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## Complete Summary

#### GUIDELINE TITLE

Guidelines for the management of patients with periodontal diseases.

#### BIBLIOGRAPHIC SOURCE(S)

Krebs KA, Clem DS 3rd, American Academy of Periodontology. Guidelines
for the management of patients with periodontal diseases. J
Periodontol 2006 Sep;77(9):1607-11.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16945041)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Periodontal diseases

#### GUIDELINE CATEGORY

Management\
Prevention\
Risk Assessment

#### CLINICAL SPECIALTY

Cardiology\
Dentistry\
Endocrinology\
Hematology\
Obstetrics and Gynecology\
Oncology\
Orthopedic Surgery\
Preventive Medicine\
Pulmonary Medicine\
Surgery

#### INTENDED USERS

Allied Health Personnel\
Dentists\
Health Care Providers\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To encourage referring dentists and periodontists to work together
    to optimize the health of patients

-   To help the dental practitioner in the rapid identification of those
    patients at greater risk for the consequences of periodontal
    inflammation and infection and, therefore, those patients most
    appropriate for specialty referral

#### TARGET POPULATION

Individuals with periodontitis or those who are at risk of moderate to
advanced periodontal disease

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Assessment/Evaluation/Risk Assessment**

Timely identification of patients who would benefit from comanagement by
the referring dentist and a periodontist

-   Patients who should be treated by a periodontist

    -   High-risk conditions and diseases

-   Patients who would likely benefit from comanagement by the referring
    dentist and the periodontist

    -   Periodontal risk factors/indicators

    -   Medical or behavioral risk factors/indicators

-   Patients who may benefit from comanagement by the referring dentist
    and the periodontist

    -   Periodontal inflammation/infection plus systemic conditions and
        diseases

    -   Candidates for high-risk therapies

**Management/Prevention**

Comanagement by referring dentist and periodontist

#### MAJOR OUTCOMES CONSIDERED

-   Periodontal inflammation and infection

-   Peri-implant disease

-   Significant root surface exposure

-   Tooth loss

-   Oral function and appearance

-   Deteriorating risk profile

-   Appropriate and timely treatment of periodontal disease

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases\
Searches of Unpublished Data

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

PubMed and Medline were searched for relevant literature from 1990 to
2006.  Specific search terms used included: clinical guidelines, general
research, periodontal maintenance, regeneration, moderate to severe
periodontal disease, risk assessment, diabetes and periodontal disease,
heart disease and periodontal disease, preterm birth and periodontal
disease, tobacco and periodontal disease, perio-systemic (general), and
referral patterns.

In addition to PubMed and Medline, the Academy conducted qualitative and
quantitative research with its members in the course of development.
This included:

a.  Focus group of 100 American Academy of Periodontology (AAP) members
    in ten locations throughout the United States. Questions about the
    practice of periodontics, including patient care, relationships with
    referring colleagues, technology, technique, and tools. This
    qualitative evaluation informed the Academy\'s understanding of the
    current environment for a practicing periodontist in the United
    States.

b.  Data from the Academy\'s [Practice Profile
    Survey](http://www.perio.org/perio-bin-nd3/commerce05/search?item=PPSPKG);
    this tri-annual survey began in 1997, and data from all surveys was
    used. This comprehensive survey of periodontal practice evaluated
    the profiles of practice characteristics including organizational
    structure, referral patterns, treatment procedures performed,
    patient characteristics, and demographic data. This information
    allowed the Academy to identify and understand the needs and
    concerns of members in clinical practice. This information, as
    collected, provides a benchmark for members to understand how their
    practice compares to others. Twenty-five hundred questionnaires were
    mailed to a random sample of Active AAP members across the country.
    Follow up post-cards were mailed 2 months after the initial mailing,
    encouraging response. The survey response rates averaged 34.7%, with
    a distribution across districts which matched Academy demographics.
    Therefore, the survey samples did reflect the Academy membership for
    demographic characteristics.

c.  The Academy\'s annual membership survey, which is sent annually to
    all 8,000 Academy members. This survey collects further information
    on demographic and practice characteristics, which informs the
    Academy\'s strategy when providing services to its members.

#### NUMBER OF SOURCE DOCUMENTS

87

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus (Committee)\
Subjective Review

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

The Task Force considered relevant research and other sources, including
patient care and the treatment process for periodontal diseases.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus\
Informal Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

A Board of Trustees-appointed task force consisting of periodontal
practitioners, academicians, and researchers developed the guidelines.
The Academy distributed a draft version of the guidelines to all
members, the American Dental Association, Academy of General Dentistry,
and American Dental Hygienists\' Association for commentary. All
organizations and more than 375 members provided commentary. The task
force revised the guidelines based on the comments received.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Comparison with Guidelines from Other Groups\
External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Guidelines from the following organizations were consulted: the American
Association of Endodontics, American Association of Clinical
Endocrinologists.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**[Level 3: Patients Who Should Be Treated by a
Periodontist]{.underline}**

Any patient with:

-   Severe chronic periodontitis

-   Furcation involvement

-   Vertical/angular bony defect(s)

-   Aggressive periodontitis (formerly known as juvenile, early-onset,
    or rapidly progressive periodontitis)

-   Periodontal abscess and other acute periodontal conditions

-   Significant root surface exposure and/or progressive gingival
    recession

-   Peri-implant disease

Any patient with periodontal diseases, regardless of severity, whom the
referring dentist prefers not to treat.

**[Level 2: Patients Who Would Likely Benefit from Comanagement by the
Referring Dentist and the Periodontist]{.underline}**

Any patient with periodontitis who demonstrates at reevaluation or any
dental examination one or more of the following risk
factors/indicators\* known to contribute to the progression of
periodontal diseases:

*Periodontal Risk Factors/Indicators*

-   Early onset of periodontal diseases (prior to the age of 35 years)

-   Unresolved inflammation at any site (e.g., bleeding upon probing,
    pus, and/or redness)

-   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

*Medical or Behavioral Risk Factors/Indicators*

-   Smoking/tobacco use

-   Diabetes

-   Osteoporosis/osteopenia

-   Drug-induced gingival conditions (e.g., phenytoins, calcium channel
    blockers, immunosuppressants, and long-term systemic steroids)

-   Compromised immune system, either acquired or drug induced

-   A deteriorating risk profile

\* It should be noted that a combination of two or more of these risk
factors/indicators may make even slight to moderate periodontitis
particularly difficult to manage (e.g., a patient under 35 years of age
who smokes).

**[Level 1: Patients Who May Benefit From Comanagement by the Referring
Dentist and the Periodontist]{.underline}**

Any patient 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

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations were based primarily on a comprehensive review of
published reports as well as input from a task force comprised of
periodontists from private practice and academia. In cases where the
data did not appear conclusive, recommendations were based on the
consensus opinion of the group.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

The Guidelines will:

-   Help the practitioner in triaging patients who currently have or who
    are at risk for the development of periodontal diseases.

-   Help the general practitioner more effectively address the
    association of periodontal diseases and systemic
    diseases/conditions.

-   Assist the general dentist and hygienist in the management of
    periodontal diseases.

-   Result in appropriate and timely treatment of periodontal diseases.

In addition, the Guidelines:

-   Should enhance the restorative outcome of dental treatment by
    establishing and maintaining a healthy periodontal foundation.

-   Are clear, concise, and should be easy to incorporate into daily
    practice and will enhance the partnership between periodontists and
    referring dentists.

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

These guidelines are in no way meant to replace a practitioner\'s
knowledge, skills, or abilities; a \"one-size-fits-all\" treatment plan
for periodontal disease does not exist.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

Guidelines were distributed to all dentist members of the American
Academy of Periodontology, American Dental Association hygienists, and
other dental health professionals. In addition, a study club
presentation was created to educate about the guidelines, and a patient
self-assessment test was created to compliment recommendations of the
guideline.

#### IMPLEMENTATION TOOLS

Patient Resources\
Staff Training/Competency Material

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Krebs KA, Clem DS 3rd, American Academy of Periodontology. Guidelines
for the management of patients with periodontal diseases. J
Periodontol 2006 Sep;77(9):1607-11.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16945041)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2006 Sep

#### GUIDELINE DEVELOPER(S)

American Academy of Periodontology - Professional Association

#### SOURCE(S) OF FUNDING

American Academy of Periodontology

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Not stated

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American Academy of Periodontology Web
site](http://www.perio.org/resources-products/pdf/management.pdf).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Continuing education courses are available from the [American
    Academy of Periodontology Web
    site](http://www.perio.org/meetings/am/index.html).

#### PATIENT RESOURCES

The following is available:

-   Assess your risk of gum disease. Patient self assessment tool.
    Electronic copies: Available from the [American Academy of
    Periodontology Web site](http://www.perio.org/consumer/4a.html).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI Institute on December 22, 2008.
The information was verified by the guideline developer on January 7,
2009.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is
copyrighted by the American Academy of Periodontology.

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 2/9/2009