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When to Refer to a Periodontist

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When to Refer to a Periodontist Indications to refer & Treatment Options AAP – Academy Report ▪ Guidelines issued by the AAP ▪ Level 1, 2 and 3 Mucogingival Concerns ▪ Indications for treatment What? ▪ Academy Report issued by the America Academy of Periodontology ▪ Meant to provide information to assist in timely identification of patients who would benefit from co- management by the referring dentist and the periodontist ▪ Not a one-size-fits-all approach Why? ▪ Greater public awareness about periodontal disease According to the NHANES survey – J.Perio 2015 - 46% of US Adults (age >30) have periodontitis - 8% mild - 64% of adults 65 and - 30% moderate older have periodontitis - 8 % severe Why? ▪ Periodontal disease is the most common cause of adult tooth loss 30-35% of all tooth extractions were caused by periodontitis Why? ▪ Research showing links between periodontal disease and other systemic conditions Cardiovascular disease Chronic pulmonary disease Pre-term low birth weight babies Respiratory infections Diabetes Stroke Why? ▪ Research showing links between periodontal disease and other systemic conditions ▪ Diabetes Bi-directional relationship between glycemic control and periodontal disease 3x more bone loss and attachment loss has been found in patients with diabetes After treatment of periodontal disease HcA1c can drop by .4% Sugar levels can drop 10% drop Why? ▪ Research showing links between periodontal disease and other systemic conditions ▪ Adverse pregnancy outcomes Pre-term birth ▪ Before 37 weeks of gestation Gram-negative organism ▪ Less than 5.5 lbs Incidence Inflammatory cytokines (especially ▪ 11.2% - women with no PGE2) and bacterial products periodontal disease ▪ 28.6 %- women with moderate to severe Early onset labor periodontal disease • Summary of epidemiologic studies and on potential contributing mechanisms • Case-control and Cross-sectional studies • Significant association between various indexes of poor dental health and CHD • Arbes evaluated the association between disease and CHD in the NHANES III • Odds of having a heart attack increased w/ the severity of perio disease • Genco found results that supported the notion that specific pathogenic bacteria found in cases of periodontal disease also may be associated w/ MI Genco, R., Offenbacher S, Beck, J. (2002) Periodontal disease and cardiovascular disease JADA, Vol. 133, 145-154 o Review article o Cartoid atherosclerosis– o Measured as an increase in the thickness of the IMT of the arterial wall. o Pilot study reported the effect of periodontal therapy on changes in carotid IMT. o People affected by mild – moderate periodontal disease o Treated w/ root debridement o Re-evaluated 6 and 12 mo later o IMT was significantly decreased at different locations along the carotid artery. o These pilot observations indicate that changes in IMT following periodontal therapy are possible in systemically healthy subjects. - Tonetti M. Periodontitis and risk for atherosclerosis: an update on intervention trials. J Clin Periodontal 13, 15-19. - Piconi, S. et al (2009) Treatment of Periodontal disease results in improvements in endothelial dysfunctional and reduction of the carotid intima-media thickness. The FASEB Journal 23. 1196-1204 Why? ▪ Meant to identify patients who are at greatest risk early ▪ Benefit from specialty care ▪ Strengthen the relationship between the general dentist/hygienist and the specialist ▪ Long-term co-management of periodontal patients Guidelines for the management of patients with Periodontal Disease ▪ Level 3 ▪ Patients who should be treated by a periodontist ▪ Level 2 ▪ Patients who would likely benefit from co-managment by the referring dentist and the periodontist ▪ Level 1 ▪ Patients who may benefit from co-managment by the referring dentist and the periodontist Any patient with: ▪ Stage III or Stage IV (formerly Severe chronic periodontitis) ▪ Furcal involvement ▪ Vertical/angular bony defects/bone loss present ▪ Stage III or Stage IV – Grade C (formerly known as: aggressive periodontitis, juvenile, early-onset, or rapidly progressive periodontitis) ▪ Significant root exposure and/or progressive gingival recession ▪ Peri-implant disease ▪ Periodontal abscess and other acute periodontal conditions/trauma ▪ Any patient with periodontal diseases, regardless of severity, whom the referring dentist prefers not to treat Any patient with: ▪ Stage III or Stage IV (formerly Severe chronic periodontitis) Any patient with: ▪ Furcal involvement Any patient with: ▪ Vertical/angular bony defect/bone loss present Any patient with: ▪ Vertical/angular bony defect/bone loss present Any patient with: ▪ Stage III or Stage IV – Grade C (formerly known as: aggressive periodontitis, juvenile, early-onset, or rapidly progressive periodontitis) Any patient with: ▪ Significant root exposure and/or progressive gingival recession Initial 5-month6-week follow post-opup Any patient with: ▪ Peri-implant disease Any patient with: ▪ Periodontal abscess and other acute periodontal conditions/trauma Any patient with: ▪ Any patient with periodontal diseases, regardless of severity, whom the referring dentist prefers not to treat Any patient with: ▪ Any patient with periodontal diseases, regardless of severity, whom the referring dentist prefers not to treat Any patient with: ▪ Stage III or Stage IV (formerly Severe chronic periodontitis) ▪ Furcal involvement ▪ Vertical/angular bony defects/bone loss present ▪ Stage III or Stage IV – Grade C (formerly known as: aggressive periodontitis, juvenile, early-onset, or rapidly progressive periodontitis) ▪ Significant root exposure and/or progressive gingival recession ▪ Peri-implant disease ▪ Periodontal abscess and other acute periodontal conditions/trauma ▪ Any patient with periodontal diseases, regardless of severity, whom the referring dentist prefers not to treat Any patient with periodontitis who has any of the following risk factors/indicators know to contribute to the progression of periodontal diseases: ▪ Periodontal risk factors/indicators ▪ Medical/behavioral risk factors/indicators Risk factor ▪ Characteristic that places an individual at increased risk of contracting a disease Risk indicator ▪ Probable or putative risk factor that has been identified in cross-sectional correlation studies but not confirmed through longitudinal studies Periodontal risk factors/indicators: ▪ Early onset of periodontal diseases (prior to the age of 35) ▪ Unresolved inflammation at any site (BOP, suppuration, erythema) ▪ Pocket depths >5 mm ▪ Vertical bone defects ▪ Radiographic evidence of progressive bone loss ▪ Progressive tooth mobility ▪ Progressive attachment loss ▪ Anatomic gingival deformities ▪ Exposed root surfaces ▪ A deteriorating risk profile Periodontal risk factors/indicators: ▪ Anatomic gingival deformities Periodontal risk factors/indicators: ▪ Anatomic gingival deformities Initial presentation 3-month post-op Medical or Behavioral risk factors/indicators: ▪ Smoking/tobacco use ▪ Diabetes ▪ Osteoporosis/osteopenia ▪ Drug-induced gingival conditions ▪ Phenytoins, calcium channel blockers, immunosuppressants, long-term systemic steroids ▪ Compromised immune system ▪ Acquired or drug induced ▪ A deteriorating risk profile Any patient with with periodontal inflammation/infection and the following systemic conditions: ▪ Diabetes ▪ Pregnancy ▪ Cardiovascular disease ▪ Chronic respiratory disease Any patient who is a candidate for the following therapies who might be exposed to risk from periodontal infection, including but not limited to the following treatments: ▪ Cancer therapy ▪ Cardiovascular surgery ▪ Joint-replacement surgery ▪ Organ transplantation 35 A general term used to describe periodontal treatment involving procedures for correction of defects in morphology, position, and/or amount of soft tissue and underlying bone support at teeth and implants. - Glossary of Terms in Periodontology (2001) Bains, et al. (2011) Mucogingival Surgery: Where we Stand Today. CDA Journal. 39: 573-583 Recession Lack of keratinized tissue Frenum pull Shallow vestibule Excess tissue/hypertrophy Abnormal color Gingival augmentation Prevention or cessation of recession Facilitation of plaque control Elimination of an aberrant frenum Increased vestibular depth Decreased root sensitivity Decreased inflammation Causes Prevalence When do I refer? - Abrasive/traumatic tooth Causes brushing habits - Periodontal inflammation - Tooth position in arch - Frenal and muscle attachment encroachment - Orthodontic movement - Underlying bony dehiscence - Genetics - Invasion of biologic width - Oral piercing Prevalence of one of more teeth with > = 3mm of Recession (%) by Age 70 60 50 % 40 30 Prevalence 20 10 0 30-39 40-49 50-59 60-69 70-79 80-90 Age Albandar. et al. (1999) Gingival recession, gingival bleeding and dental calculus in adults 30 years of age and older in the United States. J. Perioodontol.. 70:30-43 Can it worsen? When to refer? ▪ 1-2mm of recession ▪ No literature supports that it will increase ▪ 3 mm of recession ▪ 67% chance it will get worse over time ▪ 4 mm of recession ▪ 100% chance it will get worse over time Serino. et al. (1994) The prevalence and distribution of gingival recession in subjects with high standard or oral hygiene. J.Clin Perioodontol.. 21:57-63 100% root coverage 100% root coverage Partial root coverage (50-70%) Root coverage not anticipated Albandar. et al. (1999) Gingival recession, gingival bleeding and dental calculus in adults 30 years of age and older in the United States.
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