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 and tional 8% decrease by the year 2020. In thereby reduce the potential for progressive and recur- spite of the decreased use of rence of . 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 , practice setting, the treatment of with 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 for diagnosis and skills and 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 ’ 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 (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 Suggested Guidelines ment may be the lack of a well-estab- for a Comprehensive .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. 3. Medications 4. Presence of plaque and (quantity and distribution) The Periodontal 5. Smoking Treatment Protocol 6. Race/Ethnicity (PTP) 7. Systemic disease (eg, ) 8. Diagnosis 9. 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), (BOP), clin- 5. Occlusal relationships ical attachment level (CAL), degree of 6. Evidence of trauma from occlusion furcation involvement, extent of gingi- val recession, 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 ized approach to periodontal assess- ments and a working protocol as to treat- Radiographic evaluation of alveolar 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 Radiographic Evidence of Bone odontal disease. It is recognized that treatment plan.18 Loss is best determined with adequate each dental practice setting is different. Age is of relative value in that and current radiographs,17 most typically Consequently, guidelines are intended advanced amounts of periodontal a full-mouth periapical survey, including to be used in a manner that best meets destruction at an earlier age tend to indi- vertical bite-wings, or a panographic the needs of the specific patient. cate a more aggressive form of peri- radiograph supplemented with vertical Generally speaking, plaque-induced odontitis. In contrast, chronic periodon- bite-wings and selected periapical films. periodontal diseases have historically titis may slowly progress towards By definition, true periodontitis does not been categorized into versus severity over several years or decades. begin until bone loss occurs.25 Radi- periodontitis based upon whether attach- Young age combined with moderate to ographic evaluation of the distribution ment loss has occurred. The 1999 Inter- severe bone loss presents a tenuous and severity of bone loss, bone density, national Workshop for Classification of long-term prognosis and requires more root anatomy, and approximation to other Periodontal Diseases21 reclassified the aggressive therapy compared to the teeth provides specific information that plaque-induced periodontal diseases into older patient presenting with a chronic will help in determining a proper diag- 7 different classifications. In considera- form of periodontitis.19 nosis, treatment plan, and prognosis. tion of a working PTP that addresses Probing depth (PD) is defined as Bleeding on Probing (BOP) is a only the common periodontal diseases, the distance from the simple assessment of the inflammatory this paper will address health, gingivitis, to the base of the gingival crevice.20 The status of the gingiva.15,26 In patients with chronic periodontitis (formerly adult periodontal pocket, represented by a deeper pockets and/or loss of clinical periodontitis), and aggressive periodon- probing depth > 3 mm, is the principle attachment, the chances of disease pro- titis (formerly early-onset periodontitis). habitat for gram-negative, anaerobic gression are greater as the percentage of The first 7 entries in Table 2 (see back pathogenic bacteria.20 Deeper pockets bleeding sites increase.27 Conversely, cover) constitute a set of clinical criteria tend to represent more extensive lack of BOP is highly correlated with (PD, BOP, percent bone loss, tooth destruction of the underlying periodon- stability and a lack of inflammation.28 mobility, degree of furcation involve- tium and, therefore, a potentially greater This latter statement, however, does not ment, and CAL) that will facilitate dif- pathenogenic burden. apply to smokers as they tend to bleed ferentiation of health from gingivitis and Clinical Attachment Level (CAL) is less when compared to nonsmokers with between the various levels of severity defined as the distance from the CEJ to equal amounts of disease.29 of chronic periodontitis. Further, Table 2 the base of the probable crevice/pocket. In addition to the usual clinical can aid the clinician in differentiating In cases of gingival recession, the amount parameters, the clinician is well advised between chronic and aggressive peri- of recession is added to the PD to yield to consider other risk factors and their odontitis. the total amount of CAL. Although more potential impact on the development and Some practice settings may prefer a difficult to obtain, it is a better measure of progression of plaque-induced peri- system of “Periodontal Case Types” for the total extent of damage to the under- odontal diseases.18 Risk factors that are purposes of diagnosis and record keep- lying .20-22 sometimes overlooked in the diagnosis, ing. Table 3 presents the diagnostic clin- Mobility is best measured by the treatment plan, and prognosis equation ical criteria as applied to Case Types for blunt end of 2 instruments alternating include, among others: diabetes, smok- health, gingivitis, chronic periodontitis pressure in a facial-lingual direction and ing, osteoporosis, compromised immune (slight, moderate, and severe), and an apical direction to assess abnormal system, drug-induced gingival condi- . These criteria movement of the tooth. Simply tions, hormonal changes, and genetics. and Case Types are generally appropri- assessed: Grade I mobility is slightly Patients at risk for periodontal disease ate but should be considered as guide- more than normal; Grade II is moder- are often allowed to “slip between the lines only and not as a definitive diag- ately more than normal; Grade III is cracks” during a routine visit because nosis. As mentioned before, there are severe mobility facial-lingually plus api- they may be in the early stages of the numerous modifying and risk factors to cal displacement.23 Mobility patterns are disease. Risk factors increase a patient’s consider prior to evolving a diagnosis suggestive of possible , chance of developing periodontitis. The and a diagnosis-driven treatment plan. severe inflammation, and/or loss of sup- presence of one or more of these risk porting alveolar bone. factors may also indicate a benefit from Furcations represent bone loss referral in some patients. Treatment Planning between the roots of multi-rooted teeth. A deeply invasive furcation lesion is the Development of a logical and prop- equivalent of a poor long-term progno- Case Types and Periodontal erly sequenced treatment plan is a deriv- sis for the involved tooth. Simply put, a Diagnosis ative of the periodontal assessment and Grade 1 furcation involvement is incip- diagnosis. Periodontal therapy is diag- ient bone loss only; a Grade 2 is partial As part of a PTP it is necessary to nosis-driven and, to the extent possible, loss of bone producing a cul-de-sac; a establish diagnostic guidelines that will should address all modifying factors and Grade 3 is total bone loss with through- provide a framework for organizing the risk factors that impact development and and-through opening of the furcation; treatment needs of the patient. Guide- progression of plaque-induced peri- and a Grade 4 is similar to a Grade 3, but lines are not meant to replace clinical odontal disease. An overview of a typi- with gingival recession that visually knowledge or skills, nor do they imply a cal periodontal treatment plan is pre- exposes the furcation opening.24 one-size-fits-all treatment plan for peri- sented in Table 4.30

18 The Journal of Dental Hygiene Special supplement Table 3. Clinical Criteria Assigned to Periodontal Case Types of Health, Gingivitis, Chronic Periodontitis (slight, moderate, and severe), and Aggressive Periodontitis.

PD BOP Bone Mobility Furcations CAL Visual Case Type (mm) (Yes/No) Loss (%) (Grade) (Grade) (mm) Inflammation

0 (Health) 0-3 No 0 None None 0 No I (Gingivitis) 0-4 Yes 0 None None 0 Yes (localized or generalized)* II (Slight Chronic Periodontitis)† 4-5 Yes 10 I 1 1-2 Yes (localized or generalized)* III (Moderate Chronic Periodontitis)† 5-6 Yes 33 I and II 1 and 2 3-4 Yes (localized or generalized)* IV (Severe Chronic Periodontitis)† > 6 Yes > 33 I, II, or III 1, 2, 3, or 4 > 5 Yes (localized or generalized)* V (Aggressive Periodontitis)†_ > 6 Yes > 33 I, II, or III 1, 2, 3, or 4 > 5 Yes (localized or (age is significant factor) generalized)*

* Localized disease is defined as < 30% of sites are involved; and generalized disease infers >30% of sites are involved.21 † Specialty referral may be indicated for additional treatment beyond initial therapy. †_ 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 adjunc- tive 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 refer- ral, 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

Special supplement The Journal of Dental Hygiene 19 Implementation of Therapy odontitis should be managed by peri- odontal treatment and subsequent odontal maintenance (PM), performed reporting of services for insurance reim- There are a wide variety of treatment at an interval of 3 months for an indefi- bursement. In terms of nonsurgical peri- options to be considered when con- nite period of time following active ther- odontal therapy, familiarity with dental fronted with gingivitis or chronic or apy.32 The 3-month interval is critical insurance codes provides a clear method aggressive periodontitis. However, thor- (and the standard of care for moderate to document treatment and select appro- ough (SRP) is and severe chronic periodontitis and priate procedures to maximize insurance still considered the gold standard in peri- aggressive periodontitis) as it has been reimbursement for the patient. odontal therapy. Beyond SRP, no one repeatedly shown to be effective in Table 5 presents a modified descrip- treatment modality is the answer in reducing disease progression, preserv- tion of the ADA insurance codes most every case. However, the clinician must ing teeth, and controlling the subgingi- commonly used in Phase I periodontal have specific endpoints or goals that val bacterial burden.33-35 Nonetheless, the therapy (aka anti-infective therapy or therapy should achieve. If such end- PM schedule should be individualized nonsurgical therapy). The descriptions points are not achieved, then therapy and tailored to meet the needs of each are intended to reveal distinctive differ- must be re-evaluated and a decision patient. Factors such as home care, pre- ences between procedures, and guide the made concerning retreatment or spe- vious level of disease, tendency toward clinician in reimbursement procedures. cialty referral for consideration of more refraction, stability indicators, etc, To simplify decisions made by advanced therapy options. Treatment should be used in making this assess- patients, dental insurance should be options that should be considered ment. More fragile patients may need referred to as “reimbursement,” “bene- include:30 intervals of 2 months or less, and con- fit,” or “assistance” by the clinician and versely, patients intercepted in early dis- other staff members rather than “cover- • Patient education including plaque ease states who demonstrate consistent age” since the word implies complete. control and counseling in manage- stability may need less frequent inter- Most patients with dental insurance will ment of periodontal and systemic vals of 4-6 months. Regardless of the find it necessary to supplement what- risk factors interval between appointments, the peri- ever insurance benefit they receive odontal status of each patient should be toward lifetime periodontal care, as • Scaling and root planing re-evaluated at every maintenance many plans have contract limitations for • Consideration of adjunctive chemo- appointment. Only through close moni- the percentage of reimbursement asso- therapeutic agents, eg, locally or toring can disease recurrence be detected ciated with various procedures and/or systemically administered antibi- and the maintenance interval adjusted the length of time those benefits apply. otics and host response modifica- accordingly. Continual assessment of the For example, limitations of some insur- tion agents. periodontium during maintenance ance plans assign benefits for PM fol- affords the best opportunity for assur- lowing SRP but only for 24 months fol- • Re-evaluation ing long-term stability or providing lowing active therapy. As another • Consideration of referral to a spe- interceptive care.34,35 example, exclusions found in other cialist is an option that must be con- insurance plans assign benefits for SRP sidered for both legal and ethical for generalized periodontal disease but reasons.31 There are a variety of rea- Insurance Coding not for localized infection. Many sons to consider referral to a peri- patients are reticent to proceed with odontist, such as, SRP in the pres- The American Academy of Peri- treatment unless their insurance will ence of extreme amounts of dental odontology’s Parameters of Care 200036 “pay for it.” Consequently, it is advan- calculus or SRP with complications and the American Dental Association’s tageous for practices to have clear expla- of systemic disease, gingival over- Current Dental Terminology37 are avail- nations about the reality of dental insur- growth and/or inflammatory hyper- able to clinicians to guide decision-mak- ance. Figure 2 presents a sample plasia, resective surgery, regenera- ing related to providing therapeutic peri- explanation of dental insurance that can tive procedures for soft and hard tissues, periodontal , occlusal therapy, pre-prosthetic sur- Understanding Dental Insurance gery, dental implants, management of perio-systemic complications, 1. Dental insurance is a contractual agreement between the employer phobic patients requiring conscious and insurance company. The percentage of reimbursement varies sedation, etc. greatly dependent upon the premiums paid for a particular plan and limitations of the agreement. 2. Maximum payable benefits around $1000 - $1500 commonly found Periodontal Maintenance today with dental insurance plans are almost identical to the annual Therapy and Continual maximum benefit of dental insurance plans 40 years ago. Assessment 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 In general, data suggests that patients need or desire to obtain optimal dental health for a lifetime. who have undergone definitive therapy for either localized or generalized peri- Figure 2. Facts about dental insurance to share with patients.

20 The Journal of Dental Hygiene Special supplement 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 Description D0180 Comprehensive Indicated for new or established patients showing signs or symptoms of Periodontal Evaluation 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 Adult Prophylaxis 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 Full Mouth Initial removal of plaque and calculus that interfere with the ability to to Enable Comprehen- perform a comprehensive oral evaluation. This preliminary procedure is sive Evaluation and generally followed by a comprehensive periodontal evaluation for Diagnosis diagnosis and subsequent therapeutic periodontal procedures. D4341 Scaling and Root Involves therapeutic treatment of 4 or more periodontally involved teeth Planing per quadrant through definitive removal of subgingival plaque and Generalized per root preparation in order to halt the disease from progressing, thereby Quadrant creating an opportunity for healing. To be reported per quadrant inclusive of updated and radiographs for reimbursement. D4342 Scaling and Involves therapeutic treatment of 1 to 3 periodontally involved teeth per Root Planing quadrant through definitive removal of subgingival plaque biofilm and Localized per root preparation in order to halt the disease from progressing, thereby Quadrant creating an opportunity for healing. To be reported per quadrant with identification of specific teeth being treated inclusive of updated peri- odontal charting and radiographs for reimbursement. D4381 Localized Delivery of Subgingival insertion of antimicrobial medications of a therapeutic con- Antimicrobial Agents via centration into periodontal pockets that are released over a sufficient a Controlled Release length of time in order to suppress the pathogenic burden, and are Vehicle into Diseased intended to enhance the clinical results of scaling and root planing alone. Crevicular Tissue 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 Unspecified Periodontal In the absence of a specific ADA code for complete periodontal Procedure, by Report re-assessment following definitive periodontal therapy, this procedure code is being utilized to determine healing response and future treat- ment recommendations. D4910 Periodontal Maintenance 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 sur- faces. It may also include site specific scaling and root planing for areas of localized disease recurrence. It is intended to keep periodontal dis- eases 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 syn- onymous with prophylaxis, and is required at varying intervals to man- age 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. Cur- rent periodontal charting documenting the patient’s on-going periodon- tal status should be submitted for reimbursement.

Special supplement The Journal of Dental Hygiene 21 be shared with patients, assisting them in during data collection and tissue assess- Enhanced Communication Skills making independent decisions about ment, the patient should be provided a treatment, regardless of the insurance mirror to visualize with the clinician the Each clinician will develop his/her reimbursement schedule. evidence of periodontal disease, caries, own style of case presentation for peri- gingival recession, , fur- odontal therapy and will individualize cation involvement, etc. (Figure 1). Dur- the message to different patients. How- Patient Education and ing periodontal probing, the patient ever, there is significant advantage if Introduction to Periodontal should hear the pocket measurements as the entire office staff has continuity in Therapy data is being collected and recorded. In key words that are used when dis- a similar manner, during examination of cussing periodontal therapy with Effective implementation of the the radiographs, the patient should be patients. Equally important is the avoid- aforementioned concepts requires shown evidence of permanent bone loss, ance of minimizing messages such as expertise in effective patient education and contrast that to areas without bone “just a little bit of bleeding,” or “a little and introduction of periodontal therapy loss. Involving the patient in the dis- bone loss,” or “just a little bit of so that patients are prepared to make covery process visually and audibly is a plaque.” It is advisable to use language wise health decisions. Being proficient powerful tool to help patients take own- that does not trivialize conditions that in SRP procedures has little value to the ership in their own health. are not yet severe. Terms such as “slight patient who assumes they are visiting the for a “routine clean- ing.” This is particularly true if the patient already has a developing or exist- ing periodontal infection and does not understand the need for therapeutic intervention. Chronic periodontal dis- eases often provide few noticeable symptoms, especially in earlier stages of development. Thus, the need for effective communication, education, and listening skills are of particular impor- tance to today’s dental patient. The incidence of moderate and severe generalized chronic periodonti- tis 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 effec- Figure 1. Dental hygienist showing patient periodontal conditions in tive at enrolling patients into active ther- patient’s own mouth. apy everyone in the practice setting must have a basic understanding of the etiol- ogy of periodontal diseases, treatment This is also an opportune time for the bleeding,” “early bone loss,” or “slight options, consequences of nontreatment, clinician to introduce adjunctive thera- plaque” accurately describe findings and direct benefits of therapy. Patients pies to the patient such as the use of without overstating them. Periodontal are more motivated to accept treatment locally delivered antimicrobials and disease is a bacterial infection leading to recommendations when a clear diagno- other agents. For example, the clinician a host immune response that is charac- sis has been established, they are given can communicate that locally delivered terized by inflammation and degrada- the opportunity to see infection in their antimicrobials have been on the US mar- tion of periodontal tissues.22 When own mouths, their questions have been ket for many years and have been shown informing patients of periodontal dis- answered, and they understand the value to be a safe, effective treatment option. ease, using the word “infection” is more of treating periodontal infection in rela- Important information to convey powerful than “gum inflammation” and tion to their overall health. includes the ease of application; the high can create a sense of urgency regarding Many clinicians inform patients of potency of the drug at levels that will treatment. The word “hemorrhage” their periodontal status while working kill bacteria; it does not affect the rest of indicates heavy bleeding and implies a in their mouths with sharp instruments, the body; and there is no need for an condition outside healthy parameters. or give a summary of findings at the end additional appointment to remove the When the patient’s gingival tissues of the visit. Most patients are visual product since the agent biodegrades. hemorrhage easily upon provocation, learners. Consequently, patients need to Educating the patient to all of their treat- “hemorrhage” rather than “bleeding see the condition of their own mouth. ment options is vital to clear and evi- gum tissue” should be verbalized to the At the beginning of every appointment, dence-based communication. patient. The words “scaling and root

22 The Journal of Dental Hygiene Special supplement Guide for Use of Locally Delivered Antimicrobials

Where to use locally delivered antimicrobials: How to apply locally delivered antimicrobials: ➢ Pockets > 5 mm with bleeding on probing (BOP). ➢ For optimal effect from locally delivered antimicrobials • The locally delivered antimicrobial may be used at the following must be achieved: the time of scaling and root planing (SRP) or at the • Oral hygiene instructions and patient compliance re-evaluation appointment 4-6 weeks following SRP. regarding the necessary oral hygiene procedures, ie, If used first at the re-evaluation appointment, the site , use of interdental hygiene aids such must have additional SRP to remove biofilm and hard as and proxabrushes, and use of antimi- deposits that may have re-accumulated. crobial oral rinses. ➢ Residual pockets of > 5 mm with BOP or any site > 6 • Supragingival scaling and polishing. mm following initial SRP. • Definitive subgingival SRP (generally under local • Determined at re-evaluation appointment. anesthesia). • If > 4 residual pockets in a given quadrant then con- • Place locally delivered antimicrobial according to sider either retreatment (SRP) with locally delivered manufacturer’s directions. For example, in the case antimicrobial or surgical intervention. of microspheres, place one pre-meas- ➢ Sites treatment planned for osseous grafting. ured dose per pocket. If the tooth has 2 pockets that • Locally delivered antimicrobial placed 3 weeks prior need local delivery, 2 full doses should be adminis- to surgical procedure. tered. ➢ • The pocket should be as biofilm and deposit free as ➢ Probing depth at the distal-facial line-angle of 2nd possible prior to insertion. molars related to 3rd molar extractions where surgical • Insert the locally delivery product to the base of the intervention will yield a compromised result. pocket. In the case of minocycline microspheres, the ➢ Ailing/failing dental implants (peri-implantitis) where sur- tip should be placed as far into the pocket as possi- gical intervention is not indicated or will yield a compro- ble before activating mised result. the syringe/handle ➢ Grade II furcation involvements (shallow or deep) when (Figures 4 and 5). surgical intervention is not planned. Addendum: Who might benefit from use of locally delivered ➢ If probing depths are < 4 antimicrobials: mm, the clinician should ➢ Periodontal maintenance consider a conventional patients with isolated adult prophylaxis coupled probing depths of > 5 mm with oral hygiene recom- that exhibit BOP or any mendations and/or rein- Figure 4. Initial Inser- pocket > 6 mm (Figure 3). forcement. tion of the pre-meas- ➢ Patients wanting to avoid • If the patient exhibits ured tip for adminis- . multiple probing tration of minocycline ➢ High risk surgery patients. depths of 4 mm a peri- microspheres • Poorly controlled (brit- odontal maintenance tle) diabetic patients Figure 3. Pre-treatment interval of 3-4 months • Patients with a history clinical presentation should be considered until it can be deter- of recent or recurrent showing PD of 6 mm coronary or cere- mined if the patient’s brovascular events. periodontal status is • Patients with a compromised due to stable and/or improv- disease or medications. ing. • Kidney dialysis patients. • Heavy smokers (>1/2 pack/day) • Patients with physical disability that impacts oral Figure 5. Tip place- hygiene efficiency ment to base of • Mentally handicapped patients pocket for administra- ➢ Patient’s with marginal oral hygiene that is not likely to tion of minocycline improve and thereby represent a poor surgical risk. microspheres. ➢ Please note that locally applied antimicrobials may need to be placed more than one time to achieve the desired result.

Special supplement The Journal of Dental Hygiene 23 planing” may sound confusing to Suggestions for • Include assessments and diagnosis patients or imply discomfort. The words of periodontal diseases in all new “periodontal therapy” are effective Implementation of a patient visits, routine prophylaxis semantic choices when informing Periodontal Treatment appointments, and ongoing peri- patients about necessary periodontal Protocol in the General odontal maintenance to insure no treatment. “We now know” are words patient is overlooked regarding that can introduce patients to new ideas Practice Setting diagnosis of developing periodontal or treatment options to explain why disease or recurring disease. information may be different than what • General dentists and dental hygien- • Select appropriate ADA Insurance they have heard in the past, or expected ists should schedule a meeting with Procedure Codes for reporting peri- to hear at their current visit. “Halting” referring periodontists and their odontal procedures in order to max- or “arresting disease” can be used to dental hygienists to share philoso- imize the patient’s benefit. describe a measurable goal for treating phies of periodontal treatment and periodontal diseases that should be establish clarity for referrals. • Share insurance information with obtained through intervention. “Daily patients to assist them in reducing • Schedule a team meeting workshop disease control” communicates to the their dependence on dental insur- to bring all office staff up-to-date patient that they share in the role in the ance benefits, thereby enabling regarding periodontal assessments, effective removal of plaque bacteria them to make independent health diagnosis, case types, periodontal beyond what it achieve through peri- decisions related to treatment of risk factors, individualized treat- odontal treatment. periodontal diseases. ment of periodontal diseases, con- Even though some states require sequences of nontreatment (tooth written consent, effective communica- loss and possible systemic involve- tion between the clinician and the patient ment), and the value of periodontal is the important consideration of Disclosure maintenance. informed consent,39 not the completion of a form. Therefore, deliberate seman- • Establish continuity of the verbal Dr. Sweeting, Ms. Davis, and Dr. tic choices should be shared by all mem- skills and terminology the office Cobb are scientific advisors for bers of the office staff to optimize staff will utilize to communicate OraPharma, Inc. patient understanding of their periodon- effectively to patients about peri- tal conditions. odontal conditions.

References 10. Helminen SE, Vehkalahti M, Murtomaa H. Dentists’ per- ception of their treatment practices versus documented 1. Hujoel PP, Bergström J, del Aguila MA, DeRouen TA. A hid- evidence. Int Dent J 2002;52:71-74. den periodontitis epidemic during the 20th century? Com- 11. Blair, C. The economic impact of the under diagnosis of munity Dent Oral Epidemiol 2003;31:1-6. periodontal disease in general practice. Triage 2005;1:21-25. 2. Mendez D, Warner KE. Adult cigarette smoking preva- 12. American Dental Association, Survey Center. 1999 Survey lence: Declining as expected (not as desired). Am J Pub of Dental Services Rendered. Chicago IL: American Den- Health 2004;94:251-252. tal Association; 1999. 3. Cobb CM, Carrara A, El-Annan E, et al. Periodontal refer- 13. Borrell LN, Burt BA, Taylor GW. Prevalence and trends in ral patterns, 1980 versus 2000: A preliminary study. J Peri- periodontitis in the USA: The NHANES, 1988 to 2000. J odontol 2003:74:1470-1474. Dent Res 2005;84:924-930. 4. Dockter KM, Williams KB, Bray KS, Cobb CM. Relation- 14. Albandar JM, Brunelle JA, Kingman A. Destructive peri- ship between pre-referral periodontal care and peri- odontal disease in adults 30 years of age and older in the odontal status at time of referral. J Periodontol United States, 1988-1994. J Periodontol 1999;70:13-29. 2006:77:1708-1716. 15. Armitage GC. Periodontal diseases: Diagnosis. Ann Peri- 5. Bader JD, Rozier G, McFall WT, Jr., Sams DH, Graves odontol 1996;1:37-215. RC, Slome BA, Ramsey DL. Evaluating and influenc- 16. Papapanou PN, Wennstrom JL, Sellen A, Hirooka H, Gron- ing periodontal diagnostic and treatment behaviors in dahl K, Johnsson T. Periodontal treatment needs assessed general practice. J Am Dent Assoc 1990;121:720-724. by the use of clinical and radiographic criteria. Community 6. Cury PR, Martins MT, Bonecker M, De Araujo NS. Inci- Dent Oral Epedimiol 1990;18:113-119. dence of periodontal diagnosis in private dental practice. 17. American Academy of Periodontology. Parameter on com- Am J Dent 2006;19:163-165. prehensive periodontal examination. J Periodontol 7. Heins PJ, Fuller WW, Fries SE. Periodontal probe use in 2000;71(Suppl.);847-848. general practice in Florida. J Am Dent Assoc 1989;119:147- 18. Krebs KA, Clem DS, III. American Academy of Periodon- 150. tology. Guidelines for the management of patients with 8. McFall WT, Jr., Bader JD, Rozier G, Ramsey D. Presence periodontal diseases. J Periodontol 2006;77:1607-1611. of periodontal data in patient records of general practi- 19. Novak KF, Goodman SF, Takei HH. Determination of prog- tioners. J Periodontol 1988;59:445-449. nosis. In: Newman MG, Takei H, Klokkevold PR, Carranza 9. Brown LJ, Johns BA, Wall TP. The economics of peri- FA, eds. Clinical Periodontology, 10th ed. Philadelphia: odontal diseases. Periodontol 2000. 2002;29:223-234. Saunders/Elsevier; 2006; pp. 614-625.

24 The Journal of Dental Hygiene Special supplement 20. Carranza FA, Camargo PM. The periodontal pocket. In: association between plaque and gingival bleeding. Clin Newman MG, Takei H, Klokkevold PR, Carranza FA, eds. Oral Invest 2006;10:311-316. Clinical Periodontology, 10th ed. Philadelphia: Saun- 30. American Academy of Periodontology. Position paper. ders/Elsevier; 2006, pp. 434-451. Guidelines for periodontal therapy. J Periodontol 21. Armitage GC. Development of a classification system for 2001;72:1624-1628. periodontal diseases and conditions. Ann Periodontol 31. American Dental Association. Principles of ethics and code 1999;4:1-6. of professional conduct. January 2005. Available at: 22. American Academy of Periodontology. Position paper: http://www.ada.org/prof/prac/law/code/index.asp. Accessed Diagnosis of periodontal diseases. J Periodontol August 28, 2008. 2003;74:1237-1247. 32. American Academy of Periodontology. Position paper. Peri- 23. Carranza FA, Takei HH. Clinical diagnosis. In: Newman odontal maintenance. J Periodontol 2003;74:1395-1401 MG, Takei H, Klokkevold PR, Carranza FA, eds. Clinical 33. Greenwell H, Bissada NB, Wittwer JW. Periodontics in Periodontology, 10th ed. Philadelphia: Saunders/ general practice: Perspectives on periodontal diagnosis. J Elsevier; 2006, pp. 540-560. Am Dent Assoc 1989:119:537-541. 24. Carranza FA, Takei HH. Bone loss and patterns of bone 34. Hirschfeld L, Wasserman B. A long-term survey of tooth destruction. In: Newman MG, Takei H, Klokkevold PR, loss in 600 treated periodontal patients. J Periodontol Carranza FA, eds. Clinical Periodontology, 10th ed. 1978;49:225-237. Philadelphia: Saunders/Elsevier; 2006, pp. 452-466. 35. Tonetti MS, Muller-Campanile V, Lang NP. Changes in the 25. Armitage GC. Clinical evaluation of periodontal diseases. prevalence of residual pockets and in treated Periodontol 2000 1995;7:39-53 periodontal patients during a supportive maintenance care 26. Haffajee AD, Socransky SS, Lindhe J, Kent RL, Okamoto program. J Clin Periodontol 1998;25:1008-1016. H, Yoneyama T. Clinical risk indicators for periodontal 36. American Academy of Periodontology. Parameters of care. attachment loss. J Clinical Periodontol 1991;18:117-125. J Periodontol 2000;71: 847-880. 27. Claffey N, Egelberg J. Clinical indicators of probing attach- 37. American Dental Association. Current Dental Terminology. ment loss following initial periodontal treatment in 2007-2008;3-27. advanced periodontitis patients. J Clin Periodontol 38. American Academy of Periodontology. Position paper. Epi- 1995;22: 690-696. demiology of periodontal diseases. J Periodontol 28. Lang NP, Adler R, Joss A, Nyman S. Absence of bleeding 2005;76:1406-1419. on probing – an indicator of periodontal stability. J Clin 39. American Academy of Periodontology. American Acad- Periodontol 1990;17:714-721. emy of Pediatric . Guideline for periodontal 29. Muller HP, Stadermann S. Multivariate multilevel models for therapy. Pediatr Dent 2005-2006;27(7 Reference Man- repeated measures in the study of smoking effects on the ual):197-201. Table 2. Periodontal Diagnostic Guidelines. Case Slight Moderate Advanced Indicator Healthy Gingivitis Periodontitis Periodontitis Periodontitis Aggressive/Refractory Pocket Deptha < 3 mm < 4 mm 4 - 5 mm 5 -6 mm > 6mm > 6mm Bleeding Upon No Yesb Yesb Yesb Yesb Yesb Probing Six-Point Yes Yes Yes Yes Yes Yes Probing Bone Loss None None < 10% < 33% > 33% > 33% Tooth None None None < Grade II < Grade III < Grade III Mobilityc Furcationd None None < Grade I < Grade II < Grade III/IV < Grade III/IV Clinical None None 1 - 2 mm CAL 3 - 4 mm CAL > 5 mm CAL > 5 mm CAL Attachment Loss (CAL)e Other No Only gingival Signs of inflammation Signs of inflammation Signs of inflammation Signs of inflammation inflammation tissues affected may be present, including may be present, including may be present, including may be present, including by the • Edema • Edema • Edema • Edema inflammatory • Redness • Redness • Redness • Redness process • Suppuration • Suppuration • Suppuration • Suppuration • Alveolar bone level is • Alveolar bone level is • Alveolar bone level is • Same clinical signs as • No alveolar 3 - 4 mm from CEJ 4 - 6 mm from CEJ • > 6 mm from CEJ advanced but includes bone loss • Radiographic bone loss • Radiographic bone loss • Radiographic bone loss adolescents or • Localized or present present present young adults generalized • Localized or generalized • Localized or generalized • Localized or generalized • Localized or generalized • Rapid cycles of disease progression

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

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

Ongoing 6 Months 6 Months • Perio Maintenance D4910 • Perio Maintenance D4910 • Perio Maintenance D4910 • Perio Maintenance D4910 Maintenance • Prophy • Prophy - 3/4/6 months - 3/4/6 months - 3/4/6 months - 3/4/6 months • OHI • OHI • OHI D1330 • OHI D1330 • OHI D1330 • OHI D1330 • Locally Administered D4381 • Locally Administered D4381 • Locally Administered D4381 • Locally Administered D4381 Antimicrobials Antimicrobials Antimicrobials Antimicrobials • Localized SRP D4342 • Localized SRP D4342 • Localized SRP D4342 • Localized SRP D4342 - UR, UL, LR, LL - UR, UL, LR, LL - UR, UL, LR, LL - UR, UL, LR, LL • Other Treatments • Other Treatments • Other Treatments • Host Modulation a Excluding gingival overgrowth and recession ©OraPharma, Inc. 2008 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. Carranza’s Clinical Periodontology 10th ed. Philadelphia, PA: Elsevier; 2006. d Furcation Grades: Grade I: 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(I):1-6

Adapted from Periodontal Diagnostic Guidelines ©OraPharma, Inc. 2008