Periodontal Treatment Protocol (PTP) for the General Dental Practice Larry A. Sweeting, DDS; Karen Davis, RDH, BSDH; Charles M. Cobb, DDS, PhD Introduction Abstract 1 Hujoel et al estimated a 31% A sequence of interrelated steps is inherent to effective periodontal decrease in the prevalence of periodon- treatment: early and accurate diagnosis, comprehensive treatment, and titis between the years 1955 and 2000. continued periodontal maintenance and monitoring. A primary goal of Further, these authors estimate an addi- periodontal therapy is to reduce the burden of pathogenic bacteria and tional 8% decrease by the year 2020. In thereby reduce the potential for progressive inflammation and recur- spite of the decreased use of smoking rence of disease. Emerging evidence of possible perio-systemic links 2 tobacco, better understanding of the further reinforces the need for good periodontal health. In the private pathogenesis of periodontal diseases, practice setting, the treatment of patients with periodontal disease is best and more refined and goal directed ther- accomplished within the structure of a uniform and consistent Peri- apies, there remains evidence that den- odontal Treatment Protocol (PTP). Such a protocol would reinforce tistry is not consistently achieving a accurate and timely diagnosis, treatment needs based on a specific timely diagnosis and appropriate and diagnosis, and continual assessment and monitoring of outcomes. This timely treatment of existing periodonti- is best achieved if everyone in the practice setting has a general under- 3,4 tis. Although the evidence is limited, standing of the etiology of periodontal diseases, the benefits of treat- there is a strong suggestion that use of a ment, and potential consequences of nontreatment. Communication periodontal probe for diagnosis and skills and patient education are vital components of effective therapy recording of periodontal status in treat- since slight and even moderate stages of the disease often have few ment records in general dental practices noticeable symptoms to the patient. Accurate documentation and report- has yet to achieve the level of a routine ing of procedures for dental insurance reimbursement, coupled with 5-9 and consistent habit. Indeed, McFall scheduling considerations, assist general practice settings in effectively 8 et al determined that except for radi- managing the increasing volume of patients that can benefit from early ographs, most private practice patient diagnosis and treatment of periodontal diseases. This article presents records were so deficient in diagnostic the essential elements of a PTP including diagnosis, treatment planning, information that periodontal status could implementation of therapy, assessment and monitoring of therapy, insur- not be established. It should be self-evi- ance coding, introduction of the patient to periodontal therapy, and dent that treatment requires a definitive enhanced verbal skills. In addition, considerations for implementation of diagnosis, ie, a disease cannot be ade- adjunctive local delivery antimicrobials is presented. quately treated unless first diagnosed. In this regard, it is interesting to note Key Words: periodontal diseases, periodontal diagnosis, treatment that at least one study has reported a dis- protocol, periodontal maintenance, periodontal assessment, patient connect between dentists’ perception of education treatment rendered and actual treatment as recorded in patient records.10 As an example, prophylactic procedures out- number periodontal procedures by a ratio of 20:111,12 and yet the prevalence of odontitis with a concomitant decrease dental office did not vary because of chronic periodontitis (slight, moderate, in the percentage of mild-moderate dis- disease severity; and the average num- and severe) is estimated to range from a ease cases; increase in the average num- ber of periodontal maintenance vis- low of 7% (aged > 18 years)13 up to 35% ber of missing teeth per patient; and its/patient/year in the general dental (aged > 30-90 years)14 of the US adult increase in the average number of teeth office was less than the standard of care population. scheduled for extraction per patient. A according to severity of disease, eg, Cobb et al.3 compared the pattern of similar study by Docktor et al4 based on 68% of advanced periodontitis cases referral of periodontitis patients in 1980 patient records from 3 private peri- reported between 0 and 2 periodontal vs 2000 using patient record data from odontal practices located within a major maintenance visits per year rather than 3 geographically-diverse private peri- metropolitan area reported the follow- the recommended every 3 months. odontal practices. Results showed the ing: 74% of referred cases were con- Viewed in aggregate, the trends following trends occurring over the 20- sidered advanced periodontitis, of reported by Cobb et al3 and Docktor et year time span: decreased use of which 30% were treatment planned for al4 support the assertion that timely tobacco; increase in the percentage of extraction of 2 or more teeth; periodon- diagnosis and appropriate and timely cases exhibiting advanced chronic peri- tal treatment provided by the general treatment of chronic periodontitis have 16 The Journal of Dental Hygiene Special supplement not significantly improved over time. A major reason for the reported scarcity of Table 1. Modified Version of the American timely diagnosis and appropriate treat- Academy of Periodontology Suggested Guidelines ment may be the lack of a well-estab- for a Comprehensive Periodontal Examination.18 lished office protocol for the diagnosis, treatment, maintenance, and monitor- Assessment of medical history ing of periodontal disease, and involve- ment of the patient through education. Assessment of dental history Obviously, this requires dedication of energy, resources, effective communi- Assessment of periodontal risk factors cation skills, and a change in practice 1. Age philosophy. 2. Gender 3. Medications 4. Presence of plaque and calculus (quantity and distribution) The Periodontal 5. Smoking Treatment Protocol 6. Race/Ethnicity (PTP) 7. Systemic disease (eg, diabetes) 8. Oral hygiene Diagnosis 9. Socioeconomic status and level of education Assessment of extraoral and intraoral structures and tissues Regardless of recent advances in our understanding of the etiology and patho- Assessment of teeth genesis of the periodontal diseases, the 1. Mobility assessment of traditional clinical param- 2. Caries eters remain the foundation for peri- odontal diagnosis.15 Generally, such clin- 3. Furcation involvement ical parameters include probing depth 4. Position in dental arch and within alveolus (PD), bleeding on probing (BOP), clin- 5. Occlusal relationships ical attachment level (CAL), degree of 6. Evidence of trauma from occlusion furcation involvement, extent of gingi- val recession, tooth mobility, and plaque Assessment of periodontal soft tissues including peri-implant tissues score. Clinicians typically utilize the 1. Color results from the periodontal exam, radi- 2. Contour ographs, and the patient’s medical and 3. Consistency (fibrotic or edematous) dental histories to establish a diagnosis and evolve a goal/diagnosis-directed 4. Presence of purulence (suppuration) treatment plan. It has been clearly 5. Amount of keratinized and attached tissue gingiva demonstrated that different interpreta- 6. Probing depths tions of the same diagnostic information 7. Bleeding on probing can have a dramatic impact on treatment 8. Clinical attachment levels decisions.16 For this reason, a standard- 9. Presence and severity of gingival recession ized approach to periodontal assess- ments and a working protocol as to treat- Radiographic evaluation of alveolar bone loss, bone density, furcations, ment parameters would fill a logical root shape, and proximity, etc. need in the average general practice set- ting. However, due to extensive over- laps in most classification systems, any loss. The presence, location, and extent eral dental practice, only the following standardized approach is subject to vari- of furcation invasions should be noted, as principal diagnostic criteria can be ations in both clinical assessments (eg, well as the location of the gingival mar- addressed: age, PD, CAL, BOP, tooth variations in probing depth among cli- gin or CAL. Also, the patient’s age is an mobility, furcation involvement, and nicians) as well as the interpretation important factor, especially in cases of percentage of radiographic bone loss. It thereof. rapidly progressing disease and deter- must be emphasized that these criteria All effective treatment protocols mining overall long-term prognosis. represent the minimal parameters for begin with a thorough and timely diag- A modified version of the American determining a periodontal diagnosis. nosis. Six-point probing to measure PD Academy of Periodontology (AAP) There are many other important risk and and BOP is the standard of care. Based proposed guidelines for a comprehen- modifying factors that will impact on the needs of the patient, current radi- sive periodontal examination is pre- development and progression of disease ographs should be evaluated to deter- sented in Table 1.17 However, with and all such factors must be taken into mine the location and percentage of bone respect to a functional PTP for the gen- consideration when establishing a defin- Special supplement The Journal of Dental Hygiene 17 itive diagnosis and a diagnosis-driven