Download Public Health in Periodontics

Periodontal Diagnoses and
Treatment Planning
G. Todd Smith, DDS, MSD
IHS National Consultant, Periodontics
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.
Detection of disease
CPITNCommunity 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.
CPI/PSR Review
0 1 2 3 4 X
Healthy Tissues
Bleeding upon probing
Calculus/overhangs and no depth >3mm
At least one pocket 4-5mm deep
At least one pocket 6mm or greater
Less than 2 teeth/sextant
Probe comparison: WHO vs 3-6-9-12mm
This is the worst finding- a 3.5mm probing
depth with no calculus or bleeding on probing
What is the sextant score?
Pre and Post Scaling & Root Planing
4 & 5mm pockets
Healthy, with two 4mm pockets.
No calculus or bleeding.
Both sextants have CPITN scores of 3
PSR= 1 0 0
120
Same CPITN. Same diagnosis?
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
CPITN/PSR doesn’t measure:
Extent of disease in the sextant
 Magnitude of improvement

Perio exams in a public health setting
When?
•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
Radiographs and bone loss
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/density
needs to be lost before
detection on xray possible.
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 involved
Generalized > 30% of sites involved
Severity:
Slight- 3-4mm pockets, up to 30% bone loss
Moderate 4-6 mm probings, up to 50% bone loss
Severe > 6mm probings, >50% bone loss
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!
Examples of Classifying by Location,
Severity, and Type of Disease
Location Severity
Type of Disease
Gingivitis
Generalized Moderate Chronic Periodontitis
Generalized Severe Aggressive Periodontitis
Localized
Severe
Necrotizing Periodontitis
Gingivitis on a reduced periodontium
Pathway to Periodontal Disease
Genetic Risk Factors
Antibody
PMN
Host
Antigens
Microbial
ImmunoChallenge
inflamLPS
matory
Other Response
Virulence
Factors
Cytokines
Connective
Tissue
Prostanoids
and
Bone
Metabolism
MMPs
Environmental
& Acquired
Risk Factors
Tissue Breakdown Products & Ecological Factors
After Kornman, 1997.
Clinical
Signs of
Disease
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.
Risk

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 factors
Moderate- 1 risk factor
High- 2 or more risk factors
Page 2004
McGuire 2011
Kornman 2011
Major Risk Factors for Future Disease
1)
2)
3)
4)
5)
Past history of periodontitis
Smoking
Type 1 and 2 diabetes mellitus
Poor oral hygiene and irregular
professional maintenance
Obesity
Major Risk Factors for Future Disease
6) Systemic factors and inflammation
 Rheumatoid arthritis
 Chronic kidney disease
 Hematologic disorders- e.g. leukemia
 Neutrophil deficiencies
 Agranulocytosis
 Neutropenia
 Leukocyte
Adhesion Deficiency
 Histiocytosis

Genetic diseases
 Cheidak
Higashi Disease
 Down’s syndrome
 Papillon-LeFavre
Other Periodontal Risk Factors:
(which can become major risk factors)
Stress & Immunocompromised individuals
 Hormonal variationsMultiple risk factors
 Certain medications increase risk
exponentially; not just in
 Anatomic considerations
an additive manner.
 IL-1 genetic polymorphism
 Nutritional factors 3 factors= 9X risk
Nagelberg 2010
 Faulty dentistry
 Alcohol

Stabholz 2010
Kornman 2011
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
Preventing Tooth Loss
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
Recall intervals can be extended beyond 6 months
for low risk patients.
Mettes 2005
Perio 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
Perio Treatment Planning and Patient
Management Considering Risk Factors
3. Eliminate infection
Mechanical- ultrasonics and curets
Surgical- blades or lasers
Topical antimicrobials- toothpastes, mouthrinses
Local antimicrobials - gels, chips, spheres
Systemic antimicrobials – antibiotics, probiotics
4. Modulate the host response/inflammation
Local with surgery- proteins, GFs, BMP
Systemic- enzyme suppressors (LDD), antiinflammatories and antioxidants,
NSAIDS (experimental)
Perio 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)
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
1.
2.
3.
4.
5.
6.
DM control? Physician consult?
OHI mod Bass, interproximal care, mouthrinse
Periodontal exam
Scaling and root planing under LA
Systemic antibiotic-doxycycline or amox & met
Reevaluation with new perio exam in 3-6 mo
a)
b)
c)
d)
e)
Good result: Recalls every 3-6 months initially
Poor result: Localized? Local antibiotic
Generalized? Low dose doxycycline?
Plaque sampling/salivary diagnostics?
Motivate to OH! Check A1c. Periodontist referral
if possible.
53 y.o. with localized moderate chronic
periodontitis taking antihypertensive (lisinopril)
and oral dm medications. HbA1c 7.2
1 0 2
3 2 3
1.
2.
3.
4.
5.
OHI interproximal care
No periodontal exam
Dental prophylaxis, possible localized SRP
No systemic or local antibiotic
Perio recall 6 months. Check A1c and PSR
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 2
2 2 3
1.
2.
3.
4.
5.
6.
Smoking cessation
Physician consult
OHI good; reinforce
Periodontal exam
Dental prophylaxis, possible localized SRP
Perio recall 6 months. Check A1c and PSR
30 y.o. with gingivitis on a reduced periodontium,
(generalized severe aggressive periodontitis;
treated, on recall), good health, no meds, no
caries, on recall
100
120
1.
2.
3.
4.
5.
Periodontal exam if >1 year since last
Reinforce OHI interproximal care
Dental recall cleaning
No systemic or local antibiotic
Perio recall 6 months
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 4
4 4 4
1.
2.
Motivational interview
?
Rx HbA1c/physician consult
OHI
Perio exam
SRP/LA with extraction of hopeless teeth (or
full edentulation)
Systemic doxycycline
Reevaluation after 3-4 months
Periodontist referral
Removable prosthetics and 3 month recalls
with good oral hygiene and periodontal health
Current Trends in Nonsurgical Periodontal Treatment
n=35RDH and DDS/DMD in CA, Jolkovsky,Inside Dent 11/2012
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%
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)
Teamwork in managing perio in
federally mandated programs
Who is going to scale this patient?
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
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.
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.
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.
Initial Therapy- Diabetic Protocol-1997
(SRP/LA and doxycycline 100mg bid X 14 d)
3 Months Re-evaluation
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.
Generalized Severe Chronic Periodontitis
28 y.o. with FBS 347. Protocol treatment
Perio health improved 2 months post-protocol
Severe periodontal breakdown in a poorly
controlled diabetic after no dental care for 2
years post protocol.
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.
Questions?
[email protected]
Questions?
[email protected]