21 Clinical Decision-Making for Periodontal Care

Clinical Decision-Making for Periodontal Care

Foundations of Clinical Decision-Making

• Clinical Decision-Making
  • A process whereby the dental team uses information from a comprehensive periodontal assessment to arrive at an appropriate diagnosis and identify treatment strategies.
  • It is the first step of treatment planning, which involves assigning the correct diagnosis.

Guidelines for Arriving at a Periodontal Diagnosis

• Involves answering fundamental diagnostic questions:
  • Does the clinical assessment indicate periodontal health or inflammatory disease?
  • If the clinical assessment indicates inflammatory disease, is the disease gingivitis or periodontitis?
  • If the patient has gingivitis, what type is it?
  • If the patient has periodontitis, what type is it?

Identifying Periodontal Health or Inflammatory Disease

• Signs of Disease

  • Defined as directly observable or measurable features of disease.
  • Common signs of periodontal disease include:
  • Gingival erythema (redness)
  • Gingival edema (swelling)
  • Bleeding on gentle probing
  • Loss of attachment
  • Tooth mobility
  • Loss of alveolar bone support

• Symptoms of Disease

  • Features of disease noticeable only to the patient.
  • Example symptoms of Stage IV periodontitis include:
  • Loose teeth
  • Difficulty chewing
  • Profuse gingival bleeding
  • Bad taste in mouth

• Periodontitis is often referred to as a silent disease due to early symptoms being subtle and going undetected.

  • Disease can progress to an advanced state causing serious complications.
  • Patients may remain unaware of the disease until overt symptoms appear.

Signs of Inflammation in the Periodontium

• Table: Signs of Inflammation
  • Overt Signs (Readily Visible):
  • Color changes in gingiva
  • Contour changes in gingiva
  • Consistency changes in gingiva
  • Hidden Signs:
  • Bone loss (specific to periodontitis)
  • Purulence (exudate)
  • Bleeding on probing

Diagnostic Considerations

• Periodontal Health

  • If the assessment shows absence of overt or hidden signs of inflammation, the diagnosis is periodontal health, indicating that inflammatory disease is not present.
  • Other issues may be present, but patient does not have gingivitis or periodontitis.

• Inflammatory Disease

  • If signs of inflammation are present, the answer is inflammatory disease.
  • Indicates that some form of inflammatory disease is present and further diagnostic decisions must be made.

• Additional diagnostic measures may be necessary even in the absence of inflammatory disease; for instance, if a patient shows severe gingival recession and cervical abrasions despite no inflammation, evaluation for traumatic tooth brushing history may be warranted.

Differentiating Between Gingivitis and Periodontitis

• Diagnosis is based on clinical evidence of attachment loss.
  • Normal level of gingival attachment is slightly coronal to the level of the cemento-enamel junction (CEJ).
  • Clinical Attachment Loss (CAL) refers to the migration of the junctional epithelium to a position apical to the CEJ level.

Gingivitis vs. Periodontitis

• Gingivitis

  • Defined as the presence of inflammation without attachment loss.

• Periodontitis

  • Defined as inflammation with attachment loss present.

• Importance of Radiographs

  • Dental radiographs and clinical findings should be used during the clinical assessment.
  • In most cases of periodontitis, alveolar bone loss is evident on radiographs prior to clinical attachment loss being detectable by a clinician.

Types of Gingivitis and Periodontitis

• Dentists will use existing disease classifications to assign a periodontal diagnosis based on clinical features.
• Changes in 2017 classification system include:
  • Peri-implant health
  • Peri-implant mucositis
  • Peri-implantitis
• Document any other periodontal conditions identified during the diagnosis.

Recognizing the Need for Flexibility

• Clinicians must maintain flexibility when assigning diagnoses due to the potential for multiple conditions to be present:
  • It is important to recognize that determining the presence of gingivitis or periodontitis may not encapsulate the overall condition of the patient.
  • Documentation should reflect all other periodontal conditions identified.

Examples of Other Findings

• Findings that may be documented include:
  • Recession of gingival margin
  • Occlusal trauma
  • Aberrant frenum position

Documenting Periodontal and Peri-Implant Diagnosis

• Documenting the periodontal diagnosis is critical and should adhere to a standard format.
• Utilize the correct diagnostic terms per the classification scheme, such as gingivitis or periodontitis.

Disease Staging

• Classify disease using a multidimensional staging system.
  • Staging of Periodontitis defines severity, complexity of management, and the extent and distribution of disease.
  • For peri-implant diagnosis, determine if the diagnosis is peri-implant health, peri-implant mucositis, or peri-implantitis.

Documentation of Disease Stage, Grade, and Extent

• Modifiers in Disease Documentation
  • Table: Use of Modifiers
  • Disease Stage:
  • Stage I: Initial periodontitis
  • Stage II: Moderate periodontitis
  • Stage III: Severe periodontitis with potential for tooth loss
  • Stage IV: Advanced periodontitis with extensive tooth loss
  • Disease Grade:
  • Grade A: Slow rate of progression
  • Grade B: Moderate rate of progression
  • Grade C: Rapid rate of progression
  • Disease Extent:
  • Localized (30% or less of teeth involved)
  • Generalized (more than 30% of teeth involved)
  • Molar/incisor pattern (breakdown limited to molars and incisors)

Disease Grading

• Grading classification is an indicator of the anticipated rate of periodontitis progression:
  • Grade A: Slow rate
  • Grade B: Moderate rate
  • Grade C: Rapid rate
• Grading systems rely on direct/indirect evidence of progression and apply solely to periodontitis classification, not other conditions.

Treatment Planning Phases

• The comprehensive periodontal master treatment plan serves as an outline of actions for the dentist, dental hygienist, and patient aimed at restoring a healthy periodontal environment.
• Treatment plan phases include:
  • Assessment and Preliminary Therapy
  • Nonsurgical Periodontal Therapy
  • Surgical Therapy
  • Restorative Therapy
  • Periodontal Maintenance

Phases Explained:

• Assessment and Preliminary Therapy Phase:

  • Involves evaluating collected data and urgent care for any acute conditions, sometimes classified as emergency therapy.

• Nonsurgical Periodontal Therapy Phase:

  • Comprises measures used to control gingivitis or periodontitis, including intensive instrumentation and patient education.

• Surgical Therapy Phase:

  • Encompasses any surgical interventions required to eliminate periodontal disease not manageable via nonsurgical means, including dental implant placement for missing teeth.

• Restorative Therapy Phase:

  • Involves placing dental restorations and potentially replacing missing teeth with fixed or removable prosthetics.

• Periodontal Maintenance Phase:

  • Entails ongoing measures by both dental teams and patients aimed at preventing the recurrence of periodontitis once controlled.
  • The target is ensuring teeth remain functional throughout the patient's life.

Importance of Ongoing Decision-Making

• The goal of periodontal therapy is to preserve the periodontium, optimize oral health, and contribute to the overall well-being of the individual.
• The periodontium consists of dynamic tissues that can undergo physiological remodeling or pathological destruction.
• A patient's care plan often requires adjustments over time, necessitating consistent communication regarding their diagnosis and treatment plan.