Periodontal Treatment Protocol (PTP) for the General Dental Practice

Introduction

Hujoel et al¹ estimated a 31% decrease in the prevalence of periodontitis between the years 1955 and 2000. Further, these authors estimate an additional 8% decrease by the year 2020. In spite of the decreased use of smoking tobacco,² better understanding of the pathogenesis of periodontal diseases, and more refined and goal directed therapies, there remains evidence that dentistry is not consistently achieving a timely diagnosis and appropriate and timely treatment of existing periodontitis.^3,4 Although the evidence is limited, there is a strong suggestion that use of a periodontal probe for diagnosis and recording of periodontal status in treatment records in general dental practices has yet to achieve the level of a routine and consistent habit.^5-9 Indeed, McFall et al⁸ determined that except for radiographs, most private practice patient records were so deficient in diagnostic information that periodontal status could not be established. It should be self-evident that treatment requires a definitive diagnosis, ie, a disease cannot be adequately treated unless first diagnosed. In this regard, it is interesting to note that at least one study has reported a dis connect between dentists' perception of treatment rendered and actual treatment as recorded in patient records.¹⁰ As an example, prophylactic procedures out number periodontal procedures by a ratio of 20:1^11,12 and yet the prevalence of chronic periodontitis (slight, moderate, and severe) is estimated to range from a low of 7% (aged ≥ 18 years)¹³ up to 35% (aged ≥ 30-90 years)¹⁴ of the US adult population.

Cobb et al.³ compared the pattern of referral of periodontitis patients in 1980 vs 2000 using patient record data from 3 geographically-diverse private periodontal practices. Results showed the following trends occurring over the 20 year time span: decreased use of tobacco; increase in the percentage of cases exhibiting advanced chronic periodontitis with a concomitant decrease in the percentage of mild-moderate disease cases; increase in the average number of missing teeth per patient; and increase in the average number of teeth scheduled for extraction per patient. A similar study by Docktor et al⁴ based on patient records from 3 private periodontal practices located within a major metropolitan area reported the following: 74% of referred cases were considered advanced periodontitis, of which 30% were treatment planned for extraction of 2 or more teeth; periodontal treatment provided by the general dental office did not vary because of disease severity; and the average number of periodontal maintenance visits/patient/year in the general dental office was less than the standard of care according to severity of disease, eg, 68% of advanced periodontitis cases reported between 0 and 2 periodontal maintenance visits per year rather than the recommended every 3 months. Viewed in aggregate, the trends reported by Cobb et al³ and Docktor et al⁴ support the assertion that timely diagnosis and appropriate and timely treatment of chronic periodontitis have not significantly improved over time. A major reason for the reported scarcity of timely diagnosis and appropriate treatment may be the lack of a well-established office protocol for the diagnosis, treatment, maintenance, and monitoring of periodontal disease, and involvement of the patient through education. Obviously, this requires dedication of energy, resources, effective communication skills, and a change in practice philosophy.

The Periodontal Treatment Protocol (PTP)

Diagnosis

Regardless of recent advances in our understanding of the etiology and pathogenesis of the periodontal diseases, the assessment of traditional clinical parameters remain the foundation for periodontal diagnosis.¹⁵ Generally, such clinical parameters include probing depth (PD), bleeding on probing (BOP), clinical attachment level (CAL), degree of furcation involvement, extent of gingival recession, tooth mobility, and plaque score. Clinicians typically utilize the results from the periodontal exam, radiographs, and the patient's medical and dental histories to establish a diagnosis and evolve a goal/diagnosis-directed treatment plan. It has been clearly demonstrated that different interpretations of the same diagnostic information can have a dramatic impact on treatment decisions.¹⁶ For this reason, a standardized approach to periodontal assessments and a working protocol as to treatment parameters would fill a logical need in the average general practice set ting. However, due to extensive over laps in most classification systems, any standardized approach is subject to variations in both clinical assessments (eg, variations in probing depth among clinicians) as well as the interpretation thereof.

All effective treatment protocols begin with a thorough and timely diagnosis. Six-point probing to measure PD and BOP is the standard of care. Based on the needs of the patient, current radiographs should be evaluated to determine the location and percentage of bone loss. The presence, location, and extent of furcation invasions should be noted, as well as the location of the gingival margin or CAL. Also, the patient's age is an important factor, especially in cases of rapidly progressing disease and deter mining overall long-term prognosis.

A modified version of the American Academy of Periodontology (AAP) proposed guidelines for a comprehensive periodontal examination is presented in Table 1.¹⁷ However, with respect to a functional PTP for the general dental practice, only the following principal diagnostic criteria can be addressed: age, PD, CAL, BOP, tooth mobility, furcation involvement, and percentage of radiographic bone loss. It must be emphasized that these criteria represent the minimal parameters for determining a periodontal diagnosis. There are many other important risk and modifying factors that will impact development and progression of disease and all such factors must be taken into consideration when establishing a definitive diagnosis and a diagnosis-driven treatment plan.¹⁸

Age is of relative value in that advanced amounts of periodontal destruction at an earlier age tend to indicate a more aggressive form of periodontitis. In contrast, chronic periodontitis may slowly progress towards severity over several years or decades. Young age combined with moderate to severe bone loss presents a tenuous long-term prognosis and requires more aggressive therapy compared to the older patient presenting with a chronic form of periodontitis.¹⁹

Probing depth (PD) is defined as the distance from the gingival margin to the base of the gingival crevice.²⁰ The periodontal pocket, represented by a probing depth > 3 mm, is the principle habitat for gram-negative, anaerobic pathogenic bacteria.²⁰ Deeper pockets tend to represent more extensive destruction of the underlying periodontium and, therefore, a potentially greater pathogenic burden.

Clinical Attachment Level (CAL) is defined as the distance from the CEJ to the base of the probable crevice/pocket. In cases of gingival recession, the amount of recession is added to the PD to yield the total amount of CAL. Although more difficult to obtain, it is a better measure of the total extent of damage to the under lying periodontium.^20-22

Mobility is best measured by the blunt end of 2 instruments alternating pressure in a facial-lingual direction and an apical direction to assess abnormal movement of the tooth. Simply assessed: Grade I mobility is slightly more than normal; Grade II is moderately more than normal; Grade III is severe mobility facial-lingually plus apical displacement.²³ Mobility patterns are suggestive of possible occlusal trauma, severe inflammation, and/or loss of sup porting alveolar bone.

Furcations represent bone loss between the roots of multi-rooted teeth. A deeply invasive furcation lesion is the equivalent of a poor long-term prognosis for the involved tooth. Simply put, a Grade 1 furcation involvement is incipient bone loss only; a Grade 2 is partial loss of bone producing a cul-de-sac; a Grade 3 is total bone loss with through-and-through opening of the furcation; and a Grade 4 is similar to a Grade 3, but with gingival recession that visually exposes the furcation opening.²⁴

Radiographic Evidence of Bone Loss is best determined with adequate and current radiographs,¹⁷ most typically a full-mouth periapical survey, including vertical bite-wings, or a panographic radiograph supplemented with vertical bite-wings and selected periapical films. By definition, true periodontitis does not begin until bone loss occurs.²⁵ Radiographic evaluation of the distribution and severity of bone loss, bone density, root anatomy, and approximation to other teeth provides specific information that will help in determining a proper diagnosis, treatment plan, and prognosis.

Bleeding on Probing (BOP) is a simple assessment of the inflammatory status of the gingiva.^15,26 In patients with deeper pockets and/or loss of clinical attachment, the chances of disease progression are greater as the percentage of bleeding sites increase.²⁷ Conversely, lack of BOP is highly correlated with stability and a lack of inflammation.²⁸ This latter statement, however, does not apply to smokers as they tend to bleed less when compared to nonsmokers with equal amounts of disease.²⁹

In addition to the usual clinical parameters, the clinician is well advised to consider other risk factors and their potential impact on the development and progression of plaque-induced periodontal diseases.¹⁸ Risk factors that are sometimes overlooked in the diagnosis, treatment plan, and prognosis equation include, among others: diabetes, smoking, osteoporosis, compromised immune system, drug-induced gingival conditions, hormonal changes, and genetics. Patients at risk for periodontal disease are often allowed to "slip between the cracks" during a routine visit because they may be in the early stages of the disease. Risk factors increase a patient's chance of developing periodontitis. The presence of one or more of these risk factors may also indicate a benefit from specialty referral in some patients.

Case Types and Periodontal Diagnosis

As part of a PTP it is necessary to establish diagnostic guidelines that will provide a framework for organizing the treatment needs of the patient. Guidelines are not meant to replace clinical knowledge or skills, nor do they imply a one-size-fits-all treatment plan for periodontal disease. It is recognized that each dental practice setting is different. Consequently, guidelines are intended to be used in a manner that best meets the needs of the specific patient.

Generally speaking, plaque-induced periodontal diseases have historically been categorized into gingivitis versus periodontitis based upon whether attachment loss has occurred. The 1999 International Workshop for Classification of Periodontal Diseases²¹ reclassified the plaque-induced periodontal diseases into 7 different classifications. In consideration of a working PTP that addresses only the common periodontal diseases, this paper will address health, gingivitis, chronic periodontitis (formerly adult periodontitis), and aggressive periodontitis (formerly early-onset periodontitis). The first 7 entries in Table 2 constitute a set of clinical criteria (PD, BOP, percent bone loss, tooth mobility, degree of furcation involvement, and CAL) that will facilitate differentiation of health from gingivitis and between the various levels of severity of chronic periodontitis. Further, Table 2 can aid the clinician in differentiating between chronic and aggressive periodontitis.

Some practice settings may prefer a system of "Periodontal Case Types" for purposes of diagnosis and record keeping. Table 3 presents the diagnostic clinical criteria as applied to Case Types for health, gingivitis, chronic periodontitis (slight, moderate, and severe), and aggressive periodontitis. These criteria and Case Types are generally appropriate but should be considered as guidelines only and not as a definitive diagnosis. As mentioned before, there are numerous modifying and risk factors to consider prior to evolving a diagnosis and a diagnosis-driven treatment plan.

Treatment Planning

Development of a logical and properly sequenced treatment plan is a derivative of the periodontal assessment and diagnosis. Periodontal therapy is diagnosis-driven and, to the extent possible, should address all modifying factors and risk factors that impact development and progression of plaque-induced periodontal disease. An overview of a typical periodontal treatment plan is presented in Table 4.³⁰

Implementation of Therapy

There are a wide variety of treatment options to be considered when confronted with gingivitis or chronic or aggressive periodontitis. However, thorough scaling and root planing (SRP) is still considered the gold standard in periodontal therapy. Beyond SRP, no one treatment modality is the answer in every case. However, the clinician must have specific endpoints or goals that therapy should achieve. If such endpoints are not achieved, then therapy must be re-evaluated and a decision made concerning retreatment or specialty referral for consideration of more advanced therapy options. Treatment options that should be considered include:³⁰

• Patient education including plaque control and counseling in management of periodontal and systemic risk factors
• Scaling and root planing
• Consideration of adjunctive chemotherapeutic agents, eg, locally or systemically administered antibiotics and host response modification agents.
• Re-evaluation
• Consideration of referral to a specialist is an option that must be considered for both legal and ethical reasons.³¹ There are a variety of reasons to consider referral to a periodontist, such as, SRP in the presence of extreme amounts of dental calculus or SRP with complications of systemic disease, gingival overgrowth and/or inflammatory hyperplasia, resective surgery, regenerative procedures for soft and hard tissues, periodontal plastic surgery, occlusal therapy, pre-prosthetic surgery, dental implants, management of perio-systemic complications, phobic patients requiring conscious sedation, etc.

Periodontal Maintenance Therapy and Continual Assessment

In general, data suggests that patients who have undergone definitive therapy for either localized or generalized periodontitis should be managed by periodontal maintenance (PM), performed at an interval of 3 months for an indefinite period of time following active therapy.³² The 3-month interval is critical (and the standard of care for moderate and severe chronic periodontitis and aggressive periodontitis) as it has been repeatedly shown to be effective in reducing disease progression, preserving teeth, and controlling the subgingival bacterial burden.^33-35 Nonetheless, the PM schedule should be individualized and tailored to meet the needs of each patient. Factors such as home care, previous level of disease, tendency toward refraction, stability indicators, etc, should be used in making this assessment. More fragile patients may need intervals of 2 months or less, and conversely, patients intercepted in early disease states who demonstrate consistent stability may need less frequent intervals of 4-6 months. Regardless of the interval between appointments, the periodontal status of each patient should be re-evaluated at every maintenance appointment. Only through close monitoring can disease recurrence be detected and the maintenance interval adjusted accordingly. Continual assessment of the periodontium during maintenance affords the best opportunity for assuring long-term stability or providing interceptive care.^34,35

Insurance Coding

The American Academy of Periodontology's Parameters of Care 2000³⁶ and the American Dental Association's Current Dental Terminology³⁷ are available to clinicians to guide decision-making related to providing therapeutic periodontal treatment and subsequent reporting of services for insurance reimbursement. In terms of nonsurgical periodontal therapy, familiarity with dental insurance codes provides a clear method to document treatment and select appropriate procedures to maximize insurance reimbursement for the patient.

Table 5 presents a modified description of the ADA insurance codes most commonly used in Phase I periodontal therapy (aka anti-infective therapy or nonsurgical therapy). The descriptions are intended to reveal distinctive differences between procedures, and guide the clinician in reimbursement procedures.

To simplify decisions made by patients, dental insurance should be referred to as "reimbursement," "benefit," or "assistance" by the clinician and other staff members rather than "coverage" since the word implies complete. Most patients with dental insurance will find it necessary to supplement whatever insurance benefit they receive toward lifetime periodontal care, as many plans have contract limitations for the percentage of reimbursement associated with various procedures and/or the length of time those benefits apply. For example, limitations of some insurance plans assign benefits for PM following SRP but only for 24 months following active therapy. As another example, exclusions found in other insurance plans assign benefits for SRP for generalized periodontal disease but not for localized infection. Many patients are reticent to proceed with treatment unless their insurance will "pay for it." Consequently, it is advantageous for practices to have clear explanations about the reality of dental insurance. Figure 2 presents a sample explanation of dental insurance that can be shared with patients, assisting them in making independent decisions about treatment, regardless of the insurance reimbursement schedule.

Patient Education and Introduction to Periodontal Therapy

Effective implementation of the aforementioned concepts requires expertise in effective patient education and introduction of periodontal therapy so that patients are prepared to make wise health decisions. Being proficient in SRP procedures has little value to the patient who assumes they are visiting the dental hygienist for a "routine cleaning." This is particularly true if the patient already has a developing or existing 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 importance to today's dental patient.

The incidence of moderate and severe generalized chronic periodontitis 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 effective at enrolling patients into active therapy everyone in the practice setting must have a basic understanding of the etiology of periodontal diseases, treatment options, consequences of nontreatment, and direct benefits of therapy. Patients are more motivated to accept treatment recommendations when a clear diagnosis has been established, they are given the opportunity to see infection in their own mouths, their questions have been answered, and they understand the value of treating periodontal infection in relation to their overall health.

Many clinicians inform patients of their periodontal status while working in their mouths with sharp instruments, or give a summary of findings at the end of the visit. Most patients are visual learners. Consequently, patients need to see the condition of their own mouth. At the beginning of every appointment, during data collection and tissue assessment, the patient should be provided a mirror to visualize with the clinician the evidence of periodontal disease, caries, gingival recession, tooth mobility, furcation involvement, etc. (Figure 1). During periodontal probing, the patient should hear the pocket measurements as data is being collected and recorded. In a similar manner, during examination of the radiographs, the patient should be shown evidence of permanent bone loss, and contrast that to areas without bone loss. Involving the patient in the discovery process visually and audibly is a powerful tool to help patients take ownership in their own health.

This is also an opportune time for the clinician to introduce adjunctive therapies to the patient such as the use of locally delivered antimicrobials and other agents. For example, the clinician can communicate that locally delivered antimicrobials have been on the US market for many years and have been shown to be a safe, effective treatment option. Important information to convey includes the ease of application; the high potency of the drug at levels that will kill bacteria; it does not affect the rest of the body; and there is no need for an additional appointment to remove the product since the agent biodegrades. Educating the patient to all of their treatment options is vital to clear and evidence-based communication.

Enhanced Communication Skills

Each clinician will develop his/her own style of case presentation for periodontal therapy and will individualize the message to different patients. However, there is significant advantage if the entire office staff has continuity in key words that are used when discussing periodontal therapy with patients. Equally important is the avoidance of minimizing messages such as "just a little bit of bleeding," or "a little bone loss," or "just a little bit of plaque." It is advisable to use language that does not trivialize conditions that are not yet severe. Terms such as "slight bleeding," "early bone loss," or "slight plaque" accurately describe findings without overstating them.

Periodontal disease is a bacterial infection leading to a host immune response that is characterized by inflammation and degradation of periodontal tissues.²² When informing patients of periodontal disease, using the word "infection" is more powerful than "gum inflammation" and can create a sense of urgency regarding treatment. The word "hemorrhage" indicates heavy bleeding and implies a condition outside healthy parameters. When the patient's gingival tissues hemorrhage easily upon provocation, "hemorrhage" rather than "bleeding gum tissue" should be verbalized to the patient. The words "scaling and root planing" may sound confusing to patients or imply discomfort. The words "periodontal therapy" are effective semantic choices when informing patients about necessary periodontal treatment. "We now know" are words that can introduce patients to new ideas or treatment options to explain why information may be different than what they have heard in the past, or expected to hear at their current visit. "Halting" or "arresting disease" can be used to describe a measurable goal for treating periodontal diseases that should be obtained through intervention. "Daily disease control" communicates to the patient that they share in the role in the effective removal of plaque bacteria beyond what it achieve through periodontal treatment.

Even though some states require written consent, effective communication between the clinician and the patient is the important consideration of informed consent,³⁹ not the completion of a form. Therefore, deliberate semantic choices should be shared by all members of the office staff to optimize patient understanding of their periodontal conditions.

Suggestions for Implementation of a Periodontal Treatment Protocol in the General Practice Setting

• General dentists and dental hygienists should schedule a meeting with referring periodontists and their dental hygienists to share philosophies of periodontal treatment and establish clarity for referrals.
• Schedule a team meeting workshop to bring all office staff up-to-date regarding periodontal assessments, diagnosis, case types, periodontal risk factors, individualized treatment of periodontal diseases, consequences of nontreatment (tooth loss and possible systemic involvement), and the value of periodontal maintenance.
• Establish continuity of the verbal skills and terminology the office staff will utilize to communicate effectively to patients about periodontal conditions.
• Include assessments and diagnosis of periodontal diseases in all new patient visits, routine prophylaxis appointments, and ongoing periodontal maintenance to insure no patient is overlooked regarding diagnosis of developing periodontal disease or recurring disease.
• Select appropriate ADA Insurance Procedure Codes for reporting periodontal procedures in order to maximize the patient's benefit.
• Share insurance information with patients to assist them in reducing their dependence on dental insurance benefits, thereby enabling them to make independent health decisions related to treatment of periodontal diseases.

Click here to view the "Guide for Use of Locally Delivered Microbials."

Disclosure

Dr. Sweeting, Ms. Davis, and Dr. Cobb are scientific advisors for OraPharma, Inc.

References

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About the Authors

Larry Sweeting, DDS, graduated from Emory University Dental School with a Doctor of Dental Surgery degree and later earned a Certificate in Periodontics. Dr. Sweeting held a clinical part-time faculty appointment in the Post Doctoral Graduate Periodontics program at Emory University Dental School from 1986-1992 and is currently a clinical assistant professor at the Medical College of Georgia (MCG) in the Department of Periodontics. He received the MCG "2007 Educator Award" presented by the American Academy of Periodontology in recognition of outstanding teaching and mentoring in Periodontics. For the past 20 years, Dr. Sweeting has been the managing partner and dental director for a 10-office multispecialty group practice in Atlanta, Ga.

Karen Davis, RDH, BSDH, received her Bachelor of Science in Dental Hygiene from Midwestern State University. She is the founder of Cutting Edge Concepts® and a trainer for RDH Mastership Certification courses from The JP Institute of San Diego, Calif. In addition, Ms. Davis practices clinically in Dallas, Tex. She speaks internationally and has authored numerous articles related to periodontal therapy and practice management.

Charles Cobb, DDS, PhD, graduated from the University of Missouri-Kansas City with a dental degree, a Certificate of Specialty in Periodontics, and a Master of Science degree in Microbiology. He later earned a PhD in Anatomy from Georgetown University. He has held academic positions at Louisiana State University, the University of Alabama, and UMKC. In addition to teaching and research, Dr. Cobb has practiced periodontics full-time for 15 years in a private dental practice. Dr. Cobb recently retired from academics as Professor Emeritus at UMKC. He is a Diplomate of the American Board of Periodontology, has published over 165 peer-review articles, and presented over 120 programs at regional, national, and international meetings.