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Periodontal Diagnoses and Treatment Planning
G. Todd Smith, DDS, MSD IHS National Consultant, Periodontics
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Objectives:
•Accurately detect periodontal diseases using a screening index.
•Accurately diagnose and record a patient’s periodontal condition.
•Analyze risk to determine treatment and recall intervals.
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CPITN- Community Periodontal Index (of Treatment Needs), was developed in the mid 1980’s for screening populations.
It is essentially the same as the
PSR- Periodontal Screening and Recording, which was approved by the ADA and AAP in 1992 for screening patients for periodontal diseases.
CPITN- Community Periodontal Index (of Treatment Needs), was developed in the mid 1980’s for screening populations.
It is essentially the same as the
PSR- Periodontal Screening and Recording, which was approved by the ADA and AAP in 1992 for screening patients for periodontal diseases.
Detection of disease
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CPI/PSR Review
0- Healthy Tissues1- Bleeding upon probing2- Calculus/overhangs and no depth
>3mm3- At least one pocket 4-5mm deep4- At least one pocket 6mm or greaterX- Less than 2 teeth/sextant
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Probe comparison: WHO vs 3-6-9-12mm
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This is the worst finding- a 3.5mm probing depth with no calculus or bleeding on probingThis is the worst finding- a 3.5mm probing depth with no calculus or bleeding on probing
What is the sextant score?
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Pre and Post Scaling & Root PlaningPre and Post Scaling & Root Planing
Both sextants have CPITN scores of 3
4 & 5mm pocketsHealthy, with two 4mm pockets. No calculus or bleeding.
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PSR= 1 0 0
1 2 0
PSR= 1 0 0
1 2 0
Same CPITN. Same diagnosis?
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Indicators of periodontal disease Indicators of periodontal disease
•Visual redness or swelling of papilla/gingiva•Bleeding on probing•Calculus•Pockets•Mobility•Furcation involvement•Recession•Loss of attachment•Radiographic bone loss
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CPITN/PSR doesn’t measure: Extent of disease in the sextantMagnitude of improvement
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Perio exams in a public health settingWhen?
• AAP/ADA: Multiple sextant scores of 3 or > 1 sextant of 4
• Clinic’s policy, dependant on resources available.
Note: If billing private insurance for SRPs, a perio exam should be provided
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Intraoral xrays underestimate defect depth by 1.4mm Zybutz 2000
Vertical defect depth underestimated by mean of 2.2mm Cadaver study, Langen 1995
Underestimation of bone loss:Okeson 1992
Panoramic 13-32%BW’s 11-23%PA’s 9-20%
30-50% of bone volume/densityneeds to be lost before detection on xray possible.
Radiographs and bone loss
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Periodontal Diagnoses• Gingivitis- red, bleeding gums, sometimes enlarged, swollen, or tender.
Generally with no attachment or bone loss.------------------------• Chronic periodontitis -usually slowly progressive disease with loss
of gum attachment and bone.• Aggressive Periodontitis- Highly destructive, with rapid attachment
loss and bone destruction, usually affecting patients under age 30 years of age.
Location: Localized < 30% of sites involvedGeneralized > 30% of sites involved
Severity: Slight- 3-4mm pockets, up to 30% bone loss Moderate 4-6 mm probings, up to 50% bone lossSevere > 6mm probings, >50% bone loss
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Other Periodontal Diagnoses• Abscesses of the periodontium• Perio-endo lesions • Necrotizing ulcerative gingivitis and periodontitis• Perio as a manifestation of systemic disease
• Rare genetic and blood disorders (cyclic neuropenia, histiocytosis, leukemia)
• Developmental or acquired deformities• Mucogingival deformities or conditions around teeth: For example
recession, limited or no gingiva, high frenums, gingival overgrowth • Occlusal trauma- primary and secondary
• Gingivitis on reduced periodontium• Use if the periodontitis has been treated and is stabile/not
breaking down- no pockets increases or attachment loss
Most diagnoses will be gingivitis or chronic perio!
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Examples of Classifying by Location, Severity, and Type of DiseaseLocation Severity Type of Disease
Gingivitis
Generalized Moderate Chronic Periodontitis
Generalized Severe Aggressive
Periodontitis
Localized Severe Necrotizing Periodontitis
Gingivitis on a reduced periodontium
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After Kornman, 1997.
Pathway to Periodontal DiseaseGenetic Risk Factors
Host Immuno- inflam-matory
Response
MicrobialChallenge
ConnectiveTissue
andBone
Metabolism
Clinical Signs ofDisease
PMN
Antigens
LPS
Other VirulenceFactors
Environmental & Acquired
Risk Factors
Tissue Breakdown Products & Ecological Factors
Antibody
MMPs
Prostanoids
Cytokines
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Risk: predicts likelihood of developing disease and its future progression
Risk: predicts likelihood of developing disease and its future progression
33 y.o. with localized mild to moderate chronic perio in a well controlled diabetic who smokes 3-10 cigs/day. Taking diabetes, cholesterol lowering, and antihypertensive medications.
62 y.o. with generalized moderate chronic perio taking antihypertensive medications.
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RiskRisk
Diagnosis, prognosis, and treatment planning in the absence of risk information may result in over- or under treatment.
Try putting patients into periodontal risk categories and match the intensity of treatment to risk:Low- no major risk factorsModerate- 1 risk factorHigh- 2 or more risk factors
Page 2004McGuire 2011Kornman 2011
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Major Risk Factors for Future Disease
1) Past history of periodontitis
2) Smoking
3) Type 1 and 2 diabetes mellitus
4) Poor oral hygiene and irregular professional maintenance
5) Obesity
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Major Risk Factors for Future Disease6) Systemic factors and inflammation
Rheumatoid arthritisChronic kidney diseaseHematologic disorders- e.g. leukemiaNeutrophil deficiencies
AgranulocytosisNeutropeniaLeukocyte Adhesion DeficiencyHistiocytosis
Genetic diseasesCheidak Higashi DiseaseDown’s syndromePapillon-LeFavre
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Other Periodontal Risk Factors:(which can become major risk factors)Other Periodontal Risk Factors:(which can become major risk factors)
Stress & Immunocompromised individualsHormonal variationsCertain medicationsAnatomic considerations IL-1 genetic polymorphism Nutritional factorsFaulty dentistryAlcohol
Multiple risk factors increase risk exponentially; not just in an additive manner. 3 factors= 9X risk Nagelberg 2010
Stabholz 2010Kornman 2011
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Public Health in Periodontics
Identify those at low risk for periodontal breakdown
Target those at high risk for perio breakdown
Treat them before advanced perio occurs
Provide individualized recall when appropriate
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Recalls decrease tooth loss in patients with severe periodontitis.
Recalls are more important for tooth preservation than plaque scores.
Patients who didn’t comply with recalls were more
than 5X more likely to have tooth loss. Checci 2002
Preventing Tooth Loss
Recall intervals can be extended beyond 6 months for low risk patients. Mettes 2005
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Perio Treatment Planning and Patient Management Considering Risk FactorsPerio Treatment Planning and Patient
Management Considering Risk Factors
1. Risk factor reduction Diet
Oral hygiene motivation
Smoking cessation
Blood sugar control
2. Risk profile assessment Medical history
Medications
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Perio Treatment Planning and Patient Management Considering Risk FactorsPerio Treatment Planning and Patient
Management Considering Risk Factors
3. Eliminate infectionMechanical- ultrasonics and curetsSurgical- blades or lasersTopical antimicrobials- toothpastes, mouthrinsesLocal antimicrobials - gels, chips, spheresSystemic antimicrobials – antibiotics, probiotics
4. Modulate the host response/inflammationLocal with surgery- proteins, GFs, BMPSystemic- enzyme suppressors (LDD), anti-
inflammatories and antioxidants, NSAIDS (experimental)
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Perio Treatment Planning and Patient Management Considering Risk FactorsPerio Treatment Planning and Patient
Management Considering Risk Factors
Match the intensity of periodontal treatment to risk. Those at high risk:
• Aggressive monitoring• Aggressive bacterial control- topical, local
and systemic antibiotics• Address modifying factors (OH, smoking,
DM, xerostomia)• Consider host modifying drugs (e.g. LDD,
antioxidants, or anti-inflammatories)
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38 y.o. with generalized moderate chronic periodontitis, taking dm and antihypertensive medications. No dental care X 8 yrs. HbA1c 9.2. PSR 3\2\3\4\3\4
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1. DM control? Physician consult?
2. OHI mod Bass, interproximal care, mouthrinse
3. Periodontal exam
4. Scaling and root planing under LA
5. Systemic antibiotic-doxycycline or amox & met
6. Reevaluation with new perio exam in 3-6 moa) Good result: Recalls every 3-6 months initially
b) Poor result: Localized? Local antibiotic
c) Generalized? Low dose doxycycline?
d) Plaque sampling/salivary diagnostics?
e) Motivate to OH! Check A1c. Periodontist referral if possible.
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53 y.o. with localized moderate chronic periodontitis taking antihypertensive (lisinopril) and oral dm medications. HbA1c 7.2
1 0 23 2 3
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1. OHI interproximal care
2. No periodontal exam
3. Dental prophylaxis, possible localized SRP
4. No systemic or local antibiotic
5. Perio recall 6 months. Check A1c and PSR
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33 y.o. with localized mild to moderate chronic perio in a well controlled diabetic (HbA1c 6.8) who smokes 3-10 cigs/day. Hx cleaning elsewhere 1 yr ago. Taking diabetes, cholesterol lowering, and antihypertensive medications (amlodipine). No caries.
2 3 22 2 3
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1. Smoking cessation
2. Physician consult
3. OHI good; reinforce
4. Periodontal exam
5. Dental prophylaxis, possible localized SRP
6. Perio recall 6 months. Check A1c and PSR
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30 y.o. with gingivitis on a reduced periodontium, (generalized severe aggressive periodontitis; treated, on recall), good health, no meds, no caries, on recall
1 0 01 2 0
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1. Periodontal exam if >1 year since last
2. Reinforce OHI interproximal care
3. Dental recall cleaning
4. No systemic or local antibiotic
5. Perio recall 6 months
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32 y.o. with generalized moderate to severe chronic perio. Type 2 DM but doesn’t monitor BS. Taking oral hypoglycemics and lisinopril. No hx dental tx as an adult
4 3 44 4 4
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1. Motivational interview
2. ?
Rx HbA1c/physician consult OHI Perio exam SRP/LA with extraction of hopeless teeth (or full edentulation) Systemic doxycyclineReevaluation after 3-4 monthsPeriodontist referralRemovable prosthetics and 3 month recalls with good oral hygiene and periodontal health
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Periodontal exam and SRP:
1. … with antimicrobial irrigation- 71%
2. … with local antibiotics- 71%
3. … antimicrobial oral rinse- 77%
4. … with laser subg curettage- 20%,
5. … with systemic abx- 9%)
No one did saliva testing or culture and sensitivity
Note: Periodontist referral if > 5mm probings remain after treatment- 11%
Current Trends in Nonsurgical Periodontal Treatment n=35RDH and DDS/DMD in CA, Jolkovsky,Inside Dent 11/2012
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Povidone-Iodine-10% solution Betadine® and Aplicare® PI Prep solution Use 2.5 % (1/4 dilution) to 10% Solution Use in severe perio, HIV asso. perio,
abscesses, or refractory disease Inexpensive Nasty Taste Use in a small syringe (3ml endo syringe)
with a blunt needle- Dilute 1:1 and flush in the deeper pockets 3x over 10 mins immediately after scaling. J. Slots 2011
Contraindications: Allergy to iodine or shellfish Thyroid dysfunction Pregnancy Not for routine home care (decreases
thyroid synthesis; goiter)
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Teamwork in managing perio in federally mandated programsTeamwork in managing perio in federally mandated programs
Who is going to scale this patient?
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Establishing and Maintaining Perio Health in Federally Mandated Programs:
Triaging Periodontal/Hygiene Care
Hygienist/s able to meet the need.
Regular recalls provided:
DDS- Exam and Treatment Plan, Perio Tx? RDH- OHI, Perio Tx, and Recall DA- TB Prophy, OHI
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Establishing and Maintaining Perio Health Triaging Periodontal/Hygiene Care
Hygienist/s unable to meet the need.
Targeted recalls provided to those at moderate to high risk of breakdown:
DDS- Exam and tx plan; perio tx of severe cases requiring extractions if desired.
RDH- OHI, perio tx of moderate to severe cases, and those recalls.
DA- Gingivitis to mild perio (CPITN 1,2,3), select gross debridements, prophys, and recalls.
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Establishing and Maintaining Perio Health Triaging Periodontal/Hygiene Care
No hygienist
Targeted recalls provided to those at moderate to high risk of breakdown:
DDS- Exam and tx plan, perio tx of moderate to severe cases and their recalls.
DA- Gingivitis to mild perio (CPITN 1,2,3), select gross debridements, prophys, and select recalls.
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Perio EF Clinics
3-4 Chairs
Patients with CPITN’s of 1,2,&3
RDH or DDS provide check in and check out, and probings and anesthesia if indicated.
DA provides OHI and ultrasonic therapy; hand scale with advanced training.
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Initial Therapy- Diabetic Protocol-1997(SRP/LA and doxycycline 100mg bid X 14 d)
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3 Months Re-evaluation
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2010: After 13 years of very infrequent care. Re-tx SRP 2002 and 2008, 1 recall 2009. BS still in the 200’s. Gums healthier except upper ant.
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Generalized Severe Chronic Periodontitis28 y.o. with FBS 347. Protocol treatment
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Perio health improved 2 months post-protocol
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Severe periodontal breakdown in a poorly controlled diabetic after no dental care for 2 years post protocol.
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Summary:• Save clinic time with the PSR screen. Know its
limitations.
• Treatment plan with risk evaluation- those at greater risk may need more aggressive therapy.
• If all patients can be recalled-GREAT. If demand exceeds resources, target your recalls.
• The consequences of periodontal undertreatment could be more than the loss of a few teeth.