all right let's look at this example over here and come up with the appropriate staging and grading remember we only stage and grade our client that have periodontitis that have bone loss so in this case we have a 20 year 28 year old client interdental cow of three to four millimeters so let's imagine this so imagine we have a full probe in that and it's saying the most the highest interdental cow we have is three to four millimeters so let's look at the probe index these are all the probe in depth this is the gingival margin line this is the cow and let's um say we got some more readings and we got some cows let's fix that we got some cows of three we got some cows of four we got some cows of one we got some cows of two another three another four this is a hypothetical example so what we do now is we look at the highest highest cal and the highest cow we got is a four so that's what they're referring to in this case study that the highest cal is a four the proven deaths are five millimeters or less so if i were to change the color to red it would make it easier so we see some four millimeter pocket we also now see some five millimeter pockets we see some doors so what we do is we look at the entire mouth and we find the worst reading and the worst reading is a5 and that's how they came up with this that the proven deaths are five millimeters or less because we saw some five we also some saw some three two three we saw some force but the highest probe in that was a four mostly horizontal bone loss as we see um okay this person is um smoking a pack cigarette a day now what we got to do is we got to figure out what stage and grade they are so to do this we look at the um aap guidelines that they have for staging and grading so let's look at interdental cal interdental cal the highest was a four millimeter so that's not one or two three to four we didn't see any five cows we saw four millimeter cal so what we're going to do is we're going to circle this the next thing we're going to look at is the radiographic bone loss or lbl and so if we look at this free geographic bone loss here what we see over here is that um we have to find so we have to look at the entire range of graphs and we got to find the worst bone level and try i think they pretty much look similar but let's hypothetically say that this is the worst bone level that i see and so this one is saying is well where is the bone loss where is it is it 15 and if it was 15 what you would do is this is your ceja right here 15 percent would be like maybe just like right over here so that's how much 15 bone loss would look like and i mean just imagine bone level would be up to here um if it's extending to the middle third of the root which basically means and beyond the middle third so kind of like the middle if it's from here and beyond okay so if the bone level was here or less or beyond then um you would circle this or this section over here and that's what we see here we see this past the middle section is gone the radiographic bone level has passed that middle section and so what i'm going to do is i'm going to circle this one okay it has extended to the middle third of the root and beyond now the next thing we look at is tooth loss and this tooth loss is only due to periods they're not due to cavities it's only due to perio and when we look over here it says here this person has no tooth loss due to periodontitis so all their teeth are still intact so if there's no truth loss i'm going to circle this then it says well let's look at other um local features and so we're looking at program debt which is five millimeters or less so five millimeters or less volumes under this one this category this is four millimeters or less for stage one this is six millimeter or less for stage three so i'm seeing five millimeter or less um it's also saying okay the other ones are for grading so now what you do is you figure out where is the the um circle that is on the worst extreme and on the most extreme it is a stage three so in this case you i know we have circles in stage one i know we have more circles in stage two but what the rule for period on titus is you get the worst um stage and the worst stage is stage three so this person is stage three now what you do is you figure out the grade so let me scroll down and we're gonna figure out the um grade so we do the same thing we're gonna circle again so let's look over here um did we see any bone loss over the past five years when you look over here it says that there was evidence of two millimeters or more or more attachment loss over the five year period so which one does it best fall under it as well as under this category because it was two millimeters at or more so that's what this stands for over the past five years we also know that this person smokes a pack of cigarettes a day so if someone is smoking a pack which is 10 20 cigarettes or more sorry more than 10 cigarettes then we're gonna circle this one now we look at what the highest grade is and the highest grade is grade c and so that's what we're going to say this person is stage 3 grade c now normally when we do grading just some tips you should know is that we always stick with grade b if you don't know any information always assume grade b and that's what this is saying unless you have evidence to show that it's a great c so in this case we know that he's losing a lot of bone over the five year period and we also know that he is smoking a pack of a pack a day so that shifts him into grade c one last thing i want to point out is how do you figure or how do you calculate this percent bone loss over h and then you can figure out what category they fall under well there's a certain way to do this well we know his age is 28 okay so we know the age is 28 so i'm going to put 28 right over here 28. put the division sign so the division sign from here is going here then we're looking at the percent bone loss we're going to find the worst bone level bone loss here and what do you think do you so this is 50 this over here is 25 this is 50 percent i don't know would you say 70 or 80 percent or 85 maybe because it's all this is like a hundred percent would be here so let's hypothetically say 80 this person has lost 80 percent of bone and again you're guesstimating half of that is 50 you know go further down maybe this is 80 so what you're going to do is you're going to take 80 and divide it by 28 and so let's do that i'm going to pull up a calculator and we're going to do this so it's saying 80 because that's how much bone loss he has so 80 divided by his age and his age is 28. if i go 80 divided by 28 i'm getting 2.85 okay or 2.9 so his radiographic bone level is 2.9 2.9 is more than one so that puts him in this category so again he is still a great c even when you calculate the radiographic bone level he still falls under the green c category so let's look at another um example so here we have a 50 year old client the highest interdental cow was a four so three to four millimeters no tooth loss highest probing that was a five so five millimeters or less um radiographic bone loss extends to the coronal third of the root so it hasn't progressed to the middle third it's not in the middle third it's more towards the coronal third um horizontal bone loss less than two millimeters of attachment lost over the past five year period non-smoker and non-diet and not diabetic okay so let's go through these um categories again so interdental cal four millimeter was the highest so that puts us in this category not one to two the hot and it wasn't five the highest was a four major graphic bone loss well way too graphic bonus extends to the coronal third of the two so remember coronal basically means towards the crown so this is coronal this is middle and this is apical so coronal is somewhere around here so the bone levels really close to the coronal section or the coronal side okay so where does that put us over here to the corolla third is it in this cat size it isn't on stage one or is it on stage two well again let's just look at the um radiographic uh picture more closely okay so to do so we know half of that i'm just gonna bring your pen sorry okay so half of that is 50 so when you look at the end of the route to the cej and roughly half of that is 50 so this is just the radiographic bone loss hasn't been it's not extending it's not in the middle third but it it's not i think i would probably put it in this category it's not less than 15 if it was less than 15 the radiographic bone level would be a little higher because it's a little lower i would probably put them in the 15 to 33 range so i'm going to circle this where is the maximum probe in that was it a four a five or a six well let's look here five millimeter is the highest probe in that so i'm gonna circle this i'm also gonna circle this because most of the bone loss is horizontal bone loss as we see it's like an even reduction of the bone so based on this because i've circled all stage two i'm going to say that this person is a stage two periodontal client the next thing we got to figure out is well what grade is he so let's look at the grading so when we look at the grading the first thing we're going to do is we're going to look at his radiographic bone loss or cal and we're going to look at the bone level has it has he lost bone over the past five year period and it has it been two millimeters or less or is it more than two millimeters and it stays here less than two millimeters because it's less than two millimeters that's what i'm going to circle the next thing we're going to do is we're going to look calculate the percent bone loss over h so this guy is 50 years old and if we were to guesstimate his bone level we know that this is 50 so maybe he's lost i don't know 30 percent of bone right so this you know could be 30 because we know this is 50 so i'm guesstimating this could be 30. so in this case what you would do is to calculate this you would take his age okay so his age is 50 and you take his percent bone loss and his percentage of bone loss we said was 30. so we go 30 and then remember we're just following this formula divided by his h which is 50. and so when we calculate that let's bring up the calculator again i'm going to shift this over so we can see better so 30 so we go 30 divided by 50 and when i do that i get 0.6 okay 0.6 0.6 which category does this fall under i would say right here because between 0.25 and 1.0 so this person does he smoke no is he diabetic no so we can put he's not a smoker he's not diabetic okay what you want to do here is you want to find the worst area and the worst area over here is not a grade a it's a grade b because that's the worst um the worst one and so that's why i would say that he is a grade b because you always select the worst call and the worst column in this case is grade b let's do one more example here we have a 47 year old the highest interdental cow is a five four teeth lost due to perio probe in depth of six millimeter of or more radiographic bone loss extends to the middle third of root vertical bone loss we do see some and evidence of less than two millimeter attachment loss not a smoker is diabetic okay let's um start by interdental cal the highest interdental cow was five okay so let's circle this five millimeters it could also be this one too stage four but let's find more evidence to make it a stage four if it falls under this column next thing is radiographic bone level radiographic bone loss or bone level is to the middle third of the root so it's extending to the middle third of the root and beyond and let's see if we can see that in the radiograph so if we look at the way to grab we find the worst area and the worst area in my opinion is here the worst bone level is right over here and so is that like in the middle and beyond i think so it is i think it is and this is like the middle part and again to see this you kind of outline the entire root oops and the middle is over here right the middle of the bone is kind of over here and so the bone level is on the middle third of the root so that's why we're circling this tooth loss has he lost any teeth let's see four teeth lost youtube perio so we're gonna circle this four not five it says fourth so we're gonna circle four and remember these are because of periodontitis not because of cavities not wisdom teeth removal or extraction it's 14 because imperial okay let's move on probing depth six millimeter or um six millimeters or more okay let's hypothetically say that when we looked at all the probing dust the highest one we saw was six millimeters so not four the highest was not four the highest was not a five the highest was a six millimeter or more so i'm going to circle that did we see vertical bone loss yeah it says there is some vertical bone loss so we're gonna circle that all right so based on this i think we can safely say that he is in a stage three um category so stage three now let's look at the great okay so when we're looking at the grade the first thing we want to look at is um his radiographic bone loss did he lose bone over the five-year period and he did lose bone but it was less than two millimeters so less than two millimeters falls under this category what is the percentage of bone loss over age well let's just say he lost fifty percent of bone as we see here fifty percent of bone and he is forty seven years of age so what we do is we take fifty percent fifty percent of bone we're guesstimating and he is 47 years old so let's calculate that and when we do what we're going to get is 50 divided by 47 is 1.06 oh okay so 1.06 i'm just going to round it up and i'm just going to say 1.0 okay um i know it's at 1.06 but let's just round it up and make it 1.0 so that falls under this category it's like right towards the end of that category actually so 1.0 okay he is not a smoker so we're gonna circle that he has a history of diabetes um so we're gonna circle this so yeah we see some circles in grade a but the worst area is always in grade b so this guy because we have lots of circles here and we don't have any circle here if we had even one circle here he would automatically go to grade c but because we don't have any circle in the grade c region we will say that he is grade b let's actually attempt one more so this guy over here is a 53 years interdental cow of five millimeter or more more than five teeth lost due to perio probably that's for six millimeters or even more or more radiographic boneland extends to the mid third of the root and that's true when you look at his radiographic bone level so let's look at the worst one you can see that this is the middle of the root and the bone level has surpassed that middle so it is past the middle third we do see some vertical bone loss if you look here it is vertical bone loss that we do see it's not an even reduction we do see that slope and even here we can see some vertical bone loss um he's not diabetic and he smokes half a pack of cigarettes a day so what stage of grade is this uh client well he has an interdental cow of five millimeter or more so he could be either stage three or stage four i'm just gonna go with stage three just i'm gonna go with the lower end just for now um he has lost more than five teeth oh okay look at that this is four or more teeth here he said he has lost five teeth and they're all due to periodontitis so they were all mobile because of perio and he eventually lost it so five teeth has been lost probe in depth of six millimeter or more okay so probe in depth of six millimeter or more i'm going to circle that radiographic bone loss extends to the middle third of um root step to the middle third of root and beyond a circle this i could also circle this too but i'm just gonna go and be conservative and circle the stage three instead of stage four he's got vertical bone loss oh yes he has vertical bone loss okay so based on this all there's a lot of stage three circled but there's also one stage four circled and so given this i'm going to always choose the worst area right that's what we have to do with this we always choose the worst area and so for this person this guy is i cannot spell today stage four okay so stage four because the wrist one is this one here okay let's move on let's look at the grading so when we're looking at the grading it says that there is evidence of less than two millimeter additional attachment loss and one thing i want you guys to know is any time we grade automatically assume that the client has a grade b unless you have evidence to shift them to a grade a or c so automatically i'm assuming he's a grade b but let's look at all the all the information here less than two millimeter um additional attachment loss so that's this one over here he does have less than two millimeter of bone loss over the past over the past five years he is not diabetic okay so he's not diabetic he smokes half a pack of cigarettes a day okay half a pack includes 10 cigarettes a day so where do we see the most circle we see the most circle in grade b so therefore this client is a grade b client all right i hope that helps if you have any questions don't hesitate to ask