The 2017 American Academy of Periodontology (AAP) staging and grading classification has been the standard for nearly a decade, yet if you walk into 10 general practices, you will find 10 different levels of adoption.
This is not really a knowledge gap; it is a leadership gap. The framework was never the problem. The real challenge is what we do with the information once we have it, because staging and grading were never meant to be a charting exercise. They were meant to drive the treatment plan, the recall interval, and the referral conversation.
After more than 30 years of calibrating dental teams, I can tell you that most practices stage well enough but grade poorly. Below are the three changes I see that make the biggest difference when teams take the framework seriously.
Stop treating grading like paperwork
Kelly Tanner, PhD, RDH.
Staging captures severity. It looks backward at the damage already done through interdental clinical attachment loss (CAL), radiographic bone loss, and tooth loss attributable to periodontitis.
Modern practice management software handles most of the staging automatically. Type in “223," "323," or "545,” and the math takes care of itself in the periodontal chart to calculate CAL.
Grading is fundamentally different.
Grading looks ahead, asking how quickly this disease is progressing and what is driving it. It accounts for the rate of progression, systemic risk factors, and behaviors that accelerate breakdown.
Grading cannot be automated, because it requires a clinician to ask the right questions, and in most practices, those questions are not being asked. The result is that two patients with identical staging walk out of the operatory with identical treatment plans, even when one of them is grade A and the other is grade C.
Two patients can present with similar radiographic bone loss and the same probing depths. Still, one is in stable maintenance territory, and the other is heading for tooth loss within three years if nothing changes. Only grading tells you which is which.
If your practice charts the stage but skips the grade, you are essentially treating every patient as if they were average. The patient on the high end of the risk curve does not receive the closer recall or earlier referral they need, and the patient on the low end is overtreated. Grading is what individualizes the plan.
Make the HbA1c test a permanent part of the periodontal chart
For a patient with diabetes, a hemoglobin A1c at or above 7% accelerates periodontal breakdown and impairs healing after treatment. That number does not change the stage, but it dramatically changes the grade, and the grade changes everything downstream. It changes the recall interval, the adjunct decision, and the conversation we should be having with the patient's endocrinologist or primary care physician.
A stage III patient with a well-controlled A1c is fundamentally different from a stage III patient at 8.2, even though their charts look identical. They need different timelines, different adjuncts, and different referrals. Treating them as if they were the same patient is exactly the drift the grading system was designed to prevent.
In the practices I coach, the change is operational, not philosophical. The medical history form needs a place to record the most recent A1c value. The hygienist should be authorized to request it, and when the patient does not know their number, the practice needs a written protocol for following up with their physician before the next periodontal maintenance appointment.
Some forward-leaning practices have started offering chairside A1c testing for diabetic patients, particularly those whose recall intervals are tighter than their physician visits. That is where the periodontal chart can become a meaningful contributor to the patient's overall health record rather than a standalone document.
Read the lamina dura, not just the crater
Most clinicians look for the obvious signs of bone loss on radiographs: the crater, the cupped defect, and the horizontal loss between teeth. Those are real findings, but they are also late findings. By the time bone loss is visible on a film, roughly 25% of the bone is gone. That is a lagging indicator at best.
The earlier signal is the lamina dura, that thin, opaque band outlining the root. It is one of the first structures to fade when periodontal disease becomes active at a site.
When the lamina dura starts to disappear, the site is no longer healthy, even if the crestal bone still looks intact. Combine a fading lamina dura with a widened periodontal ligament, and you are likely looking at occlusal forces contributing to a process we have been calling biofilm-driven. Both can be true, and both need to be charted.
Calibrating the team to look for the lamina dura on every routine bitewing is one of the highest-yield changes I make in coaching engagements. It catches the patient who is between stages before they tip over, and it gives the grade a defensible radiographic basis.
3 changes, no new equipment
A dental practice that wants the 2017 AAP framework actually to change patient outcomes does not need new instruments, new software, or longer appointments. It needs three things, and they cost nothing.
Treat grading as a clinical decision, not a documentation field. Make the HbA1c a permanent part of the periodontal chart, and let it shape the plan the way it shapes the disease. Then train the team to read the lamina dura on every bitewing so the radiograph informs the grade rather than confirming it months too late. These are the changes that move the AAP framework from a classification system into a treatment philosophy.
Kelly Tanner, PhD, RDH, is a contributing author to DrBicuspid, where she shares insights and strategies to empower dental hygienists in their careers. As a leader in clinical training, professional development, and team dynamics, Tanner provides resources to help hygienists elevate their practice and personal growth. For further support, join her free Facebook group, Next Level Dental Hygiene Career and Personal Development, and explore group training and on-demand courses at www.nextleveldentalhygiene.com.
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