Perio II, Lecture 1 - Introduction and Diagnosis and Treatment Planning (Dr. Chuang)

Is gingivitis reversible?

Yes

Is periodontitis reversible?

No - irreversible

What are the three types of periodontitis patients?

- Stable case of periodontal health in a successfully treated periodontitis patient

- Gingival inflammation on a reduced periodontium in a successfully treated periodontitis patient

- Unstable case of recurrent periodontits

What could be the diagnosis of a patient who had crown lengthening and gingivitis?

Gingival inflammation on a reduced periodontium in a non-periodontitis patient

What classifies the severity of periodontal disease?

Staging

What classifies the progression of periodontal disease?

Grading

What is the interdental CAL for stage I periodontitis?

1-2mm

What is the interdental CAL for stage II periodontitis?

3-4mm

What is the interdental CAL for stage III and IV periodontitis?

≥5 mm

What is the radiographic bone loss for stage I periodontitis?

Coronal third: <15%

What is the radiographic bone loss for stage II periodontitis?

Coronal third: 15-33%

What is the radiographic bone loss for stage III and IV periodontitis?

Extending to the middle third of root and beyond

What stages of periodontitis have no tooth loss?

Stage I and II

What is the difference between stage III and IV?

- Stage III: ≤4 teeth loss due to periodontitis

- Stage IV: ≥5 teeth loss due to periodontitis

What stage of periodontitis?

- Max. probing depth <4 mm

- Mostly horizontal bone loss

Stage I

What stage of periodontitis?

- Max. probing depth ≤5 mm

- Mostly horizontal bone loss

Stage II

What stage of periodontitis?

In addition to previous stage complexity...

- Probing depths ≥6 mm

- Vertical bone loss ≥3 mm

- Furcation involvement Class Il or III

- Moderate ridge defects

Stage III

What stage of periodontitis?

In addition to previous stage complexity...

Need for complex rehabilitation due to:

- Masticatory dysfunction

- Secondary occlusal trauma (tooth mobility degree ≥2)

- Severe ridge defects

- Bite collapse, drifting, flaring

- < 20 remaining teeth

(10 opposing pairs)

Stage IV

What classifies a diagnosis as generalized versus localized?

Generalized: >30% of teeth invovled

What type of evidence can you use for grading for 120 recare patients?

Direct: radiograph bone loss or CAL over 5 years

What type of evidence can you use for grading for 150 new patients?

Indirect: % bone loss/age

What is the radiograph bone loss or CAL over 5 years for grade A periodontitis?

No loss over 5 years

What is the radiograph bone loss or CAL over 5 years for grade B periodontitis?

<2mm over 5 years

What is the radiograph bone loss or CAL over 5 years for grade C periodontitis?

≥2 mm over 5 years

What is the % bone loss/age for grade A periodontitis?

<0.25

What is the % bone loss/age for grade B periodontitis?

0.25 to 1.0

What is the % bone loss/age for grade C periodontitis?

≥1.0

What grade of periodontits?

Heavy biofilm deposits with low levels of destruction

Grade A

What grade of periodontitis?

Destruction commensurate with biofilm deposits

Grade B

What grade of periodontitis?

Destruction exceeds expectations given biofilm deposits; specific clinical patterns suggestive of periods of rapid progression and/or early onset disease

Grade C

How often does a Grade A periodontitis patient smoke?

Non-smoker

How often does a Grade B periodontitis patient smoke?

<10 cigarettes/day

How often does a Grade C periodontitis patient smoke?

≥10 cigarettes/day

What is the HbA1c of a Grade A periodontitis patient?

Normoglycemic/no diagnosis of diabetes

What is the HbA1c of a Grade B periodontitis patient?

<7.0%

What is the HbA1c of a Grade C periodontitis patient?

≥7.0%

Health or gingivitis?

- Probing attachment loss: None

- Probing pocket depths: ≤3 mm

- Bleeding on probing: <10%

- Radiographic bone loss: None

Health

Health or gingivitis?

- Probing attachment loss: None

- Probing pocket depths: ≤3 mm

- Bleeding on probing: ≥10%

- Radiographic bone loss: None

Gingivitis

Health or gingival inflammation for a successfully treated stable periodontitis patient?

- Probing attachment loss: Yes

- Probing pocket depths: ≤4 mm (no site ≥4mm with BOP)

- Bleeding on probing: <10%

- Radiographic bone loss: Yes

Clinical health on a reduced periodontium

Health or gingival inflammation for a successfully treated stable periodontitis patient?

- Probing attachment loss: Yes

- Probing pocket depths: ≤3 mm

- Bleeding on probing: ≥10%

- Radiographic bone loss: Yes

Gingival inflammation on a reduced periodontium

A successfully treated periodontitis patient in whom sites of gingival bleeding appear remains at high risk of disease recurrence at those sites and of progressive attachment loss. Therefore, gingivitis is defined as bleeding at a shallow site of ≤____ mm, as is the case in gingival heath. Where the probing depth is 4 mm or higher with bleeding, this is no longer a "closed pocket."

≤ 3 mm, (rather than ≤ 4 mm)

What is the diagnosis?

- No interproximal attachment loss on ≥2 teeth

- No BOP

Periodontal health

What is the diagnosis?

- No interproximal attachment loss on ≥2 teeth

- BOP ≥10%

Gingivitis

What is the diagnosis?

- Interproximal attachment loss on ≥2 teeth

- BOP <10%

Clinical health on a reduced periodontium

What is the diagnosis?

- Interproximal attachment loss on ≥2 teeth

- BOP ≥10%

- No PD >5mm

Gingival inflammation on a reduced periodontium

What is the diagnosis?

- Interproximal attachment loss on ≥2 teeth

- Deep PD ≥5mm

Periodontitis (Stage I-IV, Grade A-C)

What is the treatment end goal for a non-periodontitis patient?

Periodontal health

What is the treatment end goal for a patient with

gingival inflammation on a reduced periodontium?

Clinical health on a reduced periodontium

What is the treatment end goal for a periodontitis patient?

Clinical health on a reduced periodontium

"Diagnosis" is based on _________ and _________. But "Treatment Need" is based on _________

- Dx: Attachment Level, BOP

- Tx: Deep Probing Depth

What is the treatment for a patient with periodontal health?

Prophylaxis (D1110)

What is the treatment for a patient with gingivitis?

Prophylaxis (D1110)

What is the treatment for a patient with clinical health on a reduced periodontium?

Prophylaxis (D1110) / Perio Maintenance

What is the treatment for a patient with gingivitis on a reduced periodontium?

Prophylaxis (D1110) / Perio Maintenance

What is the treatment for a patient with periodontitis?

ScRP (Based on teeth number involved with deep PD ≥ 5 mm in each quadrant)

What are the two codes for an ScRP?

- D4342: 1-3 teeth

- D4341: 4+ teeth

What is the treatment for a patient with gingivitis and significant erythema, pseudopockets, or subgingival calculus?

Scaling in the presence of generalized moderate/severe gingivitis (D4346)

Define the following:

The sulcus is deepened because gingival enlargement without destruction of the underlying periodontal tissue (without apical migration of J.E)

Gingival pocket (pseudo pocket)

Define the following:

It is due to apical proliferation of junctional epithelium and destruction of the underlying supporting structures.

Periodontal pocket (true pocket)

What four things should a periodontitis diagnosis include?

- Periodontal diagnosis

- Peri-implant diagnosis (for each implant)

- Diagnoses for mucogingiva (recession / mucogingival defect...)

- Diagnoses tor individual teeth (endo, caries, root tip, tracture...)

According to McGuire & Nunn's Classification, what is the prognosis?

One or more of the following:

- Inadequate attachment to support the tooth

- Grade III or IV furcation involvement

- Miller class III mobility

- Tooth or teeth cannot be maintained by the professional and/or the patient

Hopeless

According to McGuire & Nunn's Classification, what is the prognosis?

One or more of the following:

- Greater than 50% attachment loss

- Grade Il or Ill furcation involvement not accessible for maintenance

- Endodontically involved tooth that must be resolved before periodontal treatment

- Tooth or teeth not easily maintained by professional and/or patient

Questionable

According to McGuire & Nunn's Classification, what is the prognosis?

One or more of the following:

- Up to 50% loss has occurred

- Grade II furcation with difficult access to the depth and position of the furcation

- Greater than Miller class I mobility

- Poor crown-to-root ratio

- Lack of patient compliance

- Presence of systemic factors

Poor

According to McGuire & Nunn's Classification, what is the prognosis?

One or more of the following:

- Up to 25% attachment loss measured clinically and radiographically

- Grade I furcation allows access for maintenance

- Tooth or teeth can be maintained with proper professional and home care

- Limited systemic factors

Fair

According to McGuire & Nunn's Classification, what is the prognosis?

One or more of the following:

- Etiologic factors can be controlled

- Adequate periodontal support

- Tooth or teeth can be adequately maintained by the professional and patient

- Controlled systemic factors

Good

What is included in the periodontal preliminary/ emergency phase?

- Emergency treatment (dental, periapical, periodontal, others)

- Extraction of hopeless teeth

What is included in the periodontal nonsurgical phase (Phase I)?

- Consultation (medical, dental, smoking cessation)

- Plaque control & patient education, Oral hygiene instructions (OHI)

- Correction of contributing factors (caries control, remove ill-fitting restorations, provisional splinting or prosthesis, occlusal adjustment)

- Prophylaxis or ScRP (depending on diagnosis)

What is included in the periodontal surgical phase (Phase II)?

- Periodontal surgeries

- Implant surgeries

- Endodontic therapy

What is included in the periodontal restoration phase (Phase III)?

- Final restorations

- Orthodontic therapy

T/F: Periodontal maintenance (D4910) is NOT recare prophylaxis (D1110.6)

True

Define the following:

Repeated ScRP over remaining deep probing sites under local anesthesia on periodontal patients every 3 months after first round of ScRP

Periodontal maintenance (D4910)

What is the diagnosis?

A) Localized gingivitis

B) Generalized gingivitis

C) Periodontitis stage I grade A

D) Periodontitis stage Ill grade C

B) Generalized gingivitis

What is the recommended treatment?

A) Prophylaxis (D1110)

B) Scaling in the presence of moderate to severe gingivitis (D4346)

C) Scaling and root planing 4+ teeth (D4341)

D) Periodontal maintenance (D4910)

B) Scaling in the presence of moderate to severe gingivitis (D4346)

What is included in the periodontal maintenance phase (Phase VI)?

- Supportive periodontal therapy (every 6 months prophylaxis, every 3 months periodontal maintenance: D4910)

- Occlusal guard