Periodontal Treatment Protocol (PTP) for the general dental practice.
A sequence of interrelated in·ter·re·late
tr. & intr.v. in·ter·re·lat·ed, in·ter·re·lat·ing, in·ter·re·lates
To place in or come into mutual relationship.
in steps is inherent to effective periodontal periodontal /peri·odon·tal/ (per?e-o-don´t'l)
1. pertaining to the periodontal ligament or periodontium.
2. near or around a tooth.
1. 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 Pathogenic bacteria
Bacteria that produce illness.
Mentioned in: Gastroenteritis and thereby reduce the potential for progressive inflammation and recurrence recurrence /re·cur·rence/ (-ker´ens) the return of symptoms after a remission.recur´rent
1. 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 Periodontal Disease Definition
Periodontal diseases are a group of diseases that affect the tissues that support and anchor the teeth. Left untreated, periodontal disease results in the destruction of the gums, alveolar bone (the part of the jaws where is best accomplished within the structure of a uniform and consistent Periodontal Treatment Protocol (PTP (1) See peer-to-peer.
(2) (Picture Transfer Protocol) An ISO standard for transferring photos from a digital camera to a computer or photo printer. ). 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 etiology /eti·ol·o·gy/ (e?te-ol´ah-je)
1. the science dealing with causes of disease.
2. the cause of a disease. 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 Dental insurance is insurance designed to pay the costs associated with dental care. Dental insurance pays a portion of the bills from dentists, hospitals, and other providers of dental services. reimbursement Reimbursement
Payment made to someone for out-of-pocket expenses has incurred. , 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 In radiotherapy, Treatment Planning is the process in which a team consisting of radiation oncologists, medical radiation physicists and dosimetrists plan the appropriate external beam radiotherapy treatment technique for a patient with cancer. Typically, medical imaging (i.e. , 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
Hujoel et al (1) estimated a 31% decrease in the prevalence of periodontitis periodontitis
Inflammation of soft tissues around the teeth (see tooth). Poor dental hygiene leads to deposition of bacterial plaque on the teeth below the gum line, irritating and eroding nearby tissues. 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 pathogenesis /patho·gen·e·sis/ (path?ah-jen´e-sis) the development of morbid conditions or of disease; more specifically the cellular events and reactions and other pathologic mechanisms occurring in the development of disease. of periodontal diseases, and more refined and goal directed therapies, there remains evidence that dentistry dentistry, treatment and care of the teeth and associated oral structures. Dentistry is mainly concerned with tooth decay, disease of the supporting structures, such as the gums, and faulty positioning of the teeth. 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 A periodontal probe is an instrument in dentistry commonly used in the dental armamentarium. It is usually long, thin, and blunted at the end. The primary purpose of a periodontal probe is to measure pocket depths around a tooth in order to establish the state of health of the for diagnosis and recording of periodontal status in treatment records in general dental practices Noun 1. dental practice - the practice of dentistry
practice - the exercise of a profession; "the practice of the law"; "I took over his practice when he retired" 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 de·fi·cient
1. Lacking an essential quality or element.
2. Inadequate in amount or degree; insufficient.
a state of being in deficit. 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 disconnect - SCSI reconnect between dentists' perception of treatment rendered and actual treatment as recorded in patient records. (10) As an example, prophylactic prophylactic /pro·phy·lac·tic/ (pro?-fi-lak´tik)
1. tending to ward off disease; pertaining to prophylaxis.
2. an agent that tends to ward off disease.
n. 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 concomitant /con·com·i·tant/ (kon-kom´i-tant) accompanying; accessory; joined with another.
concomitant adjective Accompanying, accessory, joined with another 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 according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. 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 Scarcity
The basic economic problem which arises from people having unlimited wants while there are and always will be limited resources. Because of scarcity, various economic decisions must be made to allocate resources efficiently. 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)
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 Bleeding on probing is a term used by dentists when referring to bleeding that is induced by gentle manipulation of the tissue at the depth of the gingival sulcus, or interface between the gingiva and a tooth. This is often accomplished with the use of a periodontal probe. (BOP), clinical attachment level (CAL), degree of furcation furcation /fur·ca·tion/ (fur-ka´shun) the anatomical area of a multirooted tooth where the roots divide.
1. A forking, or a forklike part or branch.
2. involvement, extent of gingival gingival (jin´jv 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 According to International Convergence of Capital Measurement and Capital Standards, known as Basel II, the standardized approach is a set of risk measurement techniques for banking institutions. The term may be used in the context of credit risk or operational risk. 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 gingival margin
The top edge or crest of the gingiva surrounding a tooth. or CAL. Also, the patient's age is an important factor, especially in cases of rapidly progressing disease and determining overall long-term prognosis prognosis /prog·no·sis/ (prog-no´sis) a forecast of the probable course and outcome of a disorder.prognos´tic
n. pl. prog·no·ses
A modified version of the American Academy of Periodontology American Academy of Periodontology (AAP),
n.pr a nonprofit professional association of dental professionals specializing in the prevention, diagnosis, and treatment of diseases affecting the periodontium and in the placement and maintenance of dental implants. (AAP AAP - Association of American Publishers ) proposed guidelines guidelines,
n.pl a set of standards, criteria, or specifications to be used or followed in the performance of certain tasks. 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 radiographic (rā´dēōgraf´ik),
adj relating to the process of radiography, the finished product, or its use. 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 tenuous Intensive care adjective Referring to a 'touch-and-go,' uncertain, or otherwise 'iffy' clinical situation 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 gingival crevice
See gingival sulcus. . (20) The periodontal pocket, represented by a probing depth > 3 mm, is the principle habitat for gram-negative, anaerobic anaerobic /an·aer·o·bic/ (an?ah-ro´bik)
1. lacking molecular oxygen.
2. growing, living, or occurring in the absence of molecular oxygen; pertaining to an anaerobe. 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 CEJ Chemical Education Journal
CEJ Center for Environmental Journalism
CEJ Center for Economic Justice
CEJ Cementoenamel Junction
CEJ Coastal Engineering Journal
CEJ Coalition for Educational Justice
CEJ Coalition for Economic Justice 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 blunt end
the end of a DNA molecule in which both strands are of the same length.
blunt end ligation
the joining of nucleotides at the end of two duplex DNA molecules. of 2 instruments alternating pressure in a facial-lingual direction and an apical apical /ap·i·cal/ (ap´i-k'l) pertaining to an apex.
1. Relating to the apex of a pyramidal or pointed structure.
2. 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 suggestive of Decision making adjective Referring to a pattern by LM or imaging, that the interpreter associates with a particular–usually malignant lesion. See Aunt Millie approach, Defensive medicine. possible occlusal trauma Occlusal trauma is a dental term that refers to the damage incurred when teeth are left in traumatic occlusion without proper treatment.
When the maxillary and mandibular dental arches approach each together, as they do, for example, during chewing or , severe inflammation, and/or loss of supporting alveolar alveolar /al·ve·o·lar/ (al-ve´o-lar) [L. alveolaris ] pertaining to an alveolus.
Relating to an alveolus. bone.
Furcations represent bone loss between the roots of multi-rooted teeth. A deeply invasive furcation lesion LESION, contracts. In the civil law this term is used to signify the injury suffered, in consequence of inequality of situation, by one who does not receive a full equivalent for what he gives in a commutative contract.
2. is the equivalent of a poor long-term prognosis for the involved tooth. Simply put, a Grade 1 furcation involvement is incipient incipient (insip´ēent),
adj beginning, initial, commencing.
beginning to exist; coming into existence. 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 radiograph /ra·dio·graph/ (-graf?) the film produced by radiography.
n. 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 approximation /ap·prox·i·ma·tion/ (ah-prok?si-ma´shun)
1. the act or process of bringing into proximity or apposition.
2. a numerical value of limited accuracy. 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 gingiva /gin·gi·va/ (jin´ji-vah) (jin-ji´vah) pl. gin´givae [L.] the gum; the mucous membrane, with supporting fibrous tissue, covering the tooth-bearing border of the jaw. . (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 con·verse 1
intr.v. con·versed, con·vers·ing, con·vers·es
1. To engage in a spoken exchange of thoughts, ideas, or feelings; talk. See Synonyms at speak.
2. , 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 Printing at the very edge of the paper. Many laser printers, including all LaserJets up to the 11x17" 4V, cannot print to the very edge, leaving a border of approximately 1/4". In commercial printing, bleeding is generally more expensive, because wider paper is often used, which is later less when compared to nonsmokers with equal amounts of disease. (29)
In addition to the usual clinical parameters, the clinician clinician /cli·ni·cian/ (kli-nish´in) an expert clinical physician and teacher.
n. 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 osteoporosis (ŏs'tēō'pərō`sĭs), disorder in which the normal replenishment of old bone tissue is severely disrupted, resulting in weakened bones and increased risk of fracture; osteopenia , compromised immune system immune system
Cells, cell products, organs, and structures of the body involved in the detection and destruction of foreign invaders, such as bacteria, viruses, and cancer cells. Immunity is based on the system's ability to launch a defense against such invaders. , 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 cat·e·go·rize
tr.v. cat·e·go·rized, cat·e·go·riz·ing, cat·e·go·riz·es
To put into a category or categories; classify.
cat into gingivitis gingivitis (jĭn'jəvī`tĭs), inflammation of the gums. It may be acute, subacute, chronic, or recurrent. The gums usually become red, swollen, and spongy, and bleed easily. 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.
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 The objective of scaling and root planing, otherwise known as conventional periodontal therapy, is to remove or eliminate the etiologic agents which cause inflammation: dental plaque, its products and calculus, (SRP SRP - A data link layer protocol. ) is still considered the gold standard in periodontal therapy. Beyond SRP, no one treatment modality treatment modality Medtalk The method used to treat a Pt for a particular condition 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 Systemic Risk
Risk common to a particular sector or country. Often refers to a risk resulting from a particular "system" that is in place, such as the regulator framework for monitoring of financial_institutions. factors
* Scaling and root planing
* Consideration of adjunctive chemotherapeutic agents This is a list of specific pharmacologic agents that are known to be of use in the treatment of cancer, otherwise known as chemotherapeutic agents. This list is organized by "type" of agent, though the subsections are not necessarily definitive and are subject to revision. , eg, locally or systemically administered antibiotics and host response modification agents.
* 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 per·i·o·don·tist
A dentist who specializes in periodontics.
a dentist who specializes in periodontics. , such as, SRP in the presence of extreme amounts of dental calculus dental calculus
See tartar. or SRP with complications of systemic disease A systemic disease is one that affects a number of organs and tissues, or affects the body as a whole  Although most medical conditions will eventually involve multiple organs in advanced stage (i.e. , gingival over-growth and/or inflammatory hyperplasia hyperplasia (hī'pərplā`zhə): see hypertrophy. , resective surgery, regenerative re·gen·er·a·tive
1. Of, relating to, or marked by regeneration.
2. Tending to regenerate.
re·gen procedures for soft and hard tissues, periodontal plastic surgery, occlusal occlusal /oc·clu·sal/ (o-kloo´z'l)
1. pertaining to the masticating surfaces of the premolar and molar teeth.
1. therapy, pre-prosthetic surgery, dental implants dental implant
An artificial tooth that is anchored in the gums or jawbone to replace a missing tooth.
dental implant , management of perio-systemic complications, phobic pho·bic
Of, relating to, arising from, or having a phobia.
One who has a phobia. patients requiring conscious sedation conscious sedation,
n a state of sedation in which the patient remains aware of his or her person, surroundings, and conditions but without experiencing pain or anxiety. , 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 in·di·vid·u·al·ize
tr.v. in·di·vid·u·al·ized, in·di·vid·u·al·iz·ing, in·di·vid·u·al·iz·es
1. To give individuality to.
2. To consider or treat individually; particularize.
3. and tailored to meet the needs of each patient. Factors such as home care, previous level of disease, tendency toward refraction refraction, in physics, deflection of a wave on passing obliquely from one transparent medium into a second medium in which its speed is different, as the passage of a light ray from air into glass. , 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 The long-term stability of an oscillator, the degree of uniformity of frequency over time, when the frequency is measured under identical environmental conditions, such as supply voltage, load, and temperature. or providing interceptive care.(34,35)
The American Academy The American Academy in Berlin is a non-partisan academic institution in Berlin. It was founded in September 1994 by a group of prominent Americans and Germans, among them Richard Holbrooke, Henry Kissinger, Richard von Weizsäcker, Fritz Stern and Otto Graf Lambsdorff and opened in 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 Ada, city, United States
Ada (ā`ə), city (1990 pop. 15,820), seat of Pontotoc co., S central Okla.; inc. 1904. It is a large cattle market and the center of a rich oil and ranch area. 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 Localized infection
An infection that is limited to a specific part of the body and has local symptoms.
Mentioned in: Hospital-Acquired Infections . 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 pro·fi·cient
Having or marked by an advanced degree of competence, as in an art, vocation, profession, or branch of learning.
An expert; an adept. in SRP procedures has little value to the patient who assumes they are visiting the dental hygienist dental hygienist
A person trained and licensed to provide preventive dental services, such as cleaning the teeth, usually in conjunction with a dentist. 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 caries
or tooth decay
Localized disease that causes decay and cavities in teeth. It begins at the tooth's surface and may penetrate the dentin and the pulp cavity. , 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 op·por·tune
1. Suited or right for a particular purpose: an opportune place to make camp.
2. Occurring at a fitting or advantageous time: an opportune arrival. time for the clinician to introduce adjunctive therapies adjunctive therapy Medtalk A therapeutic maneuver(s) with an ancillary role in treating a disease by ↓ M&M, but not part of the immediate therapy required to stabilize the Pt. Cf Adjuvant therapy. 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 potency /po·ten·cy/ (po´ten-se)
1. the ability of the male to perform coitus.
2. the relationship between the therapeutic effect of a drug and the dose necessary to achieve that effect.
3. 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 in·di·vid·u·al·ize
tr.v. in·di·vid·u·al·ized, in·di·vid·u·al·iz·ing, in·di·vid·u·al·iz·es
1. To give individuality to.
2. To consider or treat individually; particularize.
3. 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 immune response
An integrated bodily response to an antigen, especially one mediated by lymphocytes and involving recognition of antigens by specific antibodies or previously sensitized lymphocytes. 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 hemorrhage (hĕm`ərĭj), escape of blood from the circulation (arteries, veins, capillaries) to the internal or external tissues. The term is usually applied to a loss of blood that is copious enough to threaten health or life. " indicates heavy bleeding and implies a condition outside healthy parameters. When the patient's gingival tissues hemorrhage easily upon provocation Conduct by which one induces another to do a particular deed; the act of inducing rage, anger, or resentment in another person that may cause that person to engage in an illegal act. , "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 halt·ing
1. Hesitant or wavering: a halting voice.
2. Imperfect; defective: halting verse.
3. Limping; lame. " 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 prophylaxis (prō'fĭlăk`sĭs), measures designed to prevent the occurrence of disease or its dissemination. Some examples of prophylaxis are immunization against serious diseases such as smallpox or diphtheria; quarantine to confine appointments, and ongoing periodontal maintenance to insure no patient is overlooked regarding diagnosis of developing periodontal disease or recurring re·cur
intr.v. re·curred, re·cur·ring, re·curs
1. To happen, come up, or show up again or repeatedly.
2. To return to one's attention or memory.
3. To return in thought or discourse. 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 antimicrobial /an·ti·mi·cro·bi·al/ (-mi-kro´be-al)
1. killing microorganisms or suppressing their multiplication or growth.
2. an agent with such effects. 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 Biofilm
An adhesive substance, the glycocalyx, and the bacterial community which it envelops at the interface of a liquid and a surface. When a liquid is in contact with an inert surface, any bacteria within the liquid are attracted to the surface and adhere 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 quadrant, in analytic geometry
1 In analytic geometry, one of the four regions of the plane determined by two lines, the x-axis and the y-axis. then consider either retreatment (SRP) with locally delivered antimicrobial or surgical intervention.
* Sites treatment planned for osseous osseous /os·se·ous/ (os´e-us) of the nature or quality of bone; bony.
Composed of, containing, or resembling bone; bony. grafting grafting, horticultural practice of uniting parts of two plants so that they grow as one. The scion, or cion, the part grafted onto the stock or rooted part, may be a single bud, as in budding, or a cutting that has several buds. .
** Locally delivered antimicrobial placed 3 weeks prior to surgical procedure.
* Periodontal abscess abscess, localized inflamation associated with tissue necrosis. Abscesses are characterized by inflamation, which is due to the accumulation of pus in the local tissues, and often painful swelling.
* Probing depth at the distal-facial line-angle of 2nd molars related to 3rd molar molar /mo·lar/ (mo´lar)
1. pertaining to a mole of a substance.
2. a measure of the concentration of a solute, expressed as the number of moles of solute per liter of solution. Symbol M, , or mol/L. 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 periodontal surgery, (per´ēōdon´tl),
* High risk surgery patients.
** Poorly controlled (brittle (jargon) brittle - Said of software that is functional but easily broken by changes in operating environment or configuration, or by any minor tweak to the software itself. Also, any system that responds inappropriately and disastrously to abnormal but expected external stimuli; e. ) diabetic patients
** Patients with a history of recent or recurrent coronary or cerebrovascular cer·e·bro·vas·cu·lar
Relating to the blood supply to the brain, particularly with reference to pathological changes.
pertaining to the blood vessels of the cerebrum or brain. events.
** Patients with a compromised immune system due to disease or medications.
** Kidney dialysis Dialysis, Kidney Definition
Dialysis treatment replaces the function of the kidneys, which normally serve as the body's natural filtration system. patients.
** Heavy smokers (>1/2 pack/day)
** Patients with physical disability that impacts oral hygiene Oral Hygiene Definition
Oral hygiene is the practice of keeping the mouth clean and healthy by brushing and flossing to prevent tooth decay and gum disease. 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 Tooth brushing is the act of cleaning teeth with a toothbrush.
Modern medical research has shown that brushing teeth properly can prevent cavities, gingivitis, and periodontal, or gum disease, which causes at least one-third of adult tooth loss. , use of interdental interdental /in·ter·den·tal/ (-den´t'l) between the proximal surfaces of adjacent teeth in the same arch.
1. Located or made for use between the teeth.
2. hygiene aids such as dental floss dental floss
A waxed or unwaxed thread used to remove food particles and plaque from the teeth. and proxabrushes, and use of antimicrobial oral rinses.
** Supragingival scaling and polishing.
** Definitive subgingival SRP (generally under local anesthesia Anesthesia, Local Definition
Local or regional anesthesia involves the injection or application of an anesthetic drug to a specific area of the body, as opposed to the entire body and brain as occurs during general 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 addendum n. an addition to a completed written document. Most commonly this is a proposed change or explanation (such as a list of goods to be included) in a contract, or some point that has been subject of negotiation after the contract was originally proposed by :
* 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]
Dr. Sweeting sweet·ing
1. A sweet apple.
2. Archaic Sweetheart. , Ms. Davis, and Dr. Cobb are scientific advisors for OraPharma, Inc.
(1.) Hujoel PP, Bergstrom J, del Aguila MA, DeRouen TA. A hidden periodontitis epidemic during the 20th century? Community Dent Oral Epidemiol 2003;31:1-6.
(2.) Mendez D, Warner KE. Adult cigarette smoking prevalence: Declining as expected (not as desired). Am J Pub Health 2004;94:251-252.
(3.) Cobb CM, Carrara A, EI-Annan E, et al. Periodontal referral patterns, 1980 versus 2000: A preliminary study. J Periodontol 2003:74:1470-1474.
(4.) Dockter KM, Williams KB, Bray KS, Cobb CM. Relationship between pre-referral periodontal care and periodontal status at time of referral. J Periodontol 2006:77:1708-1716.
(5.) Bader JD, Rozier G, McFall WT, Jr., Sams DH, Graves RC, Slome BA, Ramsey DL. Evaluating and influencing periodontal diagnostic and treatment behaviors in general practice. J Am Dent Assoc 1990;121:720-724.
(6.) Cury PR, Martins MT, Bonecker M, De Araujo de Araujo may refer to:
(7.) Heins P J, Fuller WW, Fries SE. Periodontal probe use in general practice in Florida. J Am Dent Assoc 1989; 119:147-150.
(8.) McFall WT, Jr., Bader JD, Rozier G, Ramsey D. Presence of periodontal data in patient records of general practitioners general practitioner
n. Abbr. GP
A physician whose practice consists of providing ongoing care covering a variety of medical problems in patients of all ages, often including referral to appropriate specialists. . J Periodontol 1988;59:445-449.
(9.) Brown LJ, Johns BA, Wall TP. The economics of periodontal diseases. Periodontol 2000. 2002;29:223-234.
(10.) Helminen SE, Vehkalahti M, Murtomaa H. Dentists' perception of their treatment practices versus documented evidence. Int Dent J 2002;52:71-74.
(11.) Blair, C. The economic impact of the under diagnosis of periodontal disease in general practice. Triage triage
Division of patients for priority of care, usually into three categories: those who will not survive even with treatment; those who will survive without treatment; and those whose survival depends on treatment. 2005;1:21-25.
(12.) American Dental Association American Dental Association (ADA),
n.pr a nonprofit professional association whose membership is dental professionals in the United States. Its purpose is to assist its members in providing the highest professional and ethical care to the citizens of the , Survey Center. 1999 Survey of Dental Services Rendered. Chicago IL: American Dental Association; 1999.
(13.) Borrell LN, Burt BA, Taylor GW. Prevalence and trends in periodontitis in the USA: The NHANES NHANES National Health and Nutrition Examination Survey (US CDC) , 1988 to 2000. J Dent Res 2005;84:924-930.
(14.) Albandar JM, Brunelle JA, Kingman A. Destructive periodontal disease in adults 30 years of age and older in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. , 1988-1994. J Periodontol 1999;70:13-29.
(15.) Armitage GC. Periodontal diseases: Diagnosis. Ann Periodontol 1996;1:37-215.
(16.) Papapanou PN, Wennstrom JL, Sellen A, Hirooka H, Grondahl K, Johnsson T. Periodontal treatment needs assessed by the use of clinical and radiographic criteria. Community Dent Oral Epedimiol 1990;18:113-119.
(17.) American Academy of Periodontology. Parameter on comprehensive periodontal examination. J Periodontol 2000;71 (Suppl.);847-848.
(18.) Krebs KA, Clem DS, III. American Academy of Periodontology. Guidelines for the management of patients with periodontal diseases. J Periodontol 2006;77:1607-1611.
(19.) Novak KF, Goodman SF, Takei HH. Determination of prognosis. In: Newman MG, Takei H, Klokkevold PR, Carranza FA, eds. Clinical Periodontology periodontology,
n See periodontics. , 10th ed. Philadelphia: Saunders/Elsevier; 2006; pp. 614-625.
(20.) Carranza FA, Camargo PM. The periodontal pocket. In: Newman MG, Takei H, Klokkevold PR, Carranza FA, eds. Clinical Periodontology, 10th ed. Philadelphia: Saunders/Elsevier; 2006, pp. 434-451.
(21.) Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999;4:1-6.
(22.) American Academy of Periodontology. Position paper: Diagnosis of periodontal diseases. J Periodontol 2003;74:1237-1247.
(23.) Carranza FA, Takei HH. Clinical diagnosis. In: Newman MG, Takei H, Klokkevold PR, Carranza FA, eds. Clinical Periodontology, 10th ed. Philadelphia: Saunders/ Elsevier; 2006, pp. 540-560.
(24.) Carranza FA, Takei HH. Bone loss and patterns of bone destruction. In: Newman MG, Takei H, Klokkevold PR, Carranza FA, eds. Clinical Periodontology, 10th ed. Philadelphia: Saunders/Elsevier; 2006, pp. 452-466.
(25.) Armitage GC. Clinical evaluation clinical evaluation Medtalk An evaluation of whether a Pt has symptoms of a disease, is responding to treatment, or is having adverse reactions to therapy of periodontal diseases. Periodontol 2000 1995;7:39-53
(26.) Haffajee AD, Socransky SS, Lindhe J, Kent RL, Okamoto H, Yoneyama T. Clinical risk indicators for periodontal attachment loss. J Clinical Periodontol 1991;18:117-125.
(27.) Claffey N, Egelberg J. Clinical indicators clinical indicator Patient care An objective measure of the clinical management and outcome of Pt care of probing attachment loss following initial periodontal treatment in advanced periodontitis patients. J Clin Periodontol 1995;22: 690-696.
(28.) Lang NP, Adler R, Joss A, Nyman S Nyman refers to: Persons
(29.) Muller Mul·ler , Hermann Joseph 1890-1967.
American geneticist. He won a 1946 Nobel Prize for the study of the hereditary effect of x-rays on genes.
Mül·ler , Johannes Peter 1801-1858. HP, Stadermann S. Multivariate The use of multiple variables in a forecasting model. multilevel models Multilevel models are known by several names: hierarchical linear models, generalized linear mixed models, nested models, mixed models (in biostatistics), random coefficient or random-effects models (in econometrics), random parameter models, and split-plot designs. for repeated measures in the study of smoking effects on the association between plaque and gingival bleeding. Clin Oral Invest 2006; 10:311-316.
(30.) American Academy of Periodontology. Position paper. Guidelines for periodontal therapy. J Periodontol 2001;72:1624-1628.
(31.) American Dental Association. Principles of ethics and code of professional conduct. January 2005. Available at: http://www.ada.org/prof/prac/law/code/index.asp. Accessed August 28, 2008.
(32.) American Academy of Periodontology. Position paper. Periodontal maintenance. J Periodontol 2003;74:1395-1401
(33.) Greenwell H, Bissada NB, Wittwer JW. Periodontics periodontics: see dentistry. in general practice: Perspectives on periodontal diagnosis. J Am Dent Assoc 1989:119:537-541.
(34.) Hirschfeld L, Wasserman B. A long-term survey of tooth loss in 600 treated periodontal patients. J Periodontol 1978;49:225-237.
(35.) Tonetti MS, Muller-Campanile V, Lang NP. Changes in the prevalence of residual pockets and tooth loss in treated periodontal patients during a supportive maintenance care program. J Clin Periodontol 1998;25:1008-1016.
(36.) American Academy of Periodontology. Parameters of care. J Periodontol 2000;71: 847-880.
(37.) American Dental Association. Current Dental Terminology. 2007-2008;3-27.
(38.) American Academy of Periodontology. Position paper. Epidemiology epidemiology, field of medicine concerned with the study of epidemics, outbreaks of disease that affect large numbers of people. Epidemiologists, using sophisticated statistical analyses, field investigations, and complex laboratory techniques, investigate the cause of periodontal diseases. J Periodontol 2005;76:1406-1419.
(39.) American Academy of Periodontology. American Academy of Pediatric Dentistry pediatric dentistry,
n See pedodontics. . Guideline guideline Medtalk A series of recommendations by a body of experts in a particular discipline. See Cancer screening guidelines, Cardiac profile guidelines, Gatekeeper guidelines, Harvard guidelines, Transfusion guidelines. for periodontal therapy. Pediatr Dent 2005-2006;27(7 Reference Manual): 197-201.
Larry A. Sweeting, DDS (1) (Digital Data Storage) See DAT.
(2) (Data Dictionary System) See QuickBuild and OpenDDS.
(3) (Dataphone Digital S ; Karen Davis For others with the same name see Karen Davis (disambiguation).
Karen Davis is the president and founder of United Poultry Concerns, Inc., which she founded in 1990 as a nonprofit organization that promotes the compassionate and respectful treatment of domestic fowl and , RDH RDH
Registered Dental Hygienist
n an abbreviation for registered dental hygienist. , BSDH BSDH British Society for Disability and Oral Health (formerly: British Society of Dentistry for the Handicapped)
BSDH Bachelor of Science in Dental Hygiene ; 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.