periodontal diagnoses and treatment planning

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.

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

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

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

Both sextants have CPITN scores of 3

4 & 5mm pocketsHealthy, with two 4mm pockets. No calculus or bleeding.

PSR= 1 0 0 1 2 0

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 sextantMagnitude of improvement

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

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

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

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 DiseaseLocation Severity Type of DiseaseGingivitisGeneralized Moderate Chronic PeriodontitisGeneralized Severe Aggressive PeriodontitisLocalized Severe Necrotizing PeriodontitisGingivitis on a reduced periodontium

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 FactorsTissue Breakdown Products & Ecological Factors

Antibody

MMPs

Prostanoids

Cytokines

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 factorsModerate- 1 risk factorHigh- 2 or more risk factors

Page 2004McGuire 2011Kornman 2011

Major Risk Factors for Future Disease

1) Past history of periodontitis2) Smoking3) Type 1 and 2 diabetes mellitus4) Poor oral hygiene and irregular

professional maintenance5) Obesity

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

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

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

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

Perio Treatment Planning and Patient Management Considering Risk Factors

1. Risk factor reduction DietOral hygiene motivationSmoking cessation Blood sugar control

2. Risk profile assessment Medical historyMedications

Perio 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)

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. DM control? Physician consult?2. OHI mod Bass, interproximal care, mouthrinse3. Periodontal exam4. Scaling and root planing under LA5. Systemic antibiotic-doxycycline or amox & met6. Reevaluation with new perio exam in 3-6 mo

a) Good result: Recalls every 3-6 months initiallyb) Poor result: Localized? Local antibioticc) Generalized? Low dose doxycycline?d) Plaque sampling/salivary diagnostics?e) 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 23 2 3

1. OHI interproximal care2. No periodontal exam3. Dental prophylaxis, possible localized SRP4. No systemic or local antibiotic5. 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 22 2 3

1. Smoking cessation2. Physician consult3. OHI good; reinforce4. Periodontal exam5. Dental prophylaxis, possible localized SRP6. 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

1 0 01 2 0

1. Periodontal exam if >1 year since last2. Reinforce OHI interproximal care3. Dental recall cleaning4. No systemic or local antibiotic5. 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 44 4 4

1. Motivational interview2. ?

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

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 sensitivityNote: 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

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 hygienistTargeted 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 Periodontitis28 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?Gregory.Smith2@ihs.gov

Questions?Gregory.Smith2@ihs.gov