a of pre-doctoral periodontics faculty members. Periodon-
staging and grading system to diagnose periodontitis. The tal faculty members underwent consensus training as part
staging/grading system captures two important patient of the department calibration and their clinical perfor-
elements: history of periodontal disease, which is mea- mance was compared with those of third- and fourth-year
sured as clinical attachment loss and bone loss; and rate dental students. Agreement among faculty members and
of disease progression, which predicts the future risk of agreement among students was relatively low, for both
disease progression in the absence of treatment and con- diagnosis and treatment planning.9 In a follow-up study,
trol of risk factors.4 Other important changes included Lane et al. compared the level of calibration in diagno-
a definition of periodontal health, recognition of peri- sis and treatment planning of periodontal clinical cases
implant diseases, and introduction of new terms including among dental students at three schools. These included
supracrestal tissue attachment, traumatic occlusal force, IUSD, Marquette University School of Dentistry, and West
and gingival/periodontal phenotype.5 The 2017 classifica- Virginia University School of Dentistry. Students at IUSD
tion system also included for the first-time definitions had higher agreement in diagnosis and treatment planning
of patients with an intact periodontium, those with a than the Marquette University students and the West Vir-
reduced periodontium due to periodontitis, and those ginia University students,8 attributable to the calibration
with a reduced periodontium due to causes other than program.
periodontitis.6 In 2018, Marlow et al. compared diagnosis and treatment
One of the aims of the 2017 World Workshop was to plans among different groups using case-based clinical
design a classification system that could be implemented scenarios. The groups included full-time and part-time
in general dental practice, where over 95% of periodon- periodontology faculty at IUSD, full-time and part-
tal disease is diagnosed and managed.4 One example of time general practice faculty, full-time periodontists in pri-
such dissemination effort was the British Society of Peri- vate practice, and full-time general practitioners. The goal
 19307837, 2022, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jdd.12964 by Nat Prov Indonesia, Wiley Online Library on [10/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
GANDHI et al. 1523

was to evaluate if calibration sessions improved the diag- during consensus training sessions conducted in the Grad-
nosis and treatment planning ability of the group. The uate Periodontics Department at IUSD in the past and
authors found that the calibrated periodontal faculty had an additional 5 min to allow data entry in the computer.
a better agreement and more correct responses for diag- Thus, a total of approximately 100 min was needed to com-
noses and treatment plans than the other three groups in plete the questionnaire. Study participants were requested
the study.10 to participate in the survey on a desktop or laptop com-
Our present study builds upon those previous stud- puter to avoid image distortion and were encouraged
ies and is a part of the ongoing calibration studies in to minimize noise and devote complete attention to the
the IUSD Department of Periodontology. The aim of the survey.
present study was to evaluate the level of knowledge in The cases included were acquired from the archived
periodontal/peri-implant diagnosis and treatment plan- repository of the principal investigator. All cases included
ning using the 2017 AAP/EFP classification among first, the medical and dental history, complete periodontal
second, third- and fourth-year dental students (D1 through chart, full mouth radiographic series, and intraoral pho-
D4) of 3 dental schools. These were the IUSD, Univer- tographs.
sity of Texas School of Dentistry at Houston (UTSD), and The level of knowledge of the new classification system
University of Louisville School of Dentistry (ULSD). was expected to vary according to the year of education
the student was in at the time of the study. Accordingly, it
stands to reason that D1 students will have less experience
2 MATERIALS AND METHODS and knowledge than D2 students who will have less experi-
ence and knowledge than D3 students, and so on. Students’
Ethical approval (IU IRB #2004128486) was obtained. No access to the new classification system was ensured by
identifiable information of participants, except the disclo- offering relevant information for them to familiarize them-
sure of their status as D1, D2, D3, or D4 dental students, selves with the classification system. This was provided by
was collected. way of access to PowerPoint presentations used at their
respective institutions.
2.1 Recruitment for the study A group of three board-certified periodontists estab-
lished the diagnosis and treatment planning for all
The study recruited a minimum of 20 dental students from included cases. These consensus diagnoses and treatment
each class at all three schools. Potential participants were plans (gold standards) were used to score the appro-
recruited via email requests from a staff member who was priateness of diagnosis and treatment planning of the
neither involved in the study nor the clinical training of participants.
students. Study participation was voluntary, and refusal to
participate involved no penalty.
2.3 Statistics and data analysis

2.2 Study design and procedure With a sample size of a minimum of 20 students per class
year from each school, and with 10 cases evaluated per stu-
Ten HIPAA de-identified case records were presented to dent, the study was designed to have 80% power to detect
the participants via an online survey, encompassing a a difference in the percentage of correct responses of 20%
fixed list of answer options: two demographic questions or less between two classes of students or between two
and two questions on the diagnosis and treatment plan- schools, assuming a two-sided 5% significance level for
ning of each case. Question 1 collected information about each test, no interaction between class year and school,
the participant’s current year in dental training. Question and within-student correlation of at most 0.8, based on a
2 asked about the participant’s prior dental experience, generalized linear mixed-effects model for a binary out-
such as dental hygiene, dental assistant, and/or being a come with a logit link. Diagnosis and treatment planning
foreign-trained dentist. Questions 3 and 4 sought the par- responses were tabulated by school and class year for
ticipant’s response to an accompanying case scenario in each case. The percentages of correct diagnosis and treat-
periodontal diagnosis using 2017 AAP/EFP classification ment planning responses were tabulated by school and
and treatment planning. All participants have distributed class year for each case and across all cases. General-
the new periodontal classification scheme to aid in answer- ized linear mixed-effects models were used to examine
ing Questions 3 and 4. For each case, the maximum time the effects of class year and school on the percentage of
allotted to a participant to respond was 10 min. This was correct diagnosis and treatment planning responses. This
based on the estimate of a 5-min response time observed model is an extension of a logistic regression model that
 19307837, 2022, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jdd.12964 by Nat Prov Indonesia, Wiley Online Library on [10/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1524 GANDHI et al.

TA B L E 1 Number of responses and past dental experience

Past dental experience
Dental Dental Foreign-trained
Schools Responses # Assistant Hygienist Dentist None
IUSD
D1 24 7 1 0 16
D2 20 2 1 4 13
D3 23 0 0 9 14
D4 22 2 1 3 16
ULSD
D1 22 4 2 0 16
D2 22 5 0 0 17
D3 24 4 0 0 20
D4 24 3 0 0 21
UTSD
D1 20 3 0 0 17
D2 20 6 0 0 14
D3 22 4 0 0 18
D4 20 3 0 0 17
Total 263 43 (16.3%) 5 (6.6%) 16 (6.6%) 199 (75.7%)

includes random effects to account for correlation among T A B L E 2 Overall descriptive statistics for the number of
responses for multiple cases evaluated by each student correct and incorrect responses
and correlation among responses for multiple students Variable: diagnosis n (%)
evaluating each case. Chi-square tests were used to per- Incorrect responses 1968 (74.8%)
form secondary analyses to compare the distributions of Correct responses 662 (25.2%)
the diagnosis and treatment planning responses between Variable: Treatment
schools and between class years for each case. Addi-
Incorrect responses 875 (33.3%)
tional secondary analysis used multi-rater kappa statistics
Correct responses 1755 (66.7%)
to assess the agreement for the diagnosis and treatment
responses among the students within each class for each
school. The kappa and its standard error were used to cal- TA B L E 3 Descriptive statistics of each school
culate 95% confidence intervals as well as to compare the Variable IUSD, n (%) ULSD, n (%) UTSD, n (%)
kappas between classes and between schools. A 5% signifi-
Diagnosis
cance level was used for all tests. All the analysis was done
Incorrect 689 (77.4%) 666 (72.4%) 613 (74.8%)
using SAS version 9.4 (SAS Institute, Inc., Cary, NC).
Correct 201 (22.6%) 254 (27.6%) 207 (25.2%)
Treatment
3 RESULTS Incorrect 312 (35.1%) 286 (31.1%) 277 (33.8%)
Correct 578 (64.9%) 634 (68.9%) 543 (66.2%)
A total of 263 students from the three schools participated
in the study (Table 1). Forty-three (16.3%) students reported
previous dental assisting experience, five (2%) had previ- responses matched the diagnosis and were consistent
ous experience as a dental hygienist, and 16 (6.6%) were with the consensus diagnosis that had been established
foreign-trained dentists (Table 1). (Table 3). None of the comparisons between schools
reached statistical significance (Table 5). Table 4 presents
3.1 Periodontal diagnosis the comparisons across year classes of students. The per-
responses/question 3 centages of correct answers were significantly higher in
D2 compared to D1, D3, and D4 compared to D1 and D2
Overall, only 25.2% of the responses for the diagnosis (Table 5). However, the difference between D3 and D4 was
matched the gold standard (Table 2): 22.6% of IUSD not significant (Table 5). Kappa values for school agree-
responses, 25.2% of UTSD responses, and 27.6% of ULSD ment and the class agreement were low, ranging between
 19307837, 2022, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jdd.12964 by Nat Prov Indonesia, Wiley Online Library on [10/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
GANDHI et al. 1525

0.03 and 0.25, thus indicating poor agreement in diagnosis

68 (34%)
132 (66%)
(Table 6).

46 (23%)
154 (77%)
UTSD,
n (%)
3.2 Periodontal treatment plan

69 (28.7%)
171 (71.3%)
responses/question 4

48 (20%)
192 (80%)
ULSD,
n (%)
Overall, 66.7% of the responses to the treatment plan were
correct (Table 2). Note that, 64.9% of IUSD responses, 66.2%

56 (25.5%)
164 (74.5%) of UTSD responses, and 68.9% of ULSD responses were

55 (25%)
165 (75%)
IUSD,

correct for the treatment plan as being consistent with the

n (%)
D4

consensus treatment plan established by the three certified

46 (20.9%) periodontists (Table 3). Differences between schools were
155 (70.5%)
65 (29.5%)

174 (79.1%) not statistically significant (Table 5). Table 4 presents the
UTSD,
n (%)

comparisons across year classes of students. The percent-

age of correct answers was significantly higher in D3 and
D4 compared to D1 and D2 (Table 5). However, the differ-
154 (64.2%)
86 (35.8%)

44 (18.3%)
196 (81.7%)

ence between D1 and D2 and the difference between D3

ULSD,
n (%)

and D4 were not significant (Table 5). Kappas for school

agreement and class agreement was low, ranging between
0.06 and 0.53, thus indicating poor to a fair agreement in
48 (20.9%)
182 (79.1%)

periodontal treatment plan (Table 6).

69 (30%)
161 (70%)
IUSD,
n (%)
D3

4 DISCUSSION
97 (48.5%)
103 (51.5%)
164 (82%)
36 (18%)
UTSD,

The new classification framework for periodontal dis-

n (%)

ease centers on a multidimensional staging and grading

system.1,11 The presence of many changes in the new
150 (68.2%)
70 (31.8%)

classification system from the 1999 classification may

143 (65%)
77 (35%)
ULSD,

cause considerable variations in the diagnosis and treat-

n (%)

ment planning of periodontal disease. Although consensus

training programs for dental students have been intro-
duced, consistency in clinical decision-making among
98 (49%)
172 (86%)
28 (14%)

102 (51%)

dental students is less than ideal.12 To our knowledge,

IUSD,
n (%)
Descriptive statistics for each year of each school

no studies have examined the consistency in clinical

D2

decision-making among dental students using the new

classification of periodontal disease.
88 (44%)
112 (56%)
38 (19%)
162 (81%)

Multiple contributing factors to periodontal diseases,

UTSD,
n (%)

such as smoking and diabetes, often exacerbate variabil-

ity in periodontal diagnosis and treatment planning.9,10,11
In our study, the percentage of correct responses for
96 (43.6%)
124 (56.4%)
198 (90%)
22 (10%)

periodontal diagnosis was low compared to treatment

ULSD,
n (%)

planning. The lower rate of correct responses in periodon-

tal diagnosis could be attributed to the new classification
being more extensive and detailed, compared to the pre-
111 (46.3%)
129 (53.7%)
48 (20%)
192 (80%)

vious 1999 classification.13 It may therefore become more

IUSD,
n (%)

challenging for dental students to consider all the fac-

D1

tors involved in an accurate periodontal diagnosis.14 It

Incorrect
Incorrect

seemed counterintuitive to find that the percentage of cor-

TA B L E 4

Treatment

Correct
Correct
Diagnosis
Variable

rect responses for periodontal treatment plans was higher

than for periodontal diagnosis. Such inconsistencies in
the under-or overestimation of the disease have been
 19307837, 2022, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jdd.12964 by Nat Prov Indonesia, Wiley Online Library on [10/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1526 GANDHI et al.

TA B L E 5 Analysis of variance (ANOVA) for the correctness of diagnosis and treatment answers
ANOVA for correctness for diagnosis answers
Between schools
School Difference Standard error p-value Lower CI Upper CI
IUSD versus ULSD −0.27 0.16 0.09 −0.59 0.04
IUSD versus UTSD −0.14 0.17 0.38 −0.47 0.184
ULSD versus UTSD 0.13 0.16 0.43 −0.19 0.45
Between the year of study
Year of study
D1 versus D2 −0.43 0.20 0.034 −0.82 −0.03
D1 versus D3 −0.98 0.194 <0.01 −1.35 −0.61
D1 versus D4 −0.84 0.194 <0.01 −1.21 −0.46
D2 versus D3 −0.56 0.19 <0.01 −0.92 −0.19
D2 versus D4 −0.41 0.19 0.034 −0.78 −0.04
D3 versus D4 0.14 0.18 0.42 −0.21 0.494
ANOVA for correctness for treatment answers
Between schools
School
IUSD versus ULSD −0.20 0.17 0.25 −0.53 0.14
IUSD versus UTSD −0.054 0.18 0.76 −0.40 0.29
ULSD versus UTSD 0.11 0.18 0.41 −0.20 0.49
Between the year of study
Year of study
D1 versus D2 −0.30 0.20 0.13 −0.69 0.09
D1 versus D3 −1.57 0.20 <0.01 −1.97 −1.18
D1 versus D4 −1.38 0.20 <0.01 −1.78 −0.99
D2 versus D3 −1.27 0.20 <0.01 −1.67 −0.87
D2 versus D4 −1.08 0.20 <0.01 −1.48 −0.68
D3 versus D4 0.19 0.21 0.36 −0.21 0.594

previously reported.8 Many patients with periodontal dis- and grading of the disease are important for the compre-
ease, irrespective of the stage of the disease, respond well to hensive management of periodontal disease, the presence
mechanical therapy and chemical plaque control.10 There- of overlapping criteria may increase the difficulty for den-
fore, partial commonality in treatment protocols could tal students to differentiate between stages III and IV.17
have resulted in higher accuracy in treatment planning Similarly, grading of the disease (which determines the
compared to periodontal diagnosis. In general, clinicians rate of disease progression based on the patient’s charac-
should not argue over a diagnosis if the treatment pro- teristics and risk factors involved) becomes more complex
tocols proposed are the same irrespective of the disease to calculate as it is based on attachment loss/bone loss
condition.15 However, accurate diagnosis may lead to bet- over 5 years.13 Although additional guidance and practical
ter health outcomes as treatment objectives are better tips to apply different criteria and how to calculate clin-
defined,16 as well as supporting better communication ical attachment loss and tooth loss are provided in the
between clinicians, patients, and insurance companies.8 guidelines, training dental students to use the guidelines
No significant differences were reported among stu- for staging and grading the disease is essential.12 An eval-
dents of all three dental schools in terms of their correct uation of the consistency and accuracy of the periodontitis
responses on periodontal diagnosis or treatment planning. staging and grading classification system among periodon-
All three schools were in more agreement on treatment tal experts, general dentists, and undergraduate dental
plans than diagnoses. As suggested above, variability in students found that general dentists performed poorly
diagnosis could be attributed to the inclusion of newer compared to periodontists and dental students.12 Also, all
parameters such as staging and grading of periodontal dis- participants performed better in the staging component
eases in the new classification. Although accurate staging than in the grading portion. These findings suggested that
 19307837, 2022, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jdd.12964 by Nat Prov Indonesia, Wiley Online Library on [10/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
GANDHI et al. 1527

TA B L E 6 Multi-rater Kappa’s by school and year of study for diagnosis and treatment
Diagnosis
Year and school Kappa SE p-value Lower CL Upper CL
D1, IUSD 0.13 0.01 <0.01 0.03 0.22
D2, IUSD 0.07 0.01 <0.01 0.01 0.12
D3, IUSD 0.20 0.01 <0.01 0.08 0.33
D4, IUSD 0.18 0.01 <0.01 0.07 0.29
D1, ULSD 0.03 0.01 <0.01 0.01 0.05
D2, ULSD 0.18 0.01 <0.01 0.12 0.24
D3, ULSD 0.25 0.01 <0.01 0.13 0.38
D4, ULSD 0.19 0.01 <0.01 0.10 0.28
D1, UTSD 0.05 0.01 <0.01 0.03 0.08
D2, UTSD 0.06 0.01 <0.01 0.02 0.10
D3, UTSD 0.18 0.01 <0.01 0.09 0.28
D4, UTSD 0.24 0.01 <0.01 0.15 0.33
Treatment
Year and school
D1, IUSD 0.13 0.01 <0.01 0.002 0.25
D2, IUSD 0.14 0.01 <0.01 0.05 0.23
D3, IUSD 0.23 0.01 <0.01 0.04 0.41
D4, IUSD 0.48 0.01 <0.01 0.22 0.74
D1, ULSD 0.06 0.01 <0.01 0.02 0.09
D2, ULSD 0.14 0.01 <0.01 −0.02 0.29
D3, ULSD 0.53 0.01 <0.01 0.24 0.81
D4, ULSD 0.37 0.01 <0.01 0.17 0.57
D1, UTSD 0.07 0.01 <0.01 −0.01 0.15
D2, UTSD 0.14 0.01 <0.01 0.04 0.23
D3, UTSD 0.38 0.01 <0.01 0.2 0.56
D4, UTSD 0.43 0.01 <0.01 0.24 0.63

additional training is essential to improve the application was conducted. Conducting calibration programs helps to
of the new classification system. Another recent study maintain standardization.18 Calibrations in dental educa-
determined the degree of consistency in staging, grading, tion not only ensure that a group of individuals can assess
and extent among individuals trained to manage severe the same situation consistently and validly but also helps to
periodontitis cases and with prior exposure to the new improve students learning abilities and in developing their
periodontitis classification. They found that agreement diagnostic and clinical skills.8 Innovative approaches such
between raters and gold-standard panel was staging 76.6%, as, for example, the blended learning approach (combina-
grading 82%, and extent 84.8%. In six of nine cases included tion of online and face-to-face instructions) compared to
in the study, 77%–99% of raters consistently agreed with traditional means (face to face instructions), suggested that
the gold-standard panel, which is in contrast to the lower there is ample room to expand familiarity and proficiency
agreements observed in our study. However, our result can- in training students in the new periodontal classification.19
not be directly compared to this study, due to differences in Given the higher clinical experience of D4 students in
study design and population.11 treating periodontal disease patients, we would intuitively
A higher percentage of correct periodontal diagnosis expect them to perform better than D3 students. How-
responses were given by IUSD D1 students, ULSD D2 and ever, this was not the case. Moreover, the results of our
D3 students, and UTSD D4 students. In the case of treat- study were not aligned with findings by John et al and
ment planning, UTSD D1 students and ULSD D2, D3, and Lane et al.8,9 John et al. compared the calibration between
D4 students gave a higher percentage of correct responses. predoctoral periodontal faculty and D3- and D4 stu-
Better performance of ULSD students could be associated dents at IUSD using web-based case presentations.9 They
with exposure to training programs for periodontal faculty found higher agreements among D4 students compared
and dental students in the new classification system that to D3 students.9 Lane et al. evaluated the calibration of
 19307837, 2022, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jdd.12964 by Nat Prov Indonesia, Wiley Online Library on [10/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1528 GANDHI et al.

periodontal diagnosis and treatment planning among a reduced periodontium: consensus report of workgroup 1 of
dental students at three dental schools and found that the 2017 World Workshop on the Classification of Periodontal
agreements among D3 students were lower than among and Peri-Implant Diseases and Conditions. J Clin Periodontol.
2018;45(20):S68-s77.
D4 students.8
7. Lanning SK, Pelok SD, Williams BC, et al. Variation in periodon-
Among the strengths of the present study were pro-
tal diagnosis and treatment planning among clinical instructors.
viding dental students with additional new classification J Dent Educ. 2005;69(3):325-337.
system material, and the utilization of real clinical cases. 8. Lane BA, Luepke P, Chaves E, et al. Assessment of the
However, some of our study design features might have calibration of periodontal diagnosis and treatment planning
led to limitations in the research. Potential stress among among dental students at three dental schools. J Dent Educ.
students while answering the questionnaire within a stip- 2015;79(1):16-24.
ulated time frame, and the fact that the questionnaire 9. John V, Lee SJ, Prakasam S, Eckert GJ, Maupome G. Consensus
training: an effective tool to minimize variations in periodon-
sharply focused on a few conditions in closed question
tal diagnosis and treatment planning among dental faculty and
format are possible study limitation. Since this study was students. J Dent Educ. 2013;77(8):1022-1032.
restricted to three specific schools, the results may not be 10. Marlow AK, Hamada Y, Maupome G, Eckert GJ, John V.
generalizable. Periodontal diagnosis and treatment planning among indiana
dental faculty, periodontists, and general practice dentists: a
multi-group comparison. J Dent Educ. 2018;82(3):291-298.
5 CONCLUSION 11. Ravidà A, Travan S, Saleh MHA, et al. Agreement among inter-
national periodontal experts using the 2017 World Workshop
classification of periodontitis. J Periodontol. 2021;92(12):1675-
Overall, all three schools and students were in more
1686.
agreement on treatment plans than the diagnosis of the 12. Marini L, Tonetti MS, Nibali L, et al. The staging and grad-
periodontal conditions. Based on the findings from our ing system in defining periodontitis cases: consistency and
study, we suggest that additional training be considered accuracy amongst periodontal experts, general dentists and
to improve the understanding of the 2017 classification undergraduate students. J Clin Periodontol. 2021;48(2):205-215.
of periodontal and peri-implant diseases among dental 13. Oh SL, Yang JS, Kim YJ. Discrepancies in periodontitis classi-
students. fication among dental practitioners with different educational
backgrounds. BMC Oral Health. 2021;21(1):39.
14. Sutthiboonyapan P, Wang HL, Charatkulangkun O. Flowcharts
AC K N OW L E D G M E N T S
for easy periodontal diagnosis based on the 2018 new periodontal
The authors would like to thank the study respondents classification. Clin Adv Periodontics. 2020;10(3):155-160.
who participated in this project and Dr. Nikola Angelov, 15. Armitage GC, Cullinan MP. Comparison of the clinical fea-
Department of Periodontics, UTSD for his support in data tures of chronic and aggressive periodontitis. Periodontol 2000.
gathering. 2010;53:12-27.
16. Abou-Arraj RV, Kaur M, Alkhoury S, Swain TA, Geurs NC,
ORCID Souccar NM. The new periodontal disease classification: level
of agreement on diagnoses and treatment planning at var-
Kaveri K. Gandhi BDS, MDS https://orcid.org/0000-
ious dental education levels. J Dent Educ. 2021;85(10):1627-
0002-2691-9168 1639.
17. Siqueira R, Andrade N, Yu SH, Kornman KS, Wang HL. Chal-
REFERENCES lenges and decision making for the classification of two complex
1. Caton JG, Armitage G, Berglundh T, et al. A new classifi- periodontal cases. Clin Adv Periodontics. 2021;11(2):103-110.
cation scheme for periodontal and peri-implant diseases and 18. Garland KV, Newell KJ. Dental hygiene faculty calibration in the
conditions – introduction and key changes from the 1999 evaluation of calculus detection. J Dent Educ. 2009;73(3):383-389.
classification. J Periodontol. 2018;89(1):S1-S8. 19. Huynh AV, Latimer JM, Daubert DM, Roberts FA. Integration
2. Highfield J. Diagnosis and classification of periodontal disease. of a new classification scheme for periodontal and peri-implant
Aust Dent J. 2009;54(1):S11-S26. diseases through blended learning. J Dent Educ. 2021;86(1):51-56.
3. Armitage GC. Development of a classification system for peri-
odontal diseases and conditions. Ann Periodontol. 1999;4(1):1-6.
4. Dietrich T, Ower P, Tank M, et al. Periodontal diagnosis in the
context of the 2017 classification system of periodontal diseases How to cite this article: Gandhi KK, Katwal D,
and conditions – implementation in clinical practice. Br Dent J. Chang J, et al. Diagnosis and treatment planning
2019;226(1):16-22. using the 2017 classification of periodontal diseases
5. Dorri M. Periodontal diseases: new classification for periodontal among three dental schools. J Dent Educ.
diseases. Br Dent J. 2018;225(8):686.
2022;86:1521–1528. https://doi.org/10.1002/jdd.12964
6. Chapple ILC, Mealey BL, Van Dyke TE, et al. Periodontal
health and gingival diseases and conditions on an intact and