King Saud University, College of Dentistry Department of Preventive Dental Sciences

DIVISION OF PERIODONTOLOGY

CLINICAL MANUAL Edition 2003 – 2004

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TABLE OF CONTENTS

PAGE Preface ………………………………………………………………… 3 Introduction ………………………………………………………………… 4 General Clinical Protocol ………………………………………………… 4 Forms Used in Periodontal Clinics ………………………………………… 6 Patient Examination ………………………………………………………… 7 The Odontogram ………………………………………………………… 9 I. Gingival Diseases ………………………………………………… 12 II. Periodontitis ………………………………………………………… 13 III. Necrotizing Periodontal Diseases ………………………………… 14 IV. Abscesses of the Periodontium ………………………………… 14 V. Periodontitis Associated with Endodontic Lesions ………………… 14 VI. Developmental or acquired deformities and conditions ………… 15 The Treatment Plan ………………………………………………………… 15 Initial Treatment Plan ………………………………………………………… 15 Phases of Treatment ………………………………………………………… 15 Phase II – Re-Evaluation ………………………………………………… 17 Case Presentation ………………………………………………………… 18 Steps for Re-evaluation Procedure ………………………………………… 20 Evaluation of a students clinical performance ………………………… 21

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PAGE Appendix A: Periodontal Form 1 ………………………………………… 25 Periodontal Form 2 ………………………………………… 26 Appendix B: Radiographic Interpretation ………………………………… 27 Appendix C: Initial Preparation (Phase I Therapy) ………………………… 29 Appendix D: Introduction and use of the oral hygiene Indices ………… 32 Oral Hygiene Instruction (Chairside Procedure) ………………………… 36 Appendix E: Procedures for Scaling, Root Planning and Polishing………… 40 Appendix F: Surgical Treatment ………………………………………… 42

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PREFACE

This manual has been written for the undergraduate students in the College of

Dentistry, King Saud University who will be Inshallah the next generation of dental

practitioners in the Kingdom. It is meant to guide the student through the procedures

to be followed in patient management in the undergraduate periodontal clinic. The

preventive basis underlying the management of periodontal diseases is highlighted

and great importance is placed on patient examination and treatment planning

objectives.

From this approach, a student dentist will achieve competence in the

techniques available to prevent the occurrence of diseases, treat the diseases should

they occur and finally to maintain the health of their patients and in that way to

minimize as much as possible the need for more radical and costly periodontal

surgical procedures.

The manual was prepared by Dr. basher J. Zulqarnain and Dr. Mohammed

Eid. Later on, it was reorganized by Dr. James E. Stakiw.

Thanks are due to the following current and past members of the Division of

Periodontology who contributed greatly in the preparation of this manual:

Dr. Khalid Almas Prof. Nadir Babay

Dr. Nahed Ashri Prof. Axel Bergenholtz

Dr. Farhad Atassi Dr. Mark Zigoris

Dr. Fatin Awartani Dr. Sameer Mokeem

Thanks also for PDS Department Secretary Ms. Elizabeth Posadas for her

help in typing and organizing of this manual.

Last, it revisited and updated by Dr. Abdulaziz Al-Rasheed (9th September

2003G [1424H].

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INTRODUCTION

This manual has been prepared to assist you, the student dentist, to gain

competence in clinical techniques and administrative procedures, which once

mastered can provide the basis for the successful management of the periodontal

patient in your practices.

A description of general protocol and performance standards expected in the

clinic is presented and the importance of this manual as the reference source on most,

if not all clinical matters cannot be overstated.

• It is mandatory to bring the clinical manual during clinical sessions.

• Students should wear clean clinical uniform with I.D. badge.

• Be professional and Good Luck.

GENERAL CLINICAL PROTOCOL

1. The treatment cubicle must be clean and neat. This is the students

responsibility. All papers, extraneous instruments etc. must be stored in

the cupboards provided or at the very least be as far removed in the

operatory from the work area as possible. THIS IS IMPORTANT.

2. Students must be in the clinic on time and be ready to begin their work.

Students should wear clean clinic gowns/lab coats and appear well-

groomed and professional.

3. Instruments required for the procedure planned must be available,

sharpened, in good working condition and properly arranged on the

bracket table.

4. The patients file, evaluation forms etc. should be available with initial

entries already made before starting the actual procedures.

5. Radiographs, preferably a full-mouth series should be available and in

place on the viewer.

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6. DO NOT BEGIN any treatment until the instructor is informed of what

you plan to do for the patient! You may take a medical/dental history that

will be reviewed by the instructor prior to treatment. The instructor will

check the periodontal treatment plan and if this has been properly

completed and signed by an instructor as it should be, then the student will

be given permission to begin treatment.

7. The student should be prepared to discuss the treatment planned and the

rationale for the procedures drawing upon knowledge gained earlier

regarding etiology, progression of the disease, treatment planning, results

expected, prognosis of the dentition and other relevant topics.

8. Time appreciation and management are important clinical considerations

and the student must develop skills in these areas.

9. Evaluation of your clinical performance is based on your knowledge,

records (MUST BE ACCURATE!), patient management and clinical

skills. An instructor must check each stage of your clinical work so that

you may be adequately assessed. It is your responsibility to have an

instructor evaluate your clinical work and progress before dismissing your

patient. You will also be provided with a qualitative grade. Have your

daily record of treatment and case management completed and all

pertinent data on the evaluation forms filled in.

10. Do not call an instructor to check your work at the last minute – you

should leave at least 20 minutes for a worthwhile teaching – learning –

evaluation process. It is important that you do not RUSH through your

clinical work. There is nothing wrong in having an “incomplete” on your

daily record – this likely means you are aware of what your treatment

goals are and are in the process of logically achieving these. There is

nothing more frustrating to everyone concerned than to see you have

rushed through your work leaving calculus undetected, tissues in poor

shape, instruments in disarray and then expect to have a good grade. Be

mature and professional about your work.

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11. This manual is your GUIDE for successful clinical management of

periodontal patients. Always have it available in the clinic. The penalty

for being errant in this regard on a consistent may be a zero grade for the

day.

FORMS USED IN PERIODONTAL CLINICS

PATIENT RECORDS THROUGHOUT THE WORLD ARE IMPORTANT

LEGAL DOCUMENTS AND STUDENTS MUST LEARN TO ACCURATELY

RECORD ALL INFORMATION PERTIENNT TO THE CLINICAL

MANAGEMENT OF PATIENTS UNDER THEIR CARE. THEREFORE, FORMS

USED IN PERIODONTOLOGY ARE TO BE CONSIDERED MOST IMPORTANT

BOTH IN THEIR INHERENT VALUE REGARDING THE PATIENT AND AS A

LEARNING TOOL IN UNDERSCORING THE VALUE OF CLINICAL

RECORDS.

ALL PERTIENTN RECORDS ARE TO BE WRITTTEN WITH A LEGIBLE

HAND IN INK.

The division of periodontology uses two (2) forms in the clinic (Appendix A).

These are:

1. Periodontal Assessment and Treatment Plan (Perio Form 1).

2. Hygiene Form (Perio Form 2).

The Perio Form 1 is used to record all clinical findings relevant to the

periodontal management of the patient. By developing a keen use of all the students

relevant senses, a correct diagnosis and treatment plan for the patient is arrived at for

the benefit of all concerned. Much time (at least 1 hour) will be spent in

instructor/student analysis of this form for most patient – PLAN YOUR TIME

ACCORDINGLY. You may do odontogram charting at the first appointment

followed by completion of the remainder of the form at a subsequent appointments.

Take your time on this form. “Haste makes waste”.

The Perio Form 2 is hygiene form. This form is used to record bleeding on

probing and plaque score (percentage) on initial and subsequent visits for recall and

re-evaluation.

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PATIENT EXAMINATION

Remember, your periodontal examination must of necessity include a general

assessment of the overall health and disease status of the patient and a relevant

dental/oral/facial examination. You must practice becoming the provider of

comprehensive dental/oral health care and disease management. That is why your

instructor will stress that you do a general and dental examination in addition to the

periodontal examination of your patient.

Examination Kit

This kit includes:

1. Mouth mirror

2. Periodontal probe

3. Explorer #2

4. Cotton pliers

5. 10 x 2” x 2” autoclave gauze sponges

6. A white plastic lined paper bag or plastic cup taped to the right side of the

bracket table to receive waste.

The instruments and materials should be neatly arranged from left to right on

your bracket table. The patients file, current radiographs and student evaluation form

must be neatly displayed and readily available for the instructors use.

The following may also be required during patient examination and should be

available:

1. Large hand mirror

2. Disclosing tablets or solution

3. Dental floss

4. Ball point pen, lead and red/blue pencils

5. Articulating paper (red and blue)

6. Study casts

7. Patient toothbrush (patients should bring their own toothbrushes for each

appointment).

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Begin your professional relationship with your patient through completing the

oral hygiene section. You will want to determine your patients attitude to oral

hygiene since this will affect your management of the patient over the short and long

term.

Record your examination findings either:

1. In the patients chart; or

2. In the Perio Form 1.

General

A patient assigned to the periodontics clinic usually will have had much of the

dental chart completed by the screening/oral diagnosis divisions. It is important you

review this information. If this section is incomplete notify your instructor. It is

important you review the completed information at each visit asking the patient if

there have been any changes to their medical/dental status. Proceed on how to

complete the top part of the Perio Form 1. Any relevant medical history which may

compromise the patient on your treatment must be noted in the “Medical Alert” box.

Use red pencil for medical alert.

The next step is to complete the chief complaint, history of past treatment, and

summary of medical history sections particularly as to how the latter may affect the

clinical management of the patient. Under history of past treatment you will want to

know about history of the clinical complaint, when the patient last had dental

treatment, how long ago, what was done and were there any difficulties or

complications.

Call the instructor to obtain an approval to continue with patient examination.

Clinical Examination of a Patient

Remember a suggested approach to patient examination “from the outside to

the inside, from the large to the small”.

The aid memoire regarding oral hygiene in your clinic chart will allow you to

quickly ask the relevant questions. Ask the patient to bring the oral hygiene/plaque

control aids they use when they appear for the next appointment so you can verify the

instruments and techniques used.

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General Appearance

Note the general appearance/personality of patient whether robust or sickly,

nervous, tense or relaxed and content. Approximate height and weight.

Extra-Oral

Examine the patient and record your findings regarding lymph nodes, TMJ

status and function, masticatory musculature etc.

Intra-Oral

Record if there is bad breath (foetid odor). This may alert you to possible

pathology being present. Begin your examination by recording any change of the

lips, commissures, then go on to alveolar/buccal mucosa, tongue, floor of mouth and

upper pharynx. Do a complete oral examination.

Describe all gingival surfaces including colour, contour, consistency etc.

Describe the worst areas first followed by those with decreasing pathology and

minimally describe normal tissue findings. At the beginning of your program you

may be asked to describe normal tissues in greater detail.

THE ODONTOGRAM

The Perio Form 1, Periodontal Assessment and Treatment Plan contains

portions of chief complaint, history oral, medical history, examination, extra-oral and

intra-oral. The odontogram provides space for writing sensitivity, pocket depth,

furcation, mobility, recession, and periodontal diagnosis.

Charting on the Odontogram (Perio Form 1)

Your periodontal charting must be done neatly in pen with mucogingival

pathology noted in red pencil. At re-evlauation, periodontal pockets greater than 3

mm should be noted in red pen.

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Note: If bleeding on probing occurs, put a red dot in the square of the tooth where

bleeding occurred.

When you have completed the odontogram section of the chart, have an

instructor go over the information gathered so far.

Supplementary Tests

Indicate in this section tests which are indicated to confirm or verify the

potential problems discovered during examination of the patient.

Periodontal Radiographic Finding

Briefly describe C.M.S. findings as they are pertinent to your periodontal

examination. (For more detail see the Appendix B).

Calculus Present

Indicate the presence of calculus in each sextant by the appropriate sign as

follows:

S = Supragingival calculus

SS = Supra and subgingival calculus

SG = Subgingival calculus

Community Periodontal Index for Treatment Needs C.P.I.T.N. Classification

The student will record in the appropriate box, a number to indicate the

CPITN classification for each sextant and the aggregate score (only once). Examine

each sextant and assign a:

Code

0 If the gingival is healthy in the sextant, no bleeding upon gentle

probing of pocket depths.

1 When gingivitis is present without pocket formation (i.e. up to 3 mm

sulcus depth). There is bleeding upon gentle probing.

2 When gingivitis is present and supra and/or subgingival calculus is

present.

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3 When pathologic pockets (4 or 5mm) are present in a sextant.

4 When pathologic pockets 6 mm or deeper are present in a sextant

(Exclude pockets on the distal aspect of the 3rd molars).

X Missing sextant

NOTE : You must have at least two (2) teeth in a sextant to be counted.

Etiologic Factors

Here you should list all of the factors which have and are accounting for the

periodontal pathology you have noted in the chart so far. These are discussed further

in your lecture series.

Periodontal Diagnosis

All the relevant and important facts regarding the patient have been collected

and neatly recorded in the chart. The CORRECT periodontal diagnosis must now be

arrived at by a process of reasoning and common sense.

You will note space has been allocated in the chart for a systemic/oral

diagnosis and above each tooth a square for periodontal diagnosis. Systemic diseases

having a direct/indirect bearing on the periodontium e.g. diabetes mellitus should be

included as well as oral diagnostic findings e.g. caries, multiple missing teeth (plus

tooth numbers) etc.

In the appropriate square above each tooth, indicate the diagnostic code for

the American Academy of Periodontology (AAP) 1999 classification from the

following list:

Diagnosis (Modified from American Academy of Periodontology “AAP”

classification 1999).

This is a brief description lists of the classification and student need to return

back to the lectures in the periodontal courses and the recommended textbook

(Chapter 4, Clinical Periodontology, Carranza, 9th Edition, 2002) for more details.

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I. GINGIVAL DISEASES:

I-A. Plaque induced gingival diseases:

It include the followings:

I-A1. Gingival diseases (gingivitis) associated with dental plaque

only: State of plaque accumulation around the teeth which result in

inflammation of the gingival tissues (characterized by edema, cyanotic

bluish red color, gingival bleeding, rolled margins and bulbous

interdental papillae). The only factor here is the presence of dental

plaque, there is no systemic factors, medications or state of

malnutrition which may affect the response of the gingiva to dental

plaque.

I-A2. Gingival diseases modified by systemic factors: There is

plaque accumulation around the teeth but the response of the gingival

tissue exaggerated due to presence of systemic factors such as

pregnancy, puberty and diabetic… etc.

I-A3. Gingival diseases modified by medications: response of

gingival tissue influence by medications such as anticonvulsant drug

(phenytoin), hypertensive drug (Nifidipine) and/or immunosuppressive

drugs (Cyclosporine) in addition to the presence of plaque.

I-A4. Gingival diseases modified by malnutrition: response of

gingival tissue to plaque influence by malnutrition state such as bright

red, swollen, and bleeding gingival associated with severe Vit. C

deficiency or Scurvy.

I-B. Non-plaque induced gingival lesions:

It include the followings:

I-B1. Gingival diseases of specific bacterial origin: such as sexually

transmitted disease (syphilis, gonorrhea, and streptococcal gingivitis)

the changes in the gingiva is the result of infection with specific

bacteria.

I-B2. Gingival diseases of viral origin: such as Herpes virus

infections.

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I-B3. Gingival diseases of fungal origin: such as generalized

gingival candidosis.

I-B4. Gingival diseases of genetic origin: such as Hereditary

gingival fibromatosis.

I-B5. Traumatic lesions of the gingiva: such as chemical, physical

and/or thermal injury to the gingival tissue.

I-B6. Foreign body reactions of the gingiva: such as changes of

gingival tissue as the result of introduction of amalgam into the

gingiva during the placement of a restoration.

II. PERIODONTITIS:

It is an inflammatory disease of the supporting tissues of the teeth caused by

specific microorganisms or groups of specific microorganisms, resulting in

progressive destruction of connective tissue attachment, periodontal ligament and

alveolar bone with pocket formation, recession, or both (simply periodontitis

manifested clinically as Loss of Attachment around the teeth). It include the

followings:

II-A. Chronic Periodontitis:

Most common form of perodontitis and it is associated with

accumulation of plaque and calculus and generally has a slow to moderate rate

of disease progression.

Extent:

- Localized form: less than 30% of sites involved (Note:

attachment usually examined around 6 sites per tooth in the

mouth).

- Generalized form: more than 30% of sites involved.

Severity:

II-A1. Slight: 1-2 mm of clinical attachment loss.

II-A2. Moderate: 3-4 mm of clinical attachment loss.

II-A3. Severe: 5 mm or more of clinical attachment loss.

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Note: Clinical attachment loss is measure from CEJ to the base of the pocket

i.e. recession + pocket depth.

Recession measure: from CEJ to gingival margin.

Pocket depth measure: from gingival margin to the base of the sulcus.

II-B. Aggressive periodontitis:

It is less frequent form of periodontitis. Differ from chronic

periodontitis by an absence of large amount of plaque and calculus and has a

more rapid rate of disease progression.

- Localized form: involved permanent 1st molars and/or incisors

with proximal attachment loss (at least two teeth are affected).

- Generalized form: generalized proximal attachment loss affecting

at least three teeth other than 1st molars and incisors.

II-C. Periodontitis as a manifestation of systemic diseases:

Such as periodontitis observed in Hematological disorders (acquired

neutropenia, leukemias and other) and some genetic disorers (e.g. Papillon-

Lefevre Syndrome).

III. NECROTIZING PERIODONTAL DISEASES:

III-A. Necrotizing ulcerative gingivitis (NUG).

III-B. Necrotizing ulcerative periodontitis (NUP).

IV. ABSCESSES OF THE PERIODONTIUM:

IV-A. Gingival abscess.

IV-B. Periodontal abscess.

IV-C. Pericoronal abscess.

V. PERIODONTITIS ASSOCIATED WITH ENDODONTIC LESIONS:

V-A. Endodontic-Periodontal Lesion.

V-B. Periodontal-Endodontic Lesion.

V-C. Combined Lesion.

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VI. DEVELOPMENTAL OR ACQUIRED DEFORMITIES AND

CONDITIONS:

VI-A. Localized tooth-related factors that predispose to plaque induced

gingival diseases or periodontitis.

VI-B. Mucogingival deformities and conditions around teeth.

VI-C. Mucogingival deformities and conditions on edentulous ridges.

VI-D. Occlusal trauma.

The Treatment Plan

The formulation of a treatment plan (initial) should be written on a plain sheet

of paper.

Initial Treatment Plan

The ultimate goal of periodontal treatment is the “provision of a functional

dentition throughout the life of the individual”.

To achieve this goal, treatment is rendered in a deliberately sequenced manner

usually divided into 4 or 5 phases. The key stone to successful treatment and

management of the disease process is prevention and no phase of treatment will

achieve a successful result without a constant and repetitious adherence to the

“Principles of Prevention”.

The phases of treatment are as follows:

- Emergency treatment:

Abscess

Endodontic Therapy RCT

Extraction of hopeless tooth

Trauma etc.

Emergency treatment rendered as necessary.

Phase I: Initial Therapy (see Appendix C) for more details.

• Patient motivation, oral physiotherapy/plaque control. (see Appendix

D).

• Gross scaling, fine scaling, root planning. (see Appendix E).

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Phase II: Re-evaluate plaque control (3 weeks after initial therapy)

Re-evaluate results of initial therapy (4-6 weeks after initial therapy).

Re-evaluate oral hygiene status.

Bleeding and plaque score.

Comprehensive with previous:

Therefore, a patient to be ready for re-evaluation must have

had all local etiologic factors eliminated, “hopeless” teeth extracted

and achieved a satisfactory level of oral hygiene:

• Assess plaque control.

• Assess tissues response to initial treatment.

• Plan further treatment that should take the form of a definitive

treatment plan and may include maintenance care or

periodontal surgery.

Phase III: Surgical Therapy (see Appendix F)

Phase IV: Supportive Periodontal Therapy

• At this stage, further restorative treatment will likely be

planned.

• This program is individualized for the patient.

A hypothetical preliminary treatment plan may be as follows:

1. Emergency treatment: if indicated e.g. endo #34 or extraction 48.

2. Phase I – Initial Treatment

The order in which different aspects of treatment is carried out will

depend on the clinical findings of each case. Whether it is mainly a caries

case or primarily a periodontal cases or a variant in between these two:

a. Case presentation and patient motivation.

b. OHI: You should always √ what aids the patient is using before

giving him/her advise as to what to use. Mention what toothbrush and

brushing technique is used by the patient.

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NOTE: If the patient present with good hygiene bucally and lingually and an

acceptable hygiene interdentally, limit your instructions to interdental

cleaning. You must indicate and list all oral hygiene and teaching aids

you will prescribe to your patient. E.g. Butler 311 with modified Bass

technique, dental floss and proximal brush in molar areas.

c. Extraction: indicate the tooth number.

d. Complete endodontic treatment of 45.

e. Excavation of caries, 46, 35 and removal of overhang 37.

f. Scaling, root planning and prophylaxis.

g. Occlusal adjustment.

h. Orthodontic consultation.

Phase II – Re-evaluation

Re-evaluation: 4-6 weeks after initial therapy.

At the time of initial treatment planning for areas having 6 mm or

more pockets, it might be necessary to treat them surgically. Identify all such

areas as needing periodontal surgery (this part is actually decided at the time

of Re-evaluation). After-re-evaluation you must specify the areas that need

surgery and the suggested procedure, e.g.:

a. Gingivectomy, tooth #45-47

b. Flap, tooth #13-16

c. Crown lengthening for tooth #27

PII and B.I at acceptable levels.

a. Fixed bridge #23 to 26 – pocket depth now minimal.

4. Phase III – Corrective/Surgical Phase

• Surgery

• Prosthesis

a. Full thickness mucoperiosteal flap #13 to 17 with possible ostectomy,

M16.

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5. Phase IV – Recall or Supportive Periodontal Therapy

Plaque Control Data

If and when you are ready to defend your analysis of the case and

treatment plan are satisfied that the patient is ready for further treatment,

arrange an examination kit on the bracket table, and then call for an

instructor.

When the preliminary treatment plan is approved, enter the appropriate

data on the Perio 1 and Perio 2 Forms, have these signed by the instructor and

then present the treatment to the patient.

Case Presentation

The importance of developing an ability to present the treatment plan to the

patient cannot be over emphasized for a number of reasons the main one being the

obtaining of informed consent from the patient for the treatment you are considering

doing for the patient. In addition, be enthusiastic about the treatment planned as being

of benefit to the patient and always seek to establish in the mind of the patient that

periodontal care is a primary treatment goal that for the long term success of all dental

treatment must be accomplished first in priority.

Include the following in your case presentation:

1. Discuss what you did in the examination procedure and explain your findings.

2. Explain to the patient the etiology of his/her role in the treatment.

3. Discuss the sequential treatment plan step by step and indicate how much time

and how many visits it may take to complete the Phase I therapy.

Phase II Re-Evaluation

In the initial therapy, measures are taken to eliminate or bring as close to zero as

possible the etiologic factors for periodontal disease i.e. The BACTERIAL PLAQUE.

If the initial therapy is well done, only minimal amount of bacteria remain on the teeth

and the body is capable of dealing with the bacterial. The inflammatory reaction in the

periodontium will gradually diminish and the periodontal tissues will eventually return

to a healthy states. This will be a permanent result as long as bacterial masses are not

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allowed to accumulate in the dentogingival region. The healing process will however

continue during a period of several months which a rebuilding of ground substances and

supporting collagen fibers in the gingiva takes place. The most superficial parts of the

periodontium, the gingiva, thereby regains a firm consistency and a pale pink color.

In our evaluation of the effects of initial therapy, we should therefore leave the

patient without intervention for a period of 6 weeks.

Re-evaluation appointment must, therefore, be scheduled at least 4-6 weeks after

the completion of Phase 1 Therapy.

On the occasion of re-evaluation, the following are evaluated:

1. The ability of the patient to keep his teeth clean during a prolonged period

without professional help. This is assessed by registration of (1) tissue

appearance, (2) bleeding index, (3) plaque index (with disclosing solution).

2. The capacity of the tissues of the periodontium to heal. This is assessed through

measuring pocket depth and bleeding on probing index.

3. This is also an evaluation of the skill of the therapist to inform, motivate and

encourage the patients as well as give accurate and reasonable advice to the

patients about the cleaning of all surfaces of the teeth. It is also a test of the

dentist's skill to perform thorough scaling and root planning.

The information that is obtained must be analyzed before further

decisions are taken.

Re-evaluation is done to:

a. Determine the benefits of the treatment rendered so far.

b. Decide on the status of "questionable" teeth; and to

c. Determine if any further treatment is indicated, e.g. surgery or prescribe the

desired maintenance therapy routine.

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Steps for Re-Evaluation Procedure

The actual re-evaluation procedure must be performed in accordance with the

following guidelines:

1. Do a visual examination of the gingival tissue (presence or absence of gingival

inflammation). Take note of the gingival appearance for your own record, but

do not write anything in the gingival description section yet.

2. Inspect the mouth for visible hard and soft deposits.

3. Obtain first the Bleeding Index.

4. Call your instructor and show him your findings.

5. Take the plaque index.

6. Then if the patient is:

a. Free of visible deposits

b. The Bleeding Index is £15%

c. The Plaque Index is £20%

This means that the patient is ready and you can proceed to the next step.

7. Call an instructor to confirm your findings before proceeding.

8. At this stage, you should be able to inform the instructor that the patient is ready

(or not) for re-evaluation procedure. If you are correct, the instructor will give

you the "go ahead" to complete the re-evaluation.

9. If the patient is not ready, record your findings on the patient's chart. Re-instruct

your patient in OHI, re-scale and polish the teeth as needed and re-schedule the

patient after a week or two. The patient must leave your cubicle with a mouth

that is completely free of plaque.

You must be able to determine and explain to the instructor why the

patient is not ready for re-evaluation and what are you planning to do for

correcting this situation.

If you did not follow the step the instructor have the right to dismiss the

patient.

Phase III: After re-evaluation, patient may need advanced treatment either

periodontal surgery or prosthesis etc.

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Phase IV: Recall/Maintenance (Supportive Therapy)

Recall visits should be depending on the Periodontal Status and

clinicians judgment. Patients with high motivation and no systemic

conditions should be asked to come every 6 months. Patients with

moderate or severe periodontal disease, needs more frequent recall visits.

It may be adjusted 3-4 months or even earlier in high risk patients.

On each recall visit. The following should be emphasized.

1. Evaluation of the current oral health status.

2. Necessary maintenance treatment.

3. See if recurrence of disease or any other dental treatment needed.

4. Provide necessary periodontal scaling and root planning.

5. Motivation

EVALUATION OF A STUDENTS CLINICAL PERFORMANCE

Final Clinical Grade

All of the students' cumulative clinics experiences will be compiled, tabulated

and averaged. This numerical score is then converted to a letter grade according to the

criteria listed in the University grading and marking system.

Minimal Clinical Requirements

I. Philosophy and rationale of Teaching Clinical Periodontics in the Division of

Periodontics

The clinical teaching program is based on the premise that all clinical

procedures are new to the students when the course is begun. During the

students progress through the program, certain clinical techniques will be

practiced and eventually mastered. The degree of mastery that a student

demonstrates will influence his/her final course grade.

The student should progress toward gaining mastery of the basic

periodontal skills. However, different degrees of speed in the learning of clinical

skills are recognized and reasonable allowance is made for these variations.

Emphasis is placed on quality. However, it must be recognized that experience

is necessary to attain quality without sacrificing efficiency.

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The final two years of the student's clinical training are viewed by the

Division of Periodontics as a continuum of experience. Clinical components

form an essential part of all courses offered by the Division, but in grading, PDS

311 and 411 carry a heavy didactic weight.

Rationale for Student Evaluation for Clinical Courses

The essential objective is to prepare the student to reach a satisfactory level of

clinical proficiency. Unless regular feedback is given to the student, there is a risk of

creating unnecessary student anxiety regarding his level of achievement (e.g. grades);

which may have negative effect on learning. We had attempted to minimize the anxiety

by using the evaluation system in a more positive and constructive way.

A properly designed evaluation procedure will aid the student by recognizing

goals to be reached at specific points in the course. A well constructed and administered

evaluation process will also provide the student with appropriate feedback for self

evaluation and an opportunity to correct misconceptions or misinterpretations and to

improve the clinical skills.

This chapter also contains specific clinical objectives and a brief description of

each procedure, which forms the criteria for acceptable performance and the resulting

clinical evaluation.

Rationale of Course Requirements

The course requirements are based on the need for experience or practice of new

skills in order that they can be mastered. The first exposure to the clinics, in PDS 311,

should be considered as a learning opportunity. The students will not be graded in

technique. This is to encourage students to seek as much faculty aid and advice as they

feel necessary to accomplish maximum learning.

Once a procedure has been practiced and learnt, the student must be evaluated to

qualify for the next higher course. When the student repeatedly demonstrates and

maintains a high level of performance, it is interpreted as mastery of the clinical skill.

The required number of evaluations for the various procedures as well as the evaluation

methods is outlined elsewhere in this document.

23

Student evaluation is based on the following:

A. Preparation

i. The student must be prepared for all clinical procedures.

ii. Be punctual

iii. Have all necessary instruments available, sterilized and sharpened.

iv. Have the evaluation form properly complete and ready for appraisal.

v. Have entered the details of the procedure performed on the patient in the

daily treatment record, for the instructor's signature.

Empathy toward patient, professional appearance and behavior and

conscientious patient managements are important and included in this evaluation

category.

B. Knowledge

The student should demonstrate his/her understanding of the rationale,

objective and indications for the planned procedure. Students are expected to

review material pertaining to the planned procedure prior to coming to the clinic

and will be expected to discuss all procedures and basic concepts pertaining to

the procedure with the instructor.

C. Clinical Technique or Performance

The performance will be evaluated as follows:

E. Excellent (95%)

Will be awarded when the student performs at a satisfactory level

and does so independently. The work needs no improvement and no

faculty guidance or assistance.

VG. Very Good (90%)

G. Good (85%)

Will be awarded when the student is able to perform at a

satisfactory level with little guidance and no assistance. The procedures

needed minimal improvement.

S. Satisfactory (75%)

Will be give when the student needed considerable guidance or

instruction to complete the procedure satisfactorily. The procedure

needs considerable faculty assistance.

24

U. Unsatisfactory (40%)

Will be given when the procedure could not be completed

satisfactorily by the student, or the patient was exposed to unnecessary

risk or had been inflicted unwarranted injury.

O. Zero

This grade will be given when the performance and the

professionalism of the student is unacceptable and the patient or the

student has to be dismissed.

A student found ignorant in "knowledge" and is not prepared to perform

a procedure or has inflicted serious injury to the patient, he/she may be

dismissed from the clinic and will be given a zero "0" grade for that clinic.

3. Subjective Evaluation

While every attempt is made to insure that the clinical evaluations and

grading system is objective, it must be recognized that it may be difficult

sometimes to design a perfect system.

As such, there must be a high value placed on the individual and

cumulative judgement and experience of the Division of Periodontics faculty.

Therefore, each students' grade will be reviewed by the faculty at the end of the

grading period. Grading policy and evaluative procedures may vary from year

to year and will be presented to the student at the beginning of each academic

calendar year.

D. Grades

This is filled only by the faculty. A grade may or may not be

given at the end of the appointment at the discretion of the faculty. If the

grade for a procedure has been left blank, it means that the faculty did

not feel there was sufficient opportunity to evaluate the treatment done.

This will not affect the student's final grade. A grade however, is given

for all procedures checked as complete.

25

26

27

Appendix B: Radiographic Interpretation (a brief summary)

Examine the C.M.S radiographs in an orderly sequence so that you do not miss

any significant findings. Start with tooth #18 and work your way clockwise to tooth

#48. Assess, identify and record the following:

1. Plaque Retention Factors

Assess for visible calculus deposits, caries at or near the gingival margin

and defective restorations (overhanging margins, poor contour and open

margins.

2. Loss of Crestal Density

Examine for continuity of the crestal lamina dura. When there is active

destructive inflammation present, the crestal bone will undergo resorption and

will appear less dense than normal on the radiographs. This most often appears

more obvious on the bitewing films because of the x-ray orientation. Loss of

crestal density is very important as an indicator of periodontitis while with

clinical examination only, it is difficult to differentiate between gingivitis and

periodontitis. Where isolated areas show lack of continuity, record with tooth

number. Where 2-3 interproximal areas in a sextant are positive, record it by the

sextant number of the involved teeth.

3. Resorption Patterns

Observe the general pattern of bone resorption. Note whether it is

horizontal, vertical or a mixture with significant amounts of both. Always

generalize to report your findings by quadrant or by arch.

4. Average Distance from Alveolar Crest to the CEJ

Estimate the average distance between the CEJ and intact bony quadrant

by quadrant, and indicate the bone loss as follows: Any significant exceptions

may be noted separately. It is necessary to consider the percent of bone loss that

exists radiographically when making the diagnosis.

Measure the distance between the CEJ and the alveolar crest and

estimate the percent (%) bone loss. A guide line follows:

28

1. 0% Bone Loss bone level 1.5 mm apical to the CEJ with no signs

of loss of crestal density loss it suggest normal

bone level.

2. 20% Bone Loss bone level will be between 2-4 mm apical to

the CEJ, it suggests slight bone loss.

3. 20%-50% Bone Loss bone level more than 4 mm but <6 mm apical to

the CEJ, it suggests Moderate bone loss.

4. 50% Bone Loss bone level >6 mm apical to the CEJ it suggest

severe bone loss.

Note: Bone loss may exhibit different severity in different areas of the mouth. This

must be taken into consideration while making individual tooth diagnosis.

5. Vertical Defects

Note the location, type (angular or true vertical) and extent of the defects.

You will find that when you correlate the clinical findings with the radiographic

findings, it will be easier to interpret vertical defects more accurately.

6. Furcation Involvement

Note the location and extent of any apparent furcation involvements.

Simply record the tooth number of teeth with furcation involvement. Later try to

correlate this information with the clinical data.

7. Widened PDL Space

Record any areas with obvious widening of the PDL space.

8. Abnormal Root Form

Record any root abnormalities seen radiographically, e.g. Dilaceration,

periapical lesions, short roots (poor crown to root ratio).

9. Other Significant Findings

Any other factors which may be of significance such as periapical

pathology, cyst, poor crown to the root ratio, impacted teeth, etc. may be

recorded in this space.

29

Appendix C: Initial Preparation Phase (Phase I Therapy)

Initial therapy or phase I is the first step in the sequence of procedures that

constitute periodontal treatment. The objective of initial therapy is the reduction or

elimination of gingival inflammation. This is achieved by complete removal of all

factors responsible for gingival inflammation such as plaque, calculus, correction of

defective restorations, obturation of carious lesions, etc.

The long term success of periodontal treatment is principally dependant on

maintaining the results achieved with phase I therapy. In addition, initial therapy

provides an opportunity for the therapist to evaluate tissue response as well as the

patient's attitude toward periodontal care, both of which are crucial to the prognosis of a

periodontal condition.

Based on the concept that microbial dental deposits (plaque) produce the

primary pathogens of gingival inflammation, the specific aim of phase I therapy is to

facilitate the daily removal of such accretions from the teeth by eliminating rough and

irregular contours from the tooth surfaces and then establishing a suitable plaque control

regimen.

Advantages of Initial Preparation Phase

1. Removal of all etiologic factors may eliminate the need for periodontal surgery.

2. Oral hygiene techniques can be instituted and the patient's willingness and ability

to accomplish plaque control are evaluated.

3. It permits the dentist to evaluate the patient's tissue response to the removal of

local factors and subsequent healing.

4. Creates a local environment favorable to good oral and periodontal health.

5. Surgery can be performed with greater ease, because bleeding will be reduces

during surgery and tissue tags can be avoided.

6. Permits the dentist to establish rapport with the patient.

30

Initial preparation involves the following procedures:

1. Patient Education

Since dental plaque and calculus formation associated with inadequate

oral hygiene are by far the most common causes of periodontal diseases, it seems

natural to start the therapy by eliminating these active irritants. The concept of

plaque control as well as the rationale for other aspects of the treatment plan

should be understood by the patient before the active treatment is initiated. It is

very important of the success of the treatment plan.

2. Preliminary Scaling

The next step should be gross scaling and polishing of the teeth, followed

by specific instruction in oral hygiene.

3. Deep Caries

Carious lesions should be excavated and temporary restorations placed.

Caries in the vicinity of the gingiva interferes with plaque removal and

consequently with gingival health, even in absence of adjacent calculus or

defective restorations. Any teeth needing endodontic therapy should also be

treated at this time since further periodontal treatment would be meaningless if

endodontic treatment cannot be completed successfully.

4. Hopeless Teeth

If some teeth have been diagnosed as "hopeless" and they are not in a

strategic or vital position for temporary maintenance of occlusal relations, such

teeth should be extracted at this time. Partially impacted third molars with

communication to the oral cavity, or teeth with advanced periodontal disease or

deep caries without functional or esthetics value, should also be extracted.

5. Temporary Splinting

Although temporary splinting for hyper mobile teeth have not proved to

be useful in promoting periodontal healing during therapy, their use, however,

may expedite such treatment procedures as scaling, occlusal therapy, and

surgical periodontal therapy.

6. Thorough Scaling and Root Planning

Fine scaling and root planning are necessary to eliminate irritation from

subgingival calculus and contaminated cementum.

31

7. Recontouring of Defective Restorations

With few exceptions rough, overcontoured, overhanging, or

subgingivally located restorations and orthodontic appliances may be associated

with pronounced accumulation of plaque and periodontal inflammation. Like

calculus, such restorations or appliances interfere with efficient plaque control

and must be corrected or removed to allow for reduction or elimination of

gingival inflammation. Correction of faulty restorations is as important as the

removal of calculus and should therefore be completed at the same time.

Adequate plaque control by the patient on teeth with restorations is feasible only

if the restorations are well contoured and their surface is smooth.

32

Appendix D: Introduction and use of the Oral Hygiene Indices

Periodontal disease is caused by bacteria or bacterial products from the dental

plaque, and by their affects on the periodontal tissues. It is possible that the pathogenic

influence is mainly caused by a few species of bacteria in the plaque. Other indigenous

organisms may have little significance in the etiology of periodontal disease. So far,

however, there is no routine method available that can selectively eliminate the

pathogenic microorganisms from the plaque. Our treatment efforts, therefore, have to be

directed against the dental plaque itself.

In cause-directed periodontal disease treatment, removal of plaque and all

plaque-retaining factors along with prevention of new plaque formation is without

comparison, the most important part of our therapy.

Removal of the supragingival plaque is the responsibility of the patient during

the active treatment phase as well as during the subsequent life-long maintenance phase.

Motivating and training the patient to achieve an acceptable level of oral hygiene is the

dentist's responsibility and is one of the most difficult tasks in periodontal therapy. The

HYGIENE FORM has been introduced as an aid both to the student and to the patient in

achieving this goal. It will only fulfill its intentions when its being used according to the

following directions.

Gingival/Plaque Index

1. Dental Indices

The Gingival index (G.I.) by Leِ and Silness (1963) should be used .

The criteria are as follows:

0 = healthy gingiva

1 = redness with slight edema

2 = redness with edema and bleeding upon probing or touching the

gingiva.

3 = Severe inflammation, edema and spontaneous bleeding.

P1.I.% record the percent of plaque covered surfaces in the mouth. This

means that you divide the number of plaque covered surfaces with the total

number of surfaces and multiply that with 100. Exclude occlusal surfaces. Use

Oral Hygiene Form No. 2 for average plaque score (%) in mouth.

33

2. Registration of Plaque

First of all, fill in the Hygiene status No., the patient's name and date.

Then x-out the missing teeth so that the chart coincides with the actual number

of teeth in the mouth (in original form and in the duplicate) by black or blue ink.

Please note that all four surfaces of each tooth are to be examined for

plaque: the facial, lingual and proximal surfaces. Hence, the total number of

surfaces is equal to the number of teeth present multiplied by four.

The plaque is then registered following disclosure by staining solution or

tablets. Always use the disclosing agent in accordance with instructions given

by the manufacturer. Tablets are usually to be chewed and swashed

continuously for one minute, then the patient may rinse once. Disclosing

solutions are to be applied directly a with cotton pallet. Wait one minute and let

the patient rinse once.

Inspect all tooth surfaces (proximal surfaces must be inspected from both

the lingual and the facial sides). Mark the plaque-covered surfaces in red on the

tooth diagram. If you are in doubt whether plaque is present or not, use the side

of the probe. soft material adhering to the probe indicates plaque. Fill-in the

number of plaque-covered surfaces on the right-hand side of the form, and

calculate the plaque percentage (as mentioned above). Always write the

instructions (demonstrations) given to the patient that day in the lower right-hand

part of the form.

3. Registration of Bleeding

Bleeding on probing should be noted by a short red dot (•) outside the

probe surface area. If bleeding is found in two neighboring proximal areas, be

aware that the two dots (•) must be separate and distinct.

Bleeding on probing is registered within 30 seconds following the

insertion of the probe in the periodontal pockets in exactly the same way as

during probing for periodontal pockets. It may therefore be convenient to probe

three teeth and then go back to register the bleeding areas before continuing with

the pocket depth measurements on the remaining teeth.

34

The bleeding percentage is calculated in the same manner as the plaque

percentage, except that the number of tooth surfaces equals the number of teeth

present multiplied by 6 (surfaces).

After further explaining to the patient what you found in his/her mouth,

you can now proceed to demonstrate to him/her the correct technique to remove

the plaque.

4. Oral Hygiene Instruction

A satisfactory level of plaque control by the patient is essential for

periodontal therapy to be effective. To achieve this, it is necessary to motivate

the patient and instruct the patient in the methods to be utilized. Unfortunately,

this aspect of patient management is often not given the emphasis it deserves. In

such instances, patients seldom reach their full ability to practice proper oral

hygiene measures by the time of the re-evaluation appointment, and treatment

becomes delayed.

Patients should understand that most of what we do, e.g. surgery, etc. is

not in itself a "cure", but rather a mean to facilitate daily plaque control. Many

patients are products of the era before plaque was "in vogue", and consider what

the dentist does every six months to be sufficient to control disease. Convey the

lack of truth behind this information to the patient on a level he/she can

understand.

OHI re-enforcement should be given at the beginning of each visit,

before any plaque is removed by scaling or polishing. By setting aside time for

OHI, at the start of each visit, you convey to the patient the importance of his/her

participation in the therapy and also have enough time to do an adequate job.

Instruction requires active participation by the patient. Showing a patient

where plaque has been left and telling the patient to brush and/or floss better will

not be effective unless you work with the patient with the brush and/or floss in

his hand.

The OHI regimen must be suitable for the need of a given patient. For

example, patients with crowded teeth, bridges or exposed furcations usually

require a customized regimen with devices which specifically enable them to

35

reach problem areas. Also, patients with physical or mental impairment will

often require a modification of OHI regimen, as well as a modification of our

expectations concerning their level of performance.

Despite our most conscientious efforts at OHI, there are a number of

patients who will not be motivated to maintain a satisfactory daily level of

plaque control. Not all patients have the same values as we do. It is important,

therefore, to document your activities with respect to OHI, and the patient's level

of performance that the treatment plan can be modified accordingly. The

patients in this category are difficult to detect but usually are those who brush

and floss well only on the day of the appointment and thus, present with

persistent, generalized inflammation and little or no plaque. Role of miswak and

its effective method of use should be highlighted to patient with the message for

cleanliness.

Diagnosis of Patients Failure in the Performance of Oral Hygiene Procedures

a. The practitioner may fail to motivate the patient to become a "co-therapist".

b. The practitioner may assume a level of knowledge which the patient does not

posses and therefore provides incomplete or insufficient instruction.

c. Failure to recognize that the patient's reported behavior and actual behavior may

differ.

d. The practitioner may fail to establish a line of communication due to:

· Failure to establish a mutual confidence

· Failure to establish a credibility.

e. Failure to evaluate the adequacy of previous instructions:

· Positive approach is more effective than institution of fear.

· Praise efforts rather than demean poor plaque control.

· Patient must be shown areas of plaque retention.

f. Failure to reinforce previous instructions at each appointment.

g. Failure to re-evaluate and re-educate as necessary following periodontal surgery:

· Exposure of more clinical crown introduced new problems of

management.

· Good plaque control is absolutely essential for post-surgical success.

36

Oral Hygiene Instructions (Chairside Procedures)

First Appointment

Oral hygiene instructions should be given immediately after motivation but

BEFORE beginning scaling, root planning and polishing.

1. Show the patient evidence of dental disease in his/her own mouth. With the use

of a hand mirror show:

a. caries (evidence of existing disease).

b. restorations (evidence of past caries).

c. gingival inflammation (alteration in color and/or consistency).

d. gingival bleeding (evidence of active disease).

e. periodontal pockets (the result of disease).

2. Explain that the bacteria on the teeth are the main cause of the above diseases

and point out that they (bacteria) are usually invisible to the naked eye.

3. Ask the patient to rinse for at least one minute with disclosing solution.

4. While the patient is rinsing, explain that the solution contains a harmless

vegetable dye which stains only that part of the tooth which is "dirty" or has

bacteria on it.

5. After patient rinses a couple of times with clear water, determine the Plaque

Index (PlI) and record this in the treatment record.

6. Show relationship of red dye to areas of disease. Re-emphasize the point that the

red dye represents bacteria.

7. Ask the patient to show what tooth brushing technique he/she is currently using.

If the patient did not bring the toothbrush, open a new toothbrush pack, moisten

the bristles and ask the patient to show you his/her brushing technique.

8. Re-examine the mouth and point out areas which were missed.

9. Correct the technique where indicated. Make sure that the patient shows you the

correct technique in his/her mouth.

10. Be sure to emphasize that the main objective of using the brush is to "brush the

red off" or remove the bacteria.

11. Remind the patient to bring the toothbrush for each subsequent session.

37

Second Appointment

This is the suggested procedure when seeing your patient for the first time

following the introduction of oral hygiene instructions. Careful attention must be given

to the sequence outlined below:

1. Review the patient's record for any notations regarding:

a. past performance

b. what was dispensed (e.g. Butler 311 toothbrush, Proxa brush).

c. any special instruction given (e.g. bridge cleaning).

d. problem areas (furcations)

2. Greet the patient in your usual friendly manner and ask how he/she managed

with the use of the disclosing tablets. If he replies that they have not been used,

determine the reason. It is important to do this because somewhere along the

line you failed to convince the patient of the importance of visualizing the

plaque. It may be that they find something objectionable about the taste or the

coloration of the dye in the tablet. Nevertheless, it is important to determine why

they were not used and an effort should be made to correct this.

3. If the patient replied that they worked well but that several areas were difficult to

reach, ask the patient to show you where these areas are. Ask the patient when

they last brushed their teeth. This is important because the amount of debris or

plaque on the teeth may give you an idea of how efficiently the patient is

cleansing his teeth. For example, if the patient states that they brushed their

teeth several hours before the dental appointment and the disclosing stain reveals

extensive dental plaque, not only in covering the tooth but also in bulk and/or

thickness, this would indicate that the patient is not properly performing oral

hygiene.

4. Ask the patient to present their toothbrush. If they say they forgot it, do not

supply them with another but re-emphasize the point that it is necessary for the

instructional session for them to bring their toothbrush. They may buy a new

toothbrush from the pharmacy.

38

5. Examine the patient's mouth for any deposits, materia alba or food debris. If any

of these are present, it should be pointed out to the patient and emphasize that the

accumulation of these materials is the result of improper cleansing. The

presence of visible plaque and/or materia alba and food debris is indicative of a

poor response to oral hygiene training.

6. Areas that previously exhibited inflammation or bleeding should be reviewed.

Patients should be shown any improvement.

7. Ask the patient to use disclosing dye and determine:

a. the presence of plaque.

b. distribution of plaque.

c. thickness of plaque (thicker plaque indicates "older plaque").

Perform and record the Plaque Index in the patient chart in the

"Record of Treatment".

8. The patient should first be complimented on any improvement in his oral

hygiene and then attention must be directed to areas which were missed. At this

time, areas which were cited by the patient as difficult to clean should be

observed and patient should be aided with his own toothbrush in properly

cleaning those areas. If there is some improvement in brushing technique, then

dental floss should be suggested and demonstrated at this time for efficient

interproximal cleansing.

Note:

The above procedure should be followed on all subsequent appointments

until patients demonstrate ability and willingness to perform proper oral hygiene.

Then it should be performed on an intermittent bases for reinforcement. During

these follow-up appointments, it is important to determine whether the problems

is due to lack of motivation or lack of skill. If it is lack of skill, an electric

toothbrush might be suggested. If it is lack of motivation, then you have failed

to motivate your patient.

You must record your findings, recommendation and any oral hygiene

devices which you dispensed to the patient in the "Record of Treatment" section

of the patient's file. It is not enough to only write "OHI given".

39

9. Interproximal cleaning: In addition to dental floss, several other interdental

cleaning aids are available. Given below is a guide to select proper interdental

oral hygiene aids:

a. Type I Embrasure - use dental floss or Super floss.

b. Type II Embrasure - slight to moderate recession. Use proximal brush

(Butler Proxa Brush).

c. Type III Embrasure - extensive recession, loss of papillae. Use proxa

brush or end-tufted brush.

In short, use the largest suitable device for cleaning the

interproximal space.

10. Review the OHI lecture notes given in 211 PDS for more details.

Recommended Schedule for Home Use of Disclosing Tables

Rx: 12 Disc. tabs. (Red-cote X-pose)

Use in the evening after last meal as follows:

1. Chew tablets and swish for one minutes.

2. Look in the mirror and find stained (red) areas on teeth.

3. Use toothbrush, with toothpaste and dental floss (or suitable interdental cleaning

aid) to remove the red bacterial plaque.

4. After brushing, chew another tablet and see if any other areas were missed.

5. Use toothbrush and other aids again to remove this stain. Teeth must be

thoroughly cleaned.

6. After 3 to 4 days, change the procedure as follows.

7. Clean the teeth thoroughly first without using disclosing tablet.

8. When you are satisfied that your teeth are clean, then chew a disclosing tablet.

9. Look for and thoroughly remove any plaque remaining.

10. After that, use the tablets once a week, to check yourself (always use after tooth

cleaning).

40

Appendix E: Procedures for Scaling, Root Planing and Polishing

Now that you have completed your session of introduction to Oral Hygiene

Instruction, and coronal scaling (where indicated) you are ready to begin scaling, root

planning and polishing.

The instruments should be arranged in the order that they will be used. (left to

right). In addition to routine examination instruments, the scaling kit contains the

following scaler and curette:

Towner U15/30 (scaler for anterior teeth)

Taylor 2/3 (scaler, for posterior teeth)

Columbia 4L/4R (universal curette-posterior teeth)

Gracey 3/4, 9/10, 11/12 & 13/14 (area specific curette)

Before beginning debridement (i.e. scaling and root planing), check with a

faculty member and tell him/her how much you intend to accomplish during this session

and how you intend to mange the case overall. The faculty will then either agree with

your plan or suggest alterations in your approach. (e.g. sextant by sextant handling vs

quadrant by quadrant treatment).

Remember that:

1. Patients with subgingival calculus always require more than one appointment to

complete the procedure. 4-6 appointments may be needed.

2. Avoid long appointments. It is better to have three, one hour session than one

three hour session. Progressive resolution of inflammation due to scaling and

root planing, combined with oral hygiene efforts of the patient, result in greater

visibility of calculus (shrinkage) and less bleeding.

3. One must try to be systematic. Do not instrument all areas of the mouth in the

first session (unless you are doing GROSS scaling). You may do coronal (gross)

scaling and polishing and then thoroughly scale and root plan individual

sextants/quadrants. This will depend on the amount of supragingival calculus

and on the complexity of the case. Local anesthesia should not be used unless

permission is given by an instructor.

41

4. Although individual sextants/quadrants/arches may be evaluated during a

clinical session, the scaling, root planning and polishing procedure is NOT

considered complete until the entire mouth had been evaluated by the instructor.

However, if for some unforseen circumtance, the patient fails to return for

further appointments after one or more scaling appointments, you will still get

credit for each segment/quadrant scaled.

An instructor with grade qualitatively while checking a sextant/quadrant.

5. Subgingival scaling and root planning is a very difficult procedure. Mastery of

the skills in this procedure requires continual practice, experience and expert

guidance. You are encouraged to seek assistance at any time during the

procedure but especially when you are encountering difficulties or have any

questions. It is better to seek help when you experience a problem rather than

wait until the end of the clinic session or waiting until the instructor is checking

and grading the procedure.

6. An Oral Hygiene evaluation MUST BE PERFORMED AT THE

BEGINNING OF EACH SCALING APPOINTMENT. The Pl.I. as

calculated on the Hygiene form is recorded on the "Treatment Record" along

with a brief narrative describing the patient's performance.

42

Appendix F: Surgical Treatment

The didactic information is covered in the course PDS 411 (Advanced

Periodontal Therapy). Following are guide lines to provide an overview of periodontal

surgery and for familiarity with the surgical treatment planning objectives.

The objective of periodontal therapy is the maintenance and/or recreation of a

dentition free of disease that is functional and esthetics. The major objective is the

attainment of an intact, secure gingival attachments to the teeth. In health, the gingival

attachment consists of a sulcus bounded on its lateral wall by sulcular epithelium, at its

base by epithelial attachment (junctional epithelium), and on its medial wall by the

tooth. The normal lining of the sulcus is non-keratinized, stratified squamous epithelium

with an absence of rete pegs. The epithelium may be considered as an infection barrier.

The gingival attachment depends on the gingival fiber apparatus for adherence of the

gingiva to the tooth. In disease, however, the inflammatory process causes destruction

of the gingival fibers and disruption of the epithelium. Adherence to the tooth is lost and

pocket formation becomes a major symptom. Histologically, the sulcular wall of the

gingiva consists of a wound.

The therapeutic objective, therefore, is the excision of the gingival wound and

production of a surgical wound, which, when the inflammatory state subsides results in

healing and re-adaptation of the gingival tissues to the tooth. The

prerequisites for surgical intervention are complete cleansing of the teeth, calculus

removal and adequate ability of the patient to keep the dentition free of plaque.

The word SURGERY has been defined as the "act and art of treating diseases or

injuries by manual operation". If we use this broad definition, nearly all periodontal

treatment from hard or soft tissue curettage falls under the meaning of the term

"periodontal surgery". In periodontics the term "periodontal surgery" is applied only to

specific surgical manipulations of the periodontal soft tissues and bone and not to

debridement and root planing. These latter procedures, however, play the decisive role

in the success or failure of the surgical procedure and/or therapy.

43

1. Objectives of periodontal surgery

Traditionally, all periodontal therapy has been aimed at pocket

elimination. Pocket elimination represents on objective of periodontal surgery.

Elimination of the periodontal pocket consists of reducing the depth of the

pockets to that of a physiologic sulcus. Pocket elimination is a critical factor in

restoring periodontal health and arresting the destruction of the supporting

periodontal tissues. The main objective for reducing the depth of the pocket to

that of a normal sulcus (1-3 mm) is to facilitate access by the patient to keep the

area free of plaque. The presence of a pocket creates areas which are impossible

for the patient to keep clean. Deeper pockets, therefore, usually need surgical

eradication (correction) because of the difficulty in removing plaque near the

pocket base by means of oral physiotherapy measures. Waerhaug states that "the

deeper the pocket, the shorter the distance from the plaque to the base of the

pocket". In shallow pockets of about 3 mm the distance between the plaque and

the base of the pocket may be 1 mm or more. In pockets ³6 mm the distance

may be as little as 0.2 mm, making removal with a scaler or curette difficult and

removal with a toothbrush, dental floss and interdental cleaners nearly

impossible. It is, therefore, safe to say that the main purpose for doing

periodontal surgery is to afford both the therapist and the patient better

accessibility to plaque removal.

Probably the most important criterion used over time in determining

whether periodontal surgery is necessary is the depth of the periodontal pocket.

Other than pocket depths there are also clinically recognized physical

characteristics of the gingival tissue, such as color, size and consistency, which

must be considered. While these are highly subjective in nature they are

considered very important in evaluating state of the gingival tissue. Changes in

these characteristics can lead to the conclusion that inflammatory activity is

present. For example, a change in consistency from firm resilient to soft or

spongy could be an indication of inflammatory condition. Hemorrhage from the

pocket upon provocation is one of the most objective signs of inflammatory

activity. This indicates crevicular vascularity and a decrease in mechanical

strength of the crevicular epithelium. Some recent studies have also

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demonstrated a high correlation between the volume of GCF flow and severity

of inflammation. GCF can be used, therefore, as an indicator of early as well as

advanced gingival disease.

Clinical Signs of Periodontal Disease Activity

A priority listing of the signs of periodontal disease is:

a. Propensity of hemorrhage

b. Pocket depth

c. Crevicular fluid

d. Color, size, shape, consistency of the gingiva

The major purpose of the foregoing discussion section is to suggest that

periodontal health should be used as a criteria used disease elimination and control as a

goal, rather than pocket elimination by itself. However, once the need for surgical

therapy has been established, various techniques can be utilized. This will be briefly

discussed in the following section.

The objectives of periodontal surgery can thus be summarized in the following

list:

a. Elimination of periodontal pockets by removing soft tissue and/or recontouring

it.

b. Elimination of pockets by removing osseous tissue and/or recontouring it.

c. Correct mucogingival deficiencies and deformities.

d. Correct gingival contour that interferes with oral hygiene.

e. Prepare for restorative dentistry (e.g. crown lengthening).

f. Establish drainage from gingival or periodontal abscess turn an acute periodontal

problem into a more treatable state.

g. Improve esthetics appearance for tissue overgrowth or recession.

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Timing of Periodontal Surgery

Except for treatment (drainage) of acute periodontal abscess, all periodontal

surgery should be postponed until one month after completion of the "Initial Therapy

Phase" of periodontal treatment (also known as Initial Preparation). Initial therapy

phase represents one of the most essential phases of therapy. The primary goal of initial

therapy is to reduce or eliminate the local factors responsible for the inflammatory

periodontal disease. In this way the clinical signs of inflammatory disease can be

removed and/or reduced, and the case can be better evaluated for other techniques of

periodontal therapy.

Importance of Initial Therapy

Scaling, root planning and good home care hopefully will result in shrinkage of

the gingival tissue, followed by reattachment (or adaptation) of junctional epithelium

which may restore a physiologic gingival crevice in areas that had been considered for

surgery. Therefore, the need for periodontal surgery may be eliminated and/or reduced.

Observing the patient during the hygienic phase gives an indication of what can

be expected by way of patient cooperation in oral hygiene in the future. Such

information is important in selecting the type of periodontal surgery that will yield the

best results. It must be emphasized that periodontal surgery may do more harm than

good if adequate cooperation and plaque control cannot be established.

Technically, it is easier to perform accurate surgery when the initial incisions can

be made in fibrotic gingival tissues than in gingival tissues that are soft, edematous, and

hemorrhagic. Surgical management of the tissue including precise suturing is facilitated

by its firmness. The chances for harmful sequel such as loss of attachment associated

with periodontal surgery, are reduced when the surgery is done on fibrous, firm, gingival

tissues and teeth that are plaque-free. Performing periodontal surgery on teeth that have

been scaled and root planed and are devoid of plaque, will create a local environment

that is favorable for tissue regeneration.

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Contraindication to Periodontal Surgery

As a general principle, periodontal surgery is contraindicated for persons who

have any systemic illness in which surgery may endanger their health.

1. Bleeding disorders

Periodontal surgery involves a traumatic disruption of the tissues and

necessarily causes some bleeding. Any hemorrhagic disorder of severe nature,

such as hemophilia, thrombocytopenic purpura and so forth usually constitutes a

contraindication to periodontal surgery, unless bleeding can be controlled.

2. Lower resistance to infection

Periodontal surgery is contraindicated for patients, with severely

impaired defense mechanisms against bacterial infection such as seen in

neutropenia. Uncontrolled diabetes may also interfere with normal antibacterial

response to surgery.

3. Specific considerations

Patients with a short-life expectancy are candidates for palliative

periodontal procedures rather that periodontal surgery.

4. Poor oral hygiene

Periodontal surgery is definitely contraindicated for persons who will not

keep their teeth clean during initial therapy.

Types of Periodontal Surgical Procedures

The following is an example of periodontal surgical procedures classified into

two groups:

A. Pocket Elimination Surgery

1. Gingival Curettage

2. Gingivectomy/Gingivoplasty

3. Various types of Flap Operations

· Mucogingival Flap (unrepositioned)

· Mucogingival Flap (apically repositioned)

4. Osseous Surgery

· Bone Grafts

· Ostectomy/Osteoplasty

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B. Non-Pocket Elimination Surgery

1. Mucogingival Surgery

· Free Gingival Graft

· Pedicle Grafts

· Bone Denudation procedures

Theoretical Methods for Pocket Elimination

a. Shrinkage

b. Resection

c. Reattachment

d. Apical positioning

In cases of infrabony defects, the osseous defect itself must be eliminated in

order for pocket elimination to be successful. This can be accomplished by:

a. Obtaining reattachment to the tooth by formation of new bone "filling-

in" of the defect (induction).

b. Removing the walls of the bony defect (ostectomy/osteoplasty)

c. Combination of the above procedures (a) and (b).

Residual pocket depths and probable correct periodontal therapy

Pocket depth in mm Tissue State Therapy

Gingivitis £3 mm 4mm 4-5 mm

Inflamed Edematous Fibrous

Sc & Rp Sc & Rp Scaling & gingivectomy

Periodontitis 4 mm 5 mm 5-8 mm

edematous horizontal bone loss infrabony pockets

Sc & Rp and/or Curettage Root planing/gingivectomy Sc & Rp & flap surgery

c:Perio Clinical Manual

/betchay.updated September 9, 2003