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Periodontal Treatment Protocol (PTP) for the general dental practice.

A sequence of interrelated steps is inherent to effective periodontal treatment: early and accurate diagnosis, comprehensive treatment, and continued periodontal maintenance and monitoring. A primary goal of periodontal therapy is to reduce the burden of pathogenic bacteria and thereby reduce the potential for progressive inflammation and recurrence of disease. Emerging evidence of possible perio-systemic links further reinforces the need for good periodontal health. In the private practice setting, the treatment of patients with periodontal disease is best accomplished within the structure of a uniform and consistent Periodontal Treatment Protocol (PTP). Such a protocol would reinforce accurate and timely diagnosis, treatment needs based on a specific diagnosis, and continual assessment and monitoring of outcomes. This is best achieved if everyone in the practice setting has a general understanding of the etiology of periodontal diseases, the benefits of treatment, and potential consequences of nontreatment. Communication skills and patient education are vital components of effective therapy since slight and even moderate stages of the disease often have few noticeable symptoms to the patient. Accurate documentation and reporting of procedures for dental insurance reimbursement, coupled with scheduling considerations, assist general practice settings in effectively managing the increasing volume of patients that can benefit from early diagnosis and treatment of periodontal diseases. This article presents the essential elements of a PTP including diagnosis, treatment planning, implementation of therapy, assessment and monitoring of therapy, insurance coding, introduction of the patient to periodontal therapy, and enhanced verbal skills. In addition, considerations for implementation of adjunctive local delivery antimicrobials is presented.

Key Words: periodontal diseases, periodontal diagnosis, treatment protocol, periodontal maintenance, periodontal assessment, patient education

Introduction

Hujoel et al (1) estimated a 31% decrease in the prevalence of periodontitis between the years 1955 and 2000. Further, these authors estimate an additional 8% decrease by the year 2020. In spite of the decreased use of smoking tobacco, (2) better understanding of the pathogenesis of periodontal diseases, and more refined and goal directed therapies, there remains evidence that dentistry is not consistently achieving a timely diagnosis and appropriate and timely treatment of existing periodontitis. (3,4) Although the evidence is limited, there is a strong suggestion that use of a periodontal probe for diagnosis and recording of periodontal status in treatment records in general dental practices has yet to achieve the level of a routine and consistent habit. (5-9) Indeed, McFall et al (8) determined that except for radiographs, most private practice patient records were so deficient in diagnostic information that periodontal status could not be established. It should be self-evident that treatment requires a definitive diagnosis, ie, a disease cannot be adequately treated unless first diagnosed. In this regard, it is interesting to note that at least one study has reported a disconnect between dentists' perception of treatment rendered and actual treatment as recorded in patient records. (10) As an example, prophylactic procedures out-number periodontal procedures by a ratio of 20: l (11,12) and yet the prevalence of chronic periodontitis (slight, moderate, and severe) is estimated to range from a low of 7% (aged [greater than or equal to] 18 years) (13) up to 35% (aged [greater than or equal to] 30-90 years) (14)the US adult population.

Cobb et al. (3) compared the pattern of referral of periodontitis patients in 1980 vs 2000 using patient record data from 3 geographically-diverse private periodontal practices. Results showed the following trends occurring over the 20-year time span: decreased use of tobacco; increase in the percentage of cases exhibiting advanced chronic periodontitis with a concomitant decrease in the percentage of mild-moderate disease cases; increase in the average number of missing teeth per patient; and increase in the average number of teeth scheduled for extraction per patient. A similar study by Docktor et al (4) based on patient records from 3 private periodontal practices located within a major metropolitan area reported the following: 74% of referred cases were considered advanced periodontitis, of which 30% were treatment planned for extraction of 2 or more teeth; periodontal treatment provided by the general dental office did not vary because of disease severity: and the average number of periodontal maintenance visits/patient/year in the general dental office was less than the standard of care according to severity of disease, eg, 68% of advanced periodontitis cases reported between 0 and 2 periodontal maintenance visits per year rather than the recommended every 3 months. Viewed in aggregate, the trends reported by Cobb et al (3) and Docktor et al (4) support the assertion that timely diagnosis and appropriate and timely treatment of chronic periodontitis have not significantly improved over time. A major reason for the reported scarcity of timely diagnosis and appropriate treatment may be the lack of a well-established office protocol for the diagnosis, treatment, maintenance, and monitoring of periodontal disease, and involvement of the patient through education. Obviously, this requires dedication of energy, resources, effective communication skills, and a change in practice philosophy.

The Periodontal Treatment Protocol (PTP)

Diagnosis

Regardless of recent advances in our understanding of the etiology and pathogenesis of the periodontal diseases, the assessment of traditional clinical parameters remain the foundation for periodontal diagnosis. (15) Generally, such clinical parameters include probing depth (PD), bleeding on probing (BOP), clinical attachment level (CAL), degree of furcation involvement, extent of gingival recession, tooth mobility, and plaque score. Clinicians typically utilize the results from the periodontal exam, radiographs, and the patient's medical and dental histories to establish a diagnosis and evolve a goal/diagnosis-directed treatment plan. It has been clearly demonstrated that different interpretations of the same diagnostic information can have a dramatic impact on treatment decisions. (16) For this reason, a standardized approach to periodontal assessments and a working protocol as to treatment parameters would fill a logical need in the average general practice setting. However, due to extensive overlaps in most classification systems, any standardized approach is subject to variations in both clinical assessments (eg, variations in probing depth among clinicians) as well as the interpretation thereof.

All effective treatment protocols begin with a thorough and timely diagnosis. Six-point probing to measure PD and BOP is the standard of care. Based on the needs of the patient, current radiographs should be evaluated to determine the location and percentage of bone loss. The presence, location, and extent of furcation invasions should be noted, as well as the location of the gingival margin or CAL. Also, the patient's age is an important factor, especially in cases of rapidly progressing disease and determining overall long-term prognosis.

A modified version of the American Academy of Periodontology (AAP) proposed guidelines for a comprehensive periodontal examination is presented in Table 1. (17) However, with respect to a functional PTP for the general dental practice, only the following principal diagnostic criteria can be addressed: age, PD, CAL, BOP, tooth mobility, furcation involvement, and percentage of radiographic bone loss. It must be emphasized that these criteria represent the minimal parameters for determining a periodontal diagnosis. There are many other important risk and modifying factors that will impact development and progression of disease and all such factors must be taken into consideration when establishing a definitive diagnosis and a diagnosis-driven treatment plan. (18)

Age is of relative value in that advanced amounts of periodontal destruction at an earlier age tend to indicate a more aggressive form of periodontitis. In contrast, chronic periodontitis may slowly progress towards severity over several years or decades. Young age combined with moderate to severe bone loss presents a tenuous long-term prognosis and requires more aggressive therapy compared to the older patient presenting with a chronic form of periodontitis. (19)

Probing depth (PD) is defined as the distance from the gingival margin to the base of the gingival crevice. (20) The periodontal pocket, represented by a probing depth > 3 mm, is the principle habitat for gram-negative, anaerobic pathogenic bacteria. (20) Deeper pockets tend to represent more extensive destruction of the underlying periodontium and, therefore, a potentially greater pathenogenic burden.

Clinical Attachment Level (CAL) is defined as the distance from the CEJ to the base of the probable crevice/pocket. In cases of gingival recession, the amount of recession is added to the PD to yield the total amount of CAL. Although more difficult to obtain, it is a better measure of the total extent of damage to the underlying periodontium. (20-22)

Mobility is best measured by the blunt end of 2 instruments alternating pressure in a facial-lingual direction and an apical direction to assess abnormal movement of the tooth. Simply assessed: Grade I mobility is slightly more than normal; Grade II is moderately more than normal; Grade III is severe mobility facial-lingually plus apical displacement (23) Mobility patterns are suggestive of possible occlusal trauma, severe inflammation, and/or loss of supporting alveolar bone.

Furcations represent bone loss between the roots of multi-rooted teeth. A deeply invasive furcation lesion is the equivalent of a poor long-term prognosis for the involved tooth. Simply put, a Grade 1 furcation involvement is incipient bone loss only; a Grade 2 is partial loss of bone producing a cul-de-sac; a Grade 3 is total bone loss with through-and-through opening of the furcation; and a Grade 4 is similar to a Grade 3, but with gingival recession that visually exposes the furcation opening. (24)

Radiographic Evidence of Bone Loss is best determined with adequate and current radiographs, (17) most typically a full-mouth periapical survey, including vertical bite-wings, or a panographic radiograph supplemented with vertical bite-wings and selected periapical films. By definition, true periodontitis does not begin until bone loss occurs. (25) Radiographic evaluation of the distribution and severity of bone loss, bone density, root anatomy, and approximation to other teeth provides specific information that will help in determining a proper diagnosis, treatment plan, and prognosis.

Bleeding on Probing (BOP) is a simple assessment of the inflammatory status of the gingiva. (15,26) In patients with deeper pockets and/or loss of clinical attachment, the chances of disease progression are greater as the percentage of bleeding sites increase. (27) Conversely, lack of BOP is highly correlated with stability and a lack of inflammation. (28) This latter statement, however, does not apply to smokers as they tend to bleed less when compared to nonsmokers with equal amounts of disease. (29)

In addition to the usual clinical parameters, the clinician is well advised to consider other risk factors and their potential impact on the development and progression of plaque-induced periodontal diseases. (18) Risk factors that are sometimes overlooked in the diagnosis, treatment plan, and prognosis equation include, among others: diabetes, smoking, osteoporosis, compromised immune system, drug-induced gingival conditions, hormonal changes, and genetics. Patients at risk for periodontal disease are often allowed to "slip between the cracks" during a routine visit because they may be in the early stages of the disease. Risk factors increase a patient's chance of developing periodontitis. The presence of one or more of these risk factors may also indicate a benefit from specialty referral in some patients.

Case Types and Periodontal Diagnosis

As part of a PTP it is necessary to establish diagnostic guidelines that will provide a framework for organizing the treatment needs of the patient. Guidelines are not meant to replace clinical knowledge or skills, nor do they imply a one-size-fits-all treatment plan for periodontal disease. It is recognized that each dental practice setting is different. Consequently, guidelines are intended to be used in a manner that best meets the needs of the specific patient.

Generally speaking, plaque-induced periodontal diseases have historically been categorized into gingivitis versus periodontitis based upon whether attachment loss has occurred. The 1999 International Workshop for Classification of Periodontal Diseases (21) reclassified the plaque-induced periodontal diseases into 7 different classifications. In consideration of a working PTP that addresses only the common periodontal diseases, this paper will address health, gingivitis, chronic periodontitis (formerly adult periodontitis), and aggressive periodontitis (formerly early-onset periodontitis). The first 7 entries in Table 2 (see back cover) constitute a set of clinical criteria (PD, BOP, percent bone loss, tooth mobility, degree of furcation involvement, and CAL) that will facilitate differentiation of health from gingivitis and between the various levels of severity of chronic periodontitis. Further, Table 2 can aid the clinician in differentiating between chronic and aggressive periodontitis.

Some practice settings may prefer a system of "Periodontal Case Types" for purposes of diagnosis and record keeping. Table 3 presents the diagnostic clinical criteria as applied to Case Types for health, gingivitis, chronic periodontitis (slight, moderate, and severe), and aggressive periodontitis. These criteria and Case Types are generally appropriate but should be considered as guidelines only and not as a definitive diagnosis. As mentioned before, there are numerous modifying and risk factors to consider prior to evolving a diagnosis and a diagnosis-driven treatment plan.

Treatment Planning

Development of a logical and properly sequenced treatment plan is a derivative of the periodontal assessment and diagnosis. Periodontal therapy is diagnosis-driven and, to the extent possible, should address all modifying factors and risk factors that impact development and progression of plaque-induced periodontal disease. An overview of a typical periodontal treatment plan is presented in Table 4. (30)

Implementation of Therapy

There are a wide variety of treatment options to be considered when confronted with gingivitis or chronic or aggressive periodontitis. However, thorough scaling and root planing (SRP) is still considered the gold standard in periodontal therapy. Beyond SRP, no one treatment modality is the answer in every case. However, the clinician must have specific endpoints or goals that therapy should achieve. If such endpoints are not achieved, then therapy must be re-evaluated and a decision made concerning retreatment or specialty referral for consideration of more advanced therapy options. Treatment options that should be considered include: (30)

* Patient education including plaque control and counseling in management of periodontal and systemic risk factors

* Scaling and root planing

* Consideration of adjunctive chemotherapeutic agents, eg, locally or systemically administered antibiotics and host response modification agents.

* Re-evaluation

* Consideration of referral to a specialist is an option that must be considered for both legal and ethical reasons. (31) There are a variety of reasons to consider referral to a periodontist, such as, SRP in the presence of extreme amounts of dental calculus or SRP with complications of systemic disease, gingival over-growth and/or inflammatory hyperplasia, resective surgery, regenerative procedures for soft and hard tissues, periodontal plastic surgery, occlusal therapy, pre-prosthetic surgery, dental implants, management of perio-systemic complications, phobic patients requiring conscious sedation, etc.

Periodontal Maintenance Therapy and Continual Assessment

In general, data suggests that patients who have undergone definitive therapy for either localized or generalized periodontitis should be managed by periodontal maintenance (PM), performed at an interval of 3 months for an indefinite period of time following active therapy. (32) The 3-month interval is critical (and the standard of care for moderate and severe chronic periodontitis and aggressive periodontitis) as it has been repeatedly shown to be effective in reducing disease progression, preserving teeth, and controlling the subgingival bacterial burden. (33-35) Nonetheless, the PM schedule should be individualized and tailored to meet the needs of each patient. Factors such as home care, previous level of disease, tendency toward refraction, stability indicators, etc, should be used in making this assessment. More fragile patients may need intervals of 2 months or less, and conversely, patients intercepted in early disease states who demonstrate consistent stability may need less frequent intervals of 4-6 months. Regardless of the interval between appointments, the periodontal status of each patient should be re-evaluated at every maintenance appointment. Only through close monitoring can disease recurrence be detected and the maintenance interval adjusted accordingly. Continual assessment of the periodontium during maintenance affords the best opportunity for assuring long-term stability or providing interceptive care.(34,35)

Insurance Coding

The American Academy of Periodontology's Parameters of Care 2000 (36) and the American Dental Association's Current Dental Terminology (37) are available to clinicians to guide decision-making related to providing therapeutic periodontal treatment and subsequent reporting of services for insurance reimbursement. In terms of nonsurgical periodontal therapy, familiarity with dental insurance codes provides a clear method to document treatment and select appropriate procedures to maximize insurance reimbursement for the patient.
Figure 2. Facts about dental insurance to share with patients.

Understanding Dental Insurance

1. Dental insurance is a contractual agreement between the employer
and insurance company. The percentage of reimbursement varies
greatly dependent upon the premiums paid for a particular plan and
limitations of the agreement.

2. Maximum payable benefits around $1000 - $1500 commonly found
today with dental insurance plans are almost identical to the
annual maximum benefit of dental insurance plans 40 years ago.

3. Dental insurance is a benefit designed to help defray the costs
of quality dental care, but is not all-inclusive of what an
individual may need or desire to obtain optimal dental health for a
lifetime.


Table 5 presents a modified description of the ADA insurance codes most commonly used in Phase I periodontal therapy (aka anti-infective therapy or nonsurgical therapy). The descriptions are intended to reveal distinctive differences between procedures, and guide the clinician in reimbursement procedures.

To simplify decisions made by patients, dental insurance should be referred to as "reimbursement," "benefit," or "assistance" by the clinician and other staff members rather than "coverage" since the word implies complete. Most patients with dental insurance will find it necessary to supplement whatever insurance benefit they receive toward lifetime periodontal care, as many plans have contract limitations for the percentage of reimbursement associated with various procedures and/or the length of time those benefits apply. For example, limitations of some insurance plans assign benefits for PM following SRP but only for 24 months following active therapy. As another example, exclusions found in other insurance plans assign benefits for SRP for generalized periodontal disease but not for localized infection. Many patients are reticent to proceed with treatment unless their insurance will "pay for it." Consequently, it is advantageous for practices to have clear explanations about the reality of dental insurance. Figure 2 presents a sample explanation of dental insurance that can be shared with patients, assisting them in making independent decisions about treatment, regardless of the insurance reimbursement schedule.

Patient Education and Introduction to Periodontal Therapy

Effective implementation of the aforementioned concepts requires expertise in effective patient education and introduction of periodontal therapy so that patients are prepared to make wise health decisions. Being proficient in SRP procedures has little value to the patient who assumes they are visiting the dental hygienist for a "routine cleaning." This is particularly true if the patient already has a developing or existing periodontal infection and does not understand the need for therapeutic intervention. Chronic periodontal diseases often provide few noticeable symptoms, especially in earlier stages of development. Thus, the need for effective communication, education, and listening skills are of particular importance to today's dental patient.

The incidence of moderate and severe generalized chronic periodontitis in the US appears to affect only 5% to 15% of the adult population, whereas slight disease affects approximately 35% of the adult population. (13,14,38) Thus, most new patients and even many existing patients will ultimately be diagnosed with periodontal diseases. To be effective at enrolling patients into active therapy everyone in the practice setting must have a basic understanding of the etiology of periodontal diseases, treatment options, consequences of nontreatment, and direct benefits of therapy. Patients are more motivated to accept treatment recommendations when a clear diagnosis has been established, they are given the opportunity to see infection in their own mouths, their questions have been answered, and they understand the value of treating periodontal infection in relation to their overall health.

Many clinicians inform patients of their periodontal status while working in their mouths with sharp instruments, or give a summary of findings at the end of the visit. Most patients are visual learners. Consequently, patients need to see the condition of their own mouth. At the beginning of every appointment, during data collection and tissue assessment, the patient should be provided a mirror to visualize with the clinician the evidence of periodontal disease, caries, gingival recession, tooth mobility, furcation involvement, etc. (Figure 1). During periodontal probing, the patient should hear the pocket measurements as data is being collected and recorded. In a similar manner, during examination of the radiographs, the patient should be shown evidence of permanent bone loss, and contrast that to areas without bone loss. Involving the patient in the discovery process visually and audibly is a powerful tool to help patients take ownership in their own health.

[FIGURE 1 OMITTED]

This is also an opportune time for the clinician to introduce adjunctive therapies to the patient such as the use of locally delivered antimicrobials and other agents. For example, the clinician can communicate that locally delivered antimicrobials have been on the US market for many years and have been shown to be a safe, effective treatment option. Important information to convey includes the ease of application; the high potency of the drug at levels that will kill bacteria; it does not affect the rest of the body; and there is no need for an additional appointment to remove the product since the agent biodegrades. Educating the patient to all of their treatment options is vital to clear and evidence-based communication.

Enhanced Communication Skills

Each clinician will develop his/her own style of case presentation for periodontal therapy and will individualize the message to different patients. However, there is significant advantage if the entire office staff has continuity in key words that are used when discussing periodontal therapy with patients. Equally important is the avoidance of minimizing messages such as "just a little bit of bleeding," or "a little bone loss," or "just a little bit of plaque." It is advisable to use language that does not trivialize conditions that are not yet severe. Terms such as "slight bleeding," "early bone loss," or "slight plaque" accurately describe findings without overstating them. Periodontal disease is a bacterial infection leading to a host immune response that is characterized by inflammation and degradation of periodontal tissues. (22) When informing patients of periodontal disease, using the word "infection" is more powerful than "gum inflammation" and can create a sense of urgency regarding treatment. The word "hemorrhage" indicates heavy bleeding and implies a condition outside healthy parameters. When the patient's gingival tissues hemorrhage easily upon provocation, "hemorrhage" rather than "bleeding gum tissue" should be verbalized to the patient. The words "scaling and root planing" may sound confusing to patients or imply discomfort. The words "periodontal therapy" are effective semantic choices when informing ] patients about necessary periodontal treatment. "We now know" are words that can introduce patients to new ideas I or treatment options to explain why information may be different than what they have heard in the past, or expected to hear at their current visit. "Halting" or "arresting disease" can be used to describe a measurable goal for treating periodontal diseases that should be obtained through intervention. "Daily disease control" communicates to the patient that they share in the role in the effective removal of plaque bacteria beyond what it achieve through periodontal treatment.

Even though some states require written consent, effective communication between the clinician and the patient is the important consideration of informed consent, (39) not the completion of a form. Therefore, deliberate semantic choices should be shared by all members of the office staff to optimize patient understanding of their periodontal conditions.

Suggestions for Implementation of a Periodontal Treatment Protocol in the General Practice Setting

* General dentists and dental hygienists should schedule a meeting with referring periodontists and their dental hygienists to share philosophies of periodontal treatment and establish clarity for referrals.

* Schedule a team meeting workshop to bring all office staff up-to-date regarding periodontal assessments, diagnosis, case types, periodontal risk factors, individualized treatment of periodontal diseases, consequences of nontreatment (tooth loss and possible systemic involvement), and the value of periodontal maintenance.

* Establish continuity of the verbal skills and terminology the office staff will utilize to communicate effectively to patients about periodontal conditions.

* Include assessments and diagnosis of periodontal diseases in all new patient visits, routine prophylaxis appointments, and ongoing periodontal maintenance to insure no patient is overlooked regarding diagnosis of developing periodontal disease or recurring disease.

* Select appropriate ADA Insurance Procedure Codes for reporting periodontal procedures in order to maximize the patient's benefit.

* Share insurance information with patients to assist them in reducing their dependence on dental insurance benefits, thereby enabling them to make independent health decisions related to treatment of periodontal diseases.

Guide for Use of Locally Delivered Antimicrobials

Where to use locally delivered antimicrobials:

* Pockets [greater than or equal to] 5 mm with bleeding on probing (BOP).

** The locally delivered antimicrobial may be used at the time of scaling and root planing (SRP) or at the re-evaluation appointment 4-6 weeks following SRP. If used first at the re-evaluation appointment, the site must have additional SRP to remove biofilm and hard deposits that may have re-accumulated. * Residual pockets of [greater than or equal to]5 mm with BOP or any site [greater than or equal to]6 mm following initial SRP.

** Determined at re-evaluation appointment.

** If [greater than or equal to] 4 residual pockets in a given quadrant then consider either retreatment (SRP) with locally delivered antimicrobial or surgical intervention.

* Sites treatment planned for osseous grafting.

** Locally delivered antimicrobial placed 3 weeks prior to surgical procedure.

* Periodontal abscess

* Probing depth at the distal-facial line-angle of 2nd molars related to 3rd molar extractions where surgical intervention will yield a compromised result.

* Ailing/failing dental implants (peri-implantitis) where surgical intervention is not indicated or will yield a compromised result.

* Grade II furcation involvements (shallow or deep) when surgical intervention is not planned.

Who might benefit from use of locally delivered antimicrobials:

* Periodontal maintenance patients with isolated probing depths of [greater than or equal to]5 mm that exhibit BOP or any pocket [greater than or equal to] 6 mm (Figure 3).

* Patients wanting to avoid periodontal surgery.

* High risk surgery patients.

** Poorly controlled (brittle) diabetic patients

** Patients with a history of recent or recurrent coronary or cerebrovascular events.

** Patients with a compromised immune system due to disease or medications.

** Kidney dialysis patients.

** Heavy smokers (>1/2 pack/day)

** Patients with physical disability that impacts oral hygiene efficiency

** Mentally handicapped patients

* Patient's with marginal oral hygiene that is not likely to improve and thereby represent a poor surgical risk.

* Please note that locally applied antimicrobials may need to be placed more than one time to achieve the desired result.

[FIGURE 3 OMITTED]

How to apply locally delivered antimicrobials:

* For optimal effect from locally delivered antimicrobials the following must be achieved:

** Oral hygiene instructions and patient compliance regarding the necessary oral hygiene procedures, ie, tooth brushing, use of interdental hygiene aids such as dental floss and proxabrushes, and use of antimicrobial oral rinses.

** Supragingival scaling and polishing.

** Definitive subgingival SRP (generally under local anesthesia).

** Place locally delivered antimicrobial according to manufacturer's directions. For example, in the case of minocycline microspheres, place one pre-measured dose per pocket. If the tooth has 2 pockets that need local delivery, 2 full doses should be administered.

** The pocket should be as biofilm and deposit free as possible prior to insertion.

** Insert the locally delivery product to the base of the pocket. In the case of minocycline microspheres, the tip should be placed as far into the pocket as possible before activating the syringe/handle (Figures 4 and 5).

[FIGURE 4 OMITTED]

Addendum:

* If probing depths are [greater than or equal to] 4 mm, the clinician should consider a conventional adult prophylaxis coupled with oral hygiene recommendations and/or reinforcement

** If the patient exhibits multiple probing depths of 4 mm a periodontal maintenance interval of 3-4 months should be considered until it can be determined if the patient's periodontal status is stable and/or improving.

[FIGURE 5 OMITTED]

Disclosure

Dr. Sweeting, Ms. Davis, and Dr. Cobb are scientific advisors for OraPharma, Inc.

References

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Larry A. Sweeting, DDS; Karen Davis, RDH, BSDH; Charles M. Cobb, DDS, PhD
Table 1. Modified Version of the American
Academy of Periodontology Suggested Guidelines
for a Comprehensive Periodontal Examination. (18)

Assessment of medical history

Assessment of dental history

Assessment of periodontal risk factors

 1. Age
 2. Gender
 3. Medications
 4. Presence of plaque and calculus (quantity and distribution)
 5. Smoking
 6. Race/Ethnicity
 7. Systemic disease (eg, diabetes)
 8. Oral hygiene
 9. Socioeconomic status and level of education

Assessment of extraoral and intraoral structures and tissues

Assessment of teeth

 1. Mobility
 2. Caries
 3. Furcation involvement
 4. Position in dental arch and within alveolus
 5. Occlusal relationships
 6. Evidence of trauma from occlusion

Assessment of periodontal soft tissues including peri-implant tissues

 1. Color
 2. Contour
 3. Consistency (fibrotic or edematous)
 4. Presence of purulence (suppuration)
 5. Amount of keratinized and attached tissue gingiva
 6. Probing depths
 7. Bleeding on probing
 8. Clinical attachment levels
 9. Presence and severity of gingival recession

Radiographic evaluation of alveolar bone loss, bone density,
furcations, root shape, and proximity, etc.

Table 2. Periodontal Diagnostic Guidelines.

Case
Indicator Healthy Gingivitis

Pocket [less than or [less than or
Depth (a) equal to] 3 mm equal to] 4 mm

Bleeding Upon No Yes (b)
Probing

Six-Point Yes Yes
Probing

Bone Loss None None

Tooth None None
Mobility (c)

Furcation (d) None None

Clinical None None
Attachment
Loss (CAL) (e)

Other No Only gingival
 inflammation tissues affected
 by the
 inflammatory
 process

 * No alveolar
 bone loss
 * Localized or
 generalized

Assessment * Prophy * Prophy
 * OHI * OHI

Active * Prophy * Prophy
Therapy * OHI * OHI

Ongoing 6 Months 6 Months
Maintenance * Prophy * Prophy
 * OHI * OHI

Case Slight Moderate
Indicator Periodontitis Periodontitis

Pocket 4-5 mm 5-6 mm
Depth (a)

Bleeding Upon Yes (b) Yes (b)
Probing

Six-Point Yes Yes
Probing

Bone Loss [less than or [less than or equal
 equal to] 10% to] 33%

Tooth None [less than or equal
Mobility (c) to] Grade II

Furcation (d) < Grade I [less than or equal
 to] Grade II

Clinical 1-2 mm CAL 3-4 mm CAL
Attachment
Loss (CAL) (e)

Other Signs of inflammation Signs of inflammation
 may be present, may be present, including
 including * Edema
 * Edema * Redness
 * Redness * Suppuration
 * Suppuration * Alveolar bone level is
 * Alveolar bone level is 4-6 mm from CEJ
 3-4 mm from CEJ * Radiographic bone loss
 * Radiographic bone loss present
 present * Localized or
 * Localized or generalized
 generalized

Assessment * Comp. Oral Eval D0150 * Comp. Oral Eval D0150
 * Comp. Perio Eval D0180 * Comp. Perio Eval D0180
 * Four bitewings D0274 * Four bitewings D0274
 * Eight bitewings D0277 * Eight bitewings D0277
 * FMX D0210 * FMX D0210
 * Panoramic Film D0330 * Panoramic Film D0330
 * Full Mouth D4355
 Debride
 * Occlusal Analysis D9950

Active * Quadrant SRP D4341 * Quadrant SRP D4341
Therapy --UR, UL, LR, LL --UR, UL, LR, LL
 * Localized SRP D4342 * Localized SRP D4342
 --UR, UL, LR, LL --UR, UL, LR, LL
 * Locally D4381 * Locally D4381
 Administered Administered
 Antimicrobials Antimicrobials
 * OHI D1330 * OHI D1330
 * Specialty * Specialty
 Referral Referral
 * Other Treatments * Other Treatments

Ongoing * Perio Maintenance D4910 * Perio Maintenance D4910
Maintenance --3/4/6 months --3/4/6 months
 * OHI D1330 * OHI D1330
 * Locally D4381 * Locally D4381
 Administered Administered
 Antimicrobials Antimicrobials
 * Localized SRP D4342 * Localized SRP D4342
 --UR, UL, LR, LL --UR, UL, LR, LL
 * Other Treatments * Other Treatments

Case Advanced
Indicator Periodontitis Aggressive/Retractory

Pocket [greater than or [greater than or
Depth (a) equal to] 6mm equal to] 6mm

Bleeding Upon Yes (b) Yes (b)
Probing

Six-Point Yes Yes
Probing

Bone Loss [greater than or [greater than or
 equal to] 33% equal to] 33%

Tooth [less than or equal [less than or equal
Mobility (c) to] Grade III to] Grade III

Furcation (d) [less than or equal [less than or equal
 to] Grade III/IV to] Grade III/IV

Clinical [greater than or equal [greater than or equal
Attachment to] 5 mm CAL to] 5 mm CAL
Loss (CAL) (e)

Other Signs of inflammation Signs of inflammation
 may be present, including may be present, including
 * Edema * Edema
 * Redness * Redness
 Suppuration * Suppuration
 * Alveolar bone level is * Same clinical signs as
 [greater than or equal advanced but includes
 to] 6 mm from CEJ adolescents or
 * Radiographic bone loss young adults
 present * Localized or
 * Localized or generalized
 generalized * Rapid cycles of disease
 progression

Assessment * Comp. Oral Eval D0150 * Comp. Oral Eval D0150
 * Comp. Perio Eval D0180 * Comp. Perio Eval D0180
 * Four bitewings D0274 * Four bitewings D0274
 * Eight bitewings D0277 * Eight bitewings D0277
 * FMX D0210 * FMX D0210
 * Panoramic Film D0330 * Panoramic Film D0330
 * Full Mouth D4355 * Full Mouth D4355
 Debride Debride
 * Occlusal Analysis D9950 * Occlusal Analysis D9950
 * Specialty * Specialty
 Referral Referral

Active * Quadrant SRP D4341 * Specialty Referral
Therapy --UR, UL, LR, LL
 * Localized SRP D4342
 --UR, UL, LR, LL
 * Locally D4381
 Administered
 Antimicrobials
 * OHI D1330
 * Specialty Referral
 * Other Treatments

Ongoing * Perio Maintenance D4910 * Perio Maintenance D4910
Maintenance --3/4/6 months --3/4/6 months
 * OHI D1330 * OHI D1330
 * Locally D4381 * Locally D4381
 Administered Administered
 Antimicrobials Antimicrobials
 * Localized SRP D4342 * Localized SRP D4342
 --UR, UL, LR, LL --UR, UL, LR, LL
 * Other Treatments * Host Modulation

(a) Excluding gingival overgrowth and recession

(b) Bleeding upon probing may not be present in individuals with
periodontal disease who are smokers.

(c) Tooth Mobility: Grade I: Slightly more than normal; Grade II:
Moderately more than normal; Grade III: Severe mobility faciolingually
and mesiodistally, combined with vertical displacement. Adapted
from Newman MG, Takei H, Klokkevold PR, Carranza FA. Carranzas
Clinical Periodontology 10th ed. Philadelphia, PA: Elsevier; 2006.

(d) Furcation Grades: Grade l: Initial attachment loss with most of
the bone still intact in the furcation. No radiographic changes seen;
Grade II: The bone defect is definite horizontal bone loss that does
not extend all the way through. Vertical bone loss may also be present.
There is an opening into the furca with a bony wall at the deepest
portion. Grade III: Bone is lost across the whole width of the
furcation so no bone is attached to the furcation roof; Grade IV Bone
loss across the furcation, accompanied with gingival recession at the
furcation, is clinically visible. Adapted from Newman MG,
Takei H, Klokkevold PR, Carranza FA. Carranza's Clinical
Periodontology 10th ed. Philadelphia, PA: Elsevier, 2006.

(e) Adapted from Armitage GC. Development of a classification
system for periodontal diseases and conditions. Ann Periodontol
1999; 4(1):1-6

Adapted from Periodontal Diagnostic Guidelines [c] Pharma, Inc. 2008

Table 3. Clinical Criteria Assigned to Periodontal Case Types of
Health, Gingivitis, Chronic Periodontitis (slight, moderate, and
severe), and Aggressive Periodontitis.

 PD BOP
Case Type (mm) (Yes/No)

 0 (Health) 0-3 No
 I (Gingivitis) 0-4 Yes

 II (Slight Chronic 4-5 Yes
 Periodontitis)
 ([dagger])

III (Moderate Chronic 5-6 Yes
 Periodontitis)
 ([dagger])

 IV (Severe Chronic [greater than Yes
 Periodontitis) or equal to] 6
 ([dagger])

 V (Aggressive [greater than Yes
 Periodontitis) or equal to] 6
 ([double dagger])
 (age is
 significant factor)

 Bone Mobility Furcations
Case Type Loss (%) (Grade) (Grade)

 0 (Health) 0 None None
 I (Gingivitis) 0 None None

 II (Slight Chronic 10 1 1
 Periodontitis)
 ([dagger])

III (Moderate Chronic 33 I and II 1 and 2
 Periodontitis)
 ([dagger])

 IV (Severe Chronic > 33 I, II, or III 1, 2, 3, or 4
 Periodontitis)
 ([dagger])

 V (Aggressive > 33 I, II, or III 1, 2, 3, or 4
 Periodontitis)
 ([double dagger])
 (age is
 significant factor)

Case Type CAL Visual
 (mm) Inflammation
 0 (Health)
 I (Gingivitis) 0 No
 0 Yes (localized or
 II (Slight Chronic generalized) *
 Periodontitis) 1-2 Yes (localized or
 ([dagger]) generalized) *

III (Moderate Chronic
 Periodontitis) 3-4 Yes (localized or
 ([dagger]) generalized) *

 IV (Severe Chronic
 Periodontitis) [greater than Yes (localized or
 ([dagger]) or equal to] 5 generalized) *

 V (Aggressive
 Periodontitis) [greater than Yes (localized or
 ([double dagger]) or equal to] 5 generalized) *
 (age is
 significant factor)

* Localized disease is defined as [less than or equal to] 30% of
sites are involved; and generalized disease infers >30% of sites
are involved. (21)

([dagger]) Specialty referral may be indicated for additional
treatment beyond initial therapy.

([double dagger]) Specialty referral should be considered.

Table 4. General Overview of the Major Steps in a Typical
Periodontal Treatment Plan. (3)

Sequence of Major Phases

1. Address acute periodontal problems and/or pain

2. Review and update medical and dental histories

3. Assessment of systemic risk factors and refer for medical
consultation as needed

4. Extraoral examination

5. Oral cancer evaluation

6. Assessment of periodontal risk and modifying factors

7. Periodontal examination to include dental implants

8. Dental examination to include occlusal relationships and dental
implants

9. Radiographic examination

10. Establish a definitive diagnosis

11 Generate a diagnosis-driven periodontal treatment plan and
sequence of treatment

12. Determine required adjunctive restorative, prosthetic,
orthodontic, and/or endodontic treatments and sequence

13. Execute Phase I therapy (aka anti-infective or nonsurgical
therapy) with consideration given to adjunctive use of
chemotherapeutic agents

14. Re-evaluation (assessment) of Phase I therapy

15. If end-points are not achieved, consider selective retreatment,
need for surgical therapy, specialty referral, or use of adjunctive
diagnostic aides, eg, microbial, genetic, medical lab tests, etc.

16. Determine interval for periodontal maintenance and continued
assessment of periodontal status

Table 5. Modified Description of ADA Insurance Codes
Commonly Used for Phase I Periodontal Therapy
(aka anti-infective therapy or nonsurgical therapy).

Code
Number Treatment Procedure

D0180 Comprehensive
 Periodontal Evaluation

D1110 Adult Prophylaxis

D4355 Full Mouth Debridement
 to Enable Comprehensive
 Evaluation and
 Diagnosis

D4341 Scaling and Root
 Planing
 Generalized per
 Quadrant

D4342 Scaling and
 Root Planing
 Localized per
 Quadrant

D4381 Localized Delivery of
 Antimicrobial Agents via
 a Controlled Release
 Vehicle into Diseased
 Crevicular Tissue

D4999 Unspecified Periodontal
 Procedure, by Report

D4910 Periodontal Maintenance

Code
Number Description

D0180 Indicated for new or established
 patients showing signs or symptoms of
 periodontal disease and for patients
 with risk factors such as smoking
 or diabetes. It includes evaluation of
 periodontal conditions, probing and
 charting, evaluation and recording of
 the patient's dental and medical
 history and general health assessment.
 It may include the evaluation and
 recording of dental caries, missing or
 unerupted teeth, restorations, occlusal
 relationships and oral cancer evaluation.

D1110 Includes the removal of plaque, stain
 and calculus from tooth structures
 and is intended to control local
 irritation to gingival tissues, thereby
 preventing disease initiation.

D4355 Initial removal of plaque and calculus
 that interfere with the ability to
 perform a comprehensive oral evaluation.
 This preliminary procedure is generally
 followed by a comprehensive periodontal
 evaluation for diagnosis and subsequent
 therapeutic periodontal procedures.

D4341 Involves therapeutic treatment of 4 or
 more periodontally involved teeth
 per quadrant through definitive removal
 of subgingival plaque biofilm and
 root preparation in order to halt the
 disease from progressing, thereby
 creating an opportunity for healing. To
 be reported per quadrant inclusive
 of updated periodontal charting and
 radiographs for reimbursement.

D4342 Involves therapeutic treatment of 1 to
 3 periodontally involved teeth per
 quadrant through definitive removal of
 subgingival plaque biofilm and root
 preparation in order to halt the disease
 from progressing, thereby creating an
 opportunity for healing. To be reported
 per quadrant with identification of
 specific teeth being treated inclusive
 of updated periodontal charting and
 radiographs for reimbursement.

D4381 Subgingival insertion of antimicrobial
 medications of a therapeutic
 concentration into periodontal pockets
 that are released over a sufficient
 length of time in order to suppress the
 pathogenic burden, and are
 intended to enhance the clinical
 results of scaling and root planing
 alone. To be reported per tooth,
 identifying multiple treatment sites
 per tooth, if indicated, inclusive
 of a narrative describing systemic
 considerations for reimbursement such
 as tobacco usage, diabetes, or heart
 disease.

D4999 In the absence of a specific ADA code
 for complete periodontal re-assessment
 following definitive periodontal
 therapy, this procedure code is being
 utilized to determine healing response
 and future treatment recommendations.

D4910 Follows the completion of active
 therapy to treat periodontal infection
 for the lifetime of the dentition or
 implant replacements and includes
 removal of plaque biofilm and
 calculus from supra and subgingival
 surfaces. It may also include site
 specific scaling and root planing for
 areas of localized disease recurrence.
 It is intended to keep periodontal
 diseases under control; therefore a
 patient may move from active therapy
 to periodontal maintenance and back
 to active therapy and/or referral
 during the lifetime of the dentition
 or implant replacements. It is not
 synonymous with prophylaxis, and is
 required at varying intervals to manage
 periodontal diseases and modify risk
 factors. To be reported by both general
 and periodontal practices on patients
 having undergone active therapy
 irrespective of where the procedure is
 performed. Current periodontal charting
 documenting the patient's on-going
 periodontal status should be submitted
 for reimbursement.
COPYRIGHT 2008 American Dental Hygienists' Association
No portion of this article can be reproduced without the express written permission from the copyright holder.
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Author:Sweeting, Larry A.; Davis, Karen; Cobb, Charles M.
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Geographic Code:1USA
Date:Sep 1, 2008
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