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## Complete Summary

#### GUIDELINE TITLE

HealthPartners Dental Group and Clinics guidelines for the diagnosis and
treatment of periodontal diseases.

#### BIBLIOGRAPHIC SOURCE(S)

HealthPartners Dental Group and Clinics guidelines for the diagnosis and
treatment of periodontal diseases. Minneapolis (MN): HealthPartners;
2006 Mar 9. 85 p.

#### GUIDELINE STATUS

This is the current release of the guideline.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse (NGC)**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [July 08, 2008, Fluoroquinolones (ciprofloxacin, norfloxacin,
    ofloxacin, levofloxacin, moxifloxacin,
    gemifloxacin)](http://www.fda.gov/medwatch/safety/2008/safety08.htm#Fluoroquinolone):
    A BOXED WARNING and Medication Guide are to be added to the
    prescribing information to strengthen existing warnings about the
    increased risk of developing tendinitis and tendon rupture in
    patients taking fluoroquinolones for systemic use.

### COMPLETE SUMMARY CONTENT

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

### SCOPE

#### DISEASE/CONDITION(S)

Periodontal diseases:

-   Gingivitis

-   Chronic adult periodontal disease

-   Refractory periodontitis

-   Early onset periodontal disease

-   Tooth recession

-   Inadequacy of attached gingiva

-   Root exposure

-   Peri-implant disease

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Dentistry

#### INTENDED USERS

Dentists

#### GUIDELINE OBJECTIVE(S)

To provide the HealthPartners Dental Group dental care staff with
diagnostic and treatment algorithms for the various periodontal diseases
that emphasize patient and staff education, appropriate treatment
modalities, and guidance for periodontal referrals resulting in better,
more uniform care for this patient population

#### TARGET POPULATION

Adult and pediatric patients in the HealthPartners Dental Group

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis/Evaluation**

1.  Periodontal screening for signs of active disease

2.  Evaluation and periodontal examination

    -   Radiographs (bite wings, full-mouth, panographic)

    -   Visual exam

    -   Plaque and calculus assessment

    -   Periodontal charting

3.  Maintenance of periodontal records

4.  Evaluation of systemic conditions (e.g., diabetes, smoking,
    pregnancy)

5.  Bacterial DNA testing or cultural analysis

**Treatment/Management**

1.  Plaque control

2.  Oral hygiene instruction

3.  Referral for systemic conditions (e.g., diabetes, smoking,
    pregnancy)

4.  Compromise therapy

    -   Antimicrobial rinses (e.g., chlorhexidine, Listerine)

    -   Non-steroidal anti-inflammatory drugs (flurbiprofen, naproxen)

    -   Antibiotics (metronidazole, doxycycline, amoxicillin )

    -   Irrigation

    -   Localized antibiotic therapy (e.g., Periochip, Atridox, Arestin)

5.  Scaling and root planing (ultrasonic instrumentation combined with
    hand instrumentation)

6.  Re-evaluation of response to therapy

7.  Supportive periodontal treatment

    -   Fluoride therapy

    -   Desensitization therapy

8.  Periodontal surgery

#### MAJOR OUTCOMES CONSIDERED

-   Effectiveness of treatment in reducing disease progression and
    preventing need for surgery

-   Patient compliance

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

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

Literature searches were conducted through the University of Minnesota
Biomedical Library as well as computer searches using Medline and
PubMed.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

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

Not stated

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

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

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

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

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

Articles were reviewed and discussed by a committee of dentists,
including a periodontist.

#### 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

External Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

A draft of the guideline document was sent to expert reviewers for
comment.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Gingivitis and Chronic Adult Periodontal Disease: Initial Therapy and
Supportive Treatment**

**Diagnosis of Gingivitis**

Plaque associated gingivitis is the most common of periodontal diseases.
Diagnosis is based on the signs of inflammation. In clinical practice
identification of the signs of inflammation; redness, gingival bleeding,
and tissue edema establish the diagnosis of gingivitis or periodontitis.

It is important to distinguish gingivitis from chronic adult periodontal
disease. Signs of inflammation without any tissue attachment loss are
likely gingivitis without periodontitis. Diagnosis is more difficult
when attachment loss has occurred. It must be established whether the
attachment loss is due to an active disease process or developmental
predisposition.

Numerous systemic factors including hormonal changes associated with
adolescence and pregnancy, mouth breathing, medications, and immune
status can precipitate or intensify gingivitis. In these cases removal
of the local factors of plaque, calculus and iatrogenic dentistry can be
expected to improve the clinical status of the patient.

**Diagnosis of Chronic Adult Periodontal Disease**

Diagnosis is generally based on two criteria: evidence of active disease
process through the signs of inflammation, and documentation of
attachment loss. This is simplistic, as the importance of specific
bacteria and of the host response has been demonstrated in research. In
clinical practice, at this time, the tools for diagnosis of
periodontitis are simple. Maintenance of good record practices is
essential, as they allow identification of long term treatment success,
and permit efficient treatment of the patient.

**Comprehensive Periodontal Assessment**

A comprehensive periodontal assessment is performed by the dentist.
Complete periodontal records and recent radiographs are required. Prior
to active periodontal therapy there must be an exam to establish a
diagnosis and treatment plan. At the reevaluation visit the
comprehensive periodontal exam must be repeated by the dentist to ensure
that therapy had the desired effects, and to recommend further active
therapy, referral or maintenance interval. In maintenance, new full
mouth radiographs are required every two to five years.

*Periodontal Records*

Periodontal records at the initial and re-evaluation examination and at
each supportive periodontal therapy visit should contain:

-   Current radiographs (within 6 months in active disease, two years in
    maintenance showing all crestal bone with proper angulation)

-   Full mouth probing with attachment levels recorded

-   Notation of the extent of furcal invasion

-   Mobility recording

-   Bleeding and suppuration points

-   Plaque control evaluation with disclosing solution (may be omitted
    if patient consistently demonstrates excellent plaque control) with
    documentation; location and extent should be recorded with words
    such as heavy, generalized, posterior, facial, marginal, etc.
    Patient should see disclosed plaque and work with provider to remove

-   Notation to the oral hygiene difficulties noted, and the
    recommendations to allow for improved personal oral hygiene (p.o.h.)

-   Problem areas

-   Next visit purpose

-   Recall interval

**Classification of Periodontal Disease**

The American Dental Association (ADA) classifications are used in the
insurance industry for third party payment. They provide an indication
of previous attachment loss, but not a useful index of current disease
activity.

A more useful scheme for classification provides for the division of
plaque related adult periodontal diseases by the degree that the
attachment is compromised in the presence of the signs of inflammation
that may indicate active attachment loss. When the modifiers of local
versus generalized are applied to the descriptor for the level of
attachment loss (gingivitis and mild, moderate, and severe
periodontitis) the periodontal condition can be described. (Refer to the
original guideline document for diagnostic codes for periodontal
disease.)

**The Progressive Periodontal Lesion**

Periodontal disease does not progress linearly in time or location.
Periodontitis is site specific. While inflammation is necessary for
attachment loss, the presence of inflammation does not mean that
attachment will be lost. Loss of attachment occurs in episodes.
Discerning the active periodontal lesion from gingivitis requires keen
observation, good record keeping, and clinical judgment. In active
periodontitis the loss of attachment proceeds approximately from the
crown to the apex, but there are strong components of lateral extensions
of attachment loss. These factors, along with the resistance of the
attachment to probe penetration allow for wide variation in probing
depths over time. Regular probing of attachment and pocket depth is
essential in monitoring during periodontal therapy and maintenance.

**Microbiology of Periodontal Disease**

While it is apparent from research studies that specific bacteria play
distinct roles in periodontitis this knowledge has not changed the
therapy for adult chronic periodontitis. The subgingival space is
colonized by bacteria that occupy the depth of the pocket attaching to
epithelial cells, bacteria in the pocket exudate, and in superficial
layers of the root surface. There is a relationship between the
supragingival plaque and the number and pathogenicity of bacteria in
periodontal pockets.

Conventional non-surgical periodontal therapy strives to disrupt the
pocket bacteria through:

-   Scaling to remove calculus, allowing a reduced attachment area for
    plaque

-   Root planing to remove the superficial infected and affected root
    surface

-   Restorative treatment to eliminate areas of plaque retention and
    tissue damage

-   Oral hygiene instruction and monitoring to control supragingival and
    marginal plaque

Nonsurgical therapy is the first line of treatment of periodontal
disease in the general practice. As long as patient compliance is good
and access is possible, nonsurgical therapy provides predictable
results.

**Ultra-sonics in Periodontal Disease**

Used with hand instruments ultra-sonic scalers provide superior
debridement over either instrument alone. This is especially true in
furcal areas. Ultra-sonics disrupt calculus and bacterial colonies more
effectively in areas that have limited space for instrumentation than do
hand scalers. Ultra-sonics provide active lavage throughout therapy.
This works to remove calculus fragments that could otherwise become
incorporated in the damaged pocket epithelium.

In treatment of periodontitis ultrasonic scaling allows root debridement
with ample lavage, with minimal soft tissue damage and detoxification of
the cemental surface.

Ultrasonic scalers can be shown in electron micrographs to leave
roughened root surfaces. If used properly the surface roughness is
equivalent to that left by hand instruments. If excessive energy is
used, or if the instrument is left in a single area and not kept in
constant motion, the root surface can be damaged.

Sonic scalers are inferior to the modem ultrasonic scalers in the
treatment of periodontitis. Sonic scalers are more likely to damage root
surfaces, and have heavier tips that are not well suited for treatment
of deep pockets or in certain areas of the mouth. The heavy tips and
ease of use of the sonic scalers (such as the Titan) are advantages for
the removal of supragingival deposits.

**Treatment Goals in Periodontal Disease**

The intent of active periodontal therapy is to interrupt the progressive
destruction to the periodontium caused by inflammation. Not only does
this mean stopping the immediate loss of attachment, but leaving pocket
depths and tissue contours that are manageable for the patient with home
care and regular supportive therapy. It is also important that the
periodontium can be monitored, so that relapse can be identified and
treated.

The ultimate treatment goal is to restore and maintain the health,
comfort, function and appropriate esthetics of teeth for the lifetime of
the individual.

**Patient Compliance in Periodontal Disease**

The chronic and pain free nature of the initial stages of periodontal
disease make patient acceptance of the diagnosis and treatment
difficult. Economic factors and priorities may also influence a
patient\'s acceptance of care. When a patient refuses recommended
periodontal therapy or referral, this must be documented.

Elements of this documentation:

-   Description of the problem that requires care

-   Specific treatment proposed or reason for referral

-   Potential consequences of not following treatment recommendation or
    referral

-   The fact that the patient refuses care or referral

**Adjunctive Therapies in Gingivitis and Adult Periodontitis**

*Antibiotics*

(See also Appendix F in the original guideline document for a more
extensive discussion of antibiotics.)

[Metronidazole]{.underline} has been shown to reduce the need for
periodontal surgery when used in conjunction with scaling and root
planing.

Metronidazole 250 mg three times per day (tid) for 7 days

[Amoxicillin]{.underline} has shown little usefulness when used alone in
chronic periodontal conditions because of the presence of bacterial
resistance. In patients who cannot tolerate tetracycline, amoxicillin
with metronidazole provides a similar spectrum of activity.

Amoxicillin 250 mg tid for 7 days with

Metronidazole 250 mg tid for 7 days

[Doxycycline]{.underline} has been shown to reduce the activity of
periodontitis for up to seven months when used in conjunction with
scaling and root planing.

Doxycycline 200 mg first day 100 mg. Daily for 14-21 days

*Anti-inflammatories*

[Flurbiprofen]{.underline}, [naproxen]{.underline} and similar
anti-inflammatories have been shown to reduce the rate of periodontal
destruction in patients with rapidly progressing periodontitis, but are
not in regular therapeutic use in typical adult periodontitis.

*Anti-microbial Rinses*

(See also Appendix D in the original guideline document for a more
extensive discussion of chlorhexidine)

[Chlorhexidine]{.underline} has been shown to be effective in reducing
gingivitis. It is staining and may alter taste sensation.

Chlorhexidine 0.12% (Peridex®) 5 oz. rinse twice daily.

[Listerine®]{.underline} has been shown to be effective in reducing
gingivitis. It does not have the degree of effectiveness that is shown
by chlorhexidine, but also does not stain or alter taste sensation.

*Pocket Irrigation*

Subgingival irrigation (or lavage) is recommended by some as a method of
maintaining periodontal pockets. Studies do not present a clear
conclusion of the efficacy of pocket irrigation. There are indications
that irrigation after scaling and root planing further decreases the
number of pocket pathogens, that there is equivalency between syringe
type and the mechanical products, and that there may be some advantage
in using a medicament such as chlorhexidine (immediately after scaling
chlorhexidine may be inactivated by blood; povidone iodine has been
recommended for use in post-treatment lavage).

*Locally Administered Antibiotics*

(See also Appendix E in the guideline document for a more extensive
discussion of Periochip, Atridox and Arestin)

Significant pocket reduction has been demonstrated.

See the original guideline document for procedure codes for adjunctive
interventions.

**Supportive Periodontal Treatment**

*Goal of Supportive Periodontal Treatment*

The phase of periodontal therapy after control of the disease is
demonstrated is supportive periodontal treatment, (S.P.T.). It is the
phase of care intended to sustain the level of periodontal health
established after active therapy. As periodontal disease is chronic in
nature, S.P.T. may be a life long process. The aim of S.P.T. is to limit
the progression of attachment loss, and provide a level of monitoring
that will recognize the progression of disease. S.P.T. works to ensure
that active therapy is resumed when appropriate.

*The Mechanics of Supportive Periodontal Treatment*

The instrumentation required in an S.P.T. visit may be similar to that
required in a routine prophylaxis visit, but the attention to record
keeping and potential etiologic factors in disease is not. The S.P.T.
patient has demonstrated risk for periodontitis and the potential for
continued attachment loss. A full mouth probe and recording of pockets
greater than 4 mm, attachment loss, bleeding and suppuration is an
important part of each S.P.T. visit. The periodontal exam must establish
whether there has been a progression of disease, and identify the signs
of potential progression.

*Provider of Supportive Periodontal Treatment*

The appropriate provider of supportive treatment will vary with the:

-   Aggressiveness of the initial periodontal condition

-   Treatment provided for the initial periodontal condition

-   Complexity of the periodontal instrumentation

-   Patient compliance with home care instruction

-   Presence of risk factors (heredity, smoking, diabetes, etc.)

*General Dentist Recall*

If the general dental office was solely involved in the initial therapy,
they are responsible to set the recall interval and coordinate these
visits with the need for operative recall. The expectation is that when
a periodontal patient is treated in the general dental practice, the
standard of care is at the same level as the periodontist. This includes
record keeping and the recognition of the progression of disease.

*Shared Recall*

If the periodontist was involved in the initial therapy, he or she
should be relied upon to recommend the initial interval and provider for
recall. Appropriate operative recalls are required, and these must be
coordinated with the general dentist. The caries risk protocol should be
used as a guide in scheduling these visits. If operative needs do not
take precedence it is appropriate that the radiographic interval is set
by the periodontist. Recalls that alternate between the general dentist
and the periodontist require communication for consistent care and
understanding of the status of the case. Problems found at the visit,
recommendations made, and plans for the next recall must be communicated
not only to the patient, but to the provider for the next visit. Two
years of stable periodontal condition may indicate that care can revert
exclusively to the general practice, as long as the patient remains in
control.

*Periodontist Exclusive Recall*

When supportive therapy in a general practice setting may compromise
periodontal care periodontal recalls should occur only with the
periodontist. This would be most likely in instances where active
therapy was just completed, when there is a question about the stability
of the case, or when specific unresolved local factors (such as
furcation involvement), present specific challenges for recall.
Operative recalls at an appropriate interval should be scheduled at
general dental practice. Communication of the periodontal, operative,
and recall status of the patient should occur between providers.

**Adult Plaque Related Periodontal Disease: Algorithm Annotations**

1.  **Signs of Gingivitis or Adult Periodontitis**

    -   Periodontal screening:

        -   Clinical signs of active disease (erythema, edema, bleeding
            or suppuration on probing)

        -   Clinical or radiographic indication of attachment loss in
            individuals less than age 35 is likely some other condition;
            possibly rapidly progressing periodontal disease, or a
            primary systemic problem

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2.  **Initial Preparation to Allow for an Evaluation**

    -   Heavy calculus:

        -   When accretions prevent accurate probing initial preparation
            with an ultra-sonic scaler to remove ledges of supra and sub
            calculus is appropriate.

        -   Should initial preparation be required access to pockets may
            be compromised by a tightened gingival cuff; the ultra-sonic
            scaler can be used to \"open up\" pockets for root planning.

    -   Necrotizing gingivitis:

        -   Indicated by acute sensitivity, ulcerated gingival tissue,
            and bleeding to very gentle probing

        -   Topical and systemic medications with debridement may be
            required prior to complete periodontal assessment.

    -   Dental condition:

        -   Caries may require temporary restoration prior to
            periodontal assessment.

        -   Hopeless teeth (bone loss to apex, cracked roots,
            unrestorable operatively) may interfere in a diagnosis, and
            may require removal prior to a complete assessment.

        -   Restorations with large overhangs may need to be replaced to
            allow for a complete periodontal evaluation.

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3.  **Comprehensive Periodontal Examination**

    -   Radiographs:

        -   Bite wing radiographs showing crestal bone within six months
            are required for active periodontitis patients.

        -   A full mouth series, less than two years old, is indicated;
            if periodontitis is limited, to specify teeth periapicals in
            that region, with current bite wings and a panographic
            radiograph are acceptable

    -   Visual exam of tissues:

        -   Tissue tone (edematous, hyperplastic)

        -   Color (erythema)

    -   Plaque and calculus assessment:

        -   Plaque disclosed and described in the record

        -   Calculus amount (light, heavy, moderate)

    -   Periodontal charting:

        -   Attachment loss

        -   Pocketing

        -   Furcation (score 1 = incipient, fluting; 2 = catch, probing
            has a horizontal component; 3 = through and through)

        -   Bleeding and suppuration

        -   Mobility (score 1 is mobility that is slightly greater than
            normal; 2 represents approximately 1 mm of mobility; 3 is
            greater than 1 mm of mobility or depressable apically)

        -   Mucogingival relationships

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4.  **Plaque Related Gingivitis**

    -   Characteristics of plaque related gingivitis:

        -   Indications of active disease (edema, erythema, bleeding on
            probing, or suppuration) without indications of attachment
            loss in probing or radiographs

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5.  **Adult Periodontitis with Slight to Moderate Loss of Periodontal
    Support**

    -   Characteristics of adult periodontitis with slight loss of
        attachment in affected teeth:

        -   Indications of active disease (edema, erythema, bleeding on
            probing, or suppuration)

        -   Mobility may be present

        -   If molar teeth are involved class I furcation involvement
            may be present.

        -   Radiographic bone loss may be apparent.

        -   Attachment loss of 2-3 mm

        -   Pocket depth of 4-5 mm

        -   Age 35 years of age or older (inflammation and attachment
            loss in younger individuals is likely some other condition;
            possibly rapidly progressing periodontal disease, or a
            primary systemic problem)

    -   Characteristics of adult periodontitis with moderate loss of
        attachment in affected teeth:

        -   Indications of active disease (edema, erythema, bleeding on
            probing, or suppuration)

        -   Mobility may be present

        -   Loss of up to one third of the attachment level

        -   If molar teeth are involved furcation involvement should not
            exceed class one (incipient).

        -   Radiographic bone loss will be apparent.

        -   Attachment loss of more than 4-5 mm

        -   Pocket depth of 5-6 mm

        -   Age 35 years of age or older (inflammation and attachment
            loss in younger individuals is likely some other condition;
            possibly rapidly progressing periodontal disease, or a
            primary systemic problem)

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6.  **Adult Periodontitis with Advanced Loss of Periodontal Support**

    -   Characteristics of adult periodontitis with advanced loss of
        attachment in affected teeth:

        -   Indications of active disease (edema, erythema, bleeding on
            probing, or suppuration)

        -   Mobility may be present

        -   Loss of more than one third of the attachment level

        -   If molar teeth are involved greater than class I furcation
            involvement can be expected.

        -   Radiographic bone loss will be apparent.

        -   Attachment loss of more than 5 mm

        -   Pocket depth of greater than 6 mm

        -   Age 35 years of age or older (inflammation and attachment
            loss in younger individuals is likely some other condition;
            possibly rapidly progressing periodontal disease, or a
            primary systemic problem)

**Plaque Related Gingivitis: Algorithm Annotations**

1.  **Local factors**

    -   Oral hygiene:

        -   Good oral hygiene is an essential element in predictable
            treatment of gingivitis.

    -   Calculus:

        -   Provides both a physical irritant and a refuge for bacteria
            and bacterial toxins

        -   Effective removal of calculus is important in altering the
            bacterial flora and treating gingivitis.

    -   Contact relationships:

        -   Open contacts can subject the periodontal tissues to the
            direct irritation of food impaction.

    -   Defective restorations:

        -   Marginal openings are a refuge for bacteria.

        -   Overhanging margins alter tissue contours, retain bacteria,
            and frustrate hygiene efforts.

    -   Tooth malposition:

        -   Tipped teeth can produce pseudopocketing and complicate
            hygiene efforts.

        -   Root approximation hinders hygiene efficacy and can result
            in accelerated bone loss in the presence of inflammation.

    -   Orthodontic therapy:

        -   Orthodontic appliances are found to often promote localized
            gingivitis by direct irritation and plaque retention.

        -   If gingivitis cannot be controlled through oral hygiene the
            use of adjunctive agents such as chlorhexidine gluconate or
            a power toothbrush should be considered.

        -   Removal of orthodontic appliances should be considered if
            gingivitis is severe.

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2.  **Systemic Factors (see also appendix B of the original guideline
    document)**

    -   Systemic medical conditions:

        -   Diabetes

        -   Corticosteroid therapy

        -   Chemotherapeutic agents

        -   Hematological disorders

        -   Tobacco habit

        -   Drug abuse

        -   Pregnancy and other endocrine factors

        -   Medications that cause tissue hypertrophy

        -   Mouth breathing

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3.  **Referrals for Systemic Issues (see also appendix B of the original
    guideline document)**

    -   Smoking and oral tobacco use:

        -   Clinic based smoking cessation

    -   Medications:

        -   Physician referral to explore alternative therapies with
            less periodontal impact

    -   Host response:

        -   An apparent failure of host response in patients with a
            diagnosed or suspected metabolic disorder may suggest a
            referral for medical evaluation.

    -   Mouth breathing:

        -   Surgical correction of the nasal airway may reduce mouth
            breathing.

        -   Orthodontic therapy, alone or in combination with
            orthognathic treatment can sometimes reduce mouth breathing.

        -   Use of a protectant, such as orobase at night on affected
            tissues at bed time may help reduce the affects of the
            drying affects of mouth breathing.

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4.  **Scaling**

    -   Criteria:

        -   Complete removal of plaque and calculus

    -   Treatment:

        -   Ultra-sonic instrumentation saves time with supragingival
            deposits and provides improved instrumentation where access
            is poor.

    -   May require local anesthesia

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5.  **Is an Adequate Response to Therapy Likely?**

    -   Factors that increase the likelihood of resolution:

        -   Heavy, accessible calculus deposits

        -   Edematous versus hyperplastic tissues

        -   Good patient acceptance of oral hygiene instruction

        -   Good tooth alignment

    -   Factors that decrease the likelihood of resolution:

        -   Mucogingival problems

        -   Hyperplastic tissues

        -   Minimal calculus at initial instrumentation

        -   Excellent oral hygiene at initial exam

        -   Low patient acceptance of problem

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6.  **Re-evaluation for Response to Therapy**

    -   Generally a re-evaluation should be scheduled, especially in
        cases of moderate to severe gingivitis, and when an adjunctive
        mouth rinse is prescribed.

    -   When a reevaluation is prescribed:

        -   It should be scheduled at 4-6 weeks after last treatment
            appointment.

        -   Oral hygiene should be reviewed.

        -   Periodontal exam is repeated.

        -   Remove residual calculus.

        -   Expect resolution of signs of active disease.

        -   Clinical judgment is critical in determining whether
            treatment was successful.

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7.  **Non-plaque Related Gingivitis**

    -   A number of forms of gingivitis are found in association with
        other diseases or conditions. Desquamative gingivitis is
        characterized by sloughing of the gingival epithelium, leaving a
        red gingival surface. Estimates are that more than 90% of these
        cases are a manifestation of cicatrical pemphigoid and erosive
        lichen planus. Allergies and other dermatological disorders have
        been associated with this form of gingivitis.

    -   Idiopathic gingivitis or gingivofibromatosis is of unknown
        etiology. Clinical presentation includes enlargement of gingival
        tissues that begins with the eruption of the primary and
        secondary teeth. This enlargement may regress after the
        extraction of teeth.

    -   Herpetic gingivostomatitis can present as painful ulcerations of
        the gingival tissues and is the result of infection with the
        herpes simplex I virus. The infection may present as vesicles
        that form and then rupture, leaving painful ulcerations with
        red, halo-like margins. Fever, malaise, and lymphadonopathy may
        be present. Treatment is primarily palliative. It is important
        that adequate nutrition is maintained.

    -   Necrotizing ulcerative periodontitis (NUP) is a severe and
        rapidly progressive disease that demonstrates a distinctive
        erythema of the gingiva, soft tissue necrosis, and severe loss
        of periodontal attachment. Necrotizing ulcerative gingivitis
        (NUG) (previously known as atypical necrotizing ulcerative
        gingivitis \[ANUG\]) can be localized or generalized. The
        interproximal papillae may have a punched out look, and be
        covered by a grayish-white membrane. Pain and halitosis are
        common features. Other symptoms include rapid onset, malaise,
        lymphadenopathy, loss of appetite, and occasional fever.
        Commonly sited etiologies for NUG include lack of oral hygiene,
        stress, anxiety, fatigue, lowered immune resistance, nutritional
        impairment, smoking, and calculus. Increased numbers of oral
        bacteria, such as spirochetes and fusiform bacteria are seen.

    -   During the acute phase of NUG the most effective treatment is
        the use of the ultrasonic scaler. This not only allows for the
        removal of gross debris such as calculus but also provides a
        gingival lavage that helps flush the bacteria from gingival
        pockets. This treatment generally reduces the acute symptoms
        sufficiently to allow for effective subgingival scaling and root
        planing as necessary. Oral rinses such as Peridex® can be
        beneficial. Antibiotics are generally not indicated unless the
        patient has systemic involvement such as elevated temperature,
        spread of the infection into the pharynx, or lymphadenopathy.
        Surgery to repair gingival defects may be indicated after the
        infection has been resolved.

**Adult Periodontitis with Slight/Moderate Loss of Periodontal Support:
Algorithm Annotations**

1.  **Local factors**

    -   Oral hygiene:

        -   Good oral hygiene producing a low plaque level is an
            essential element in predictable periodontal therapy.

    -   Calculus:

        -   Provides both a physical irritant and a refuge for bacteria
            and bacterial toxins.

        -   Effective removal of calculus is important in altering the
            bacterial flora of the periodontal pocket.

    -   Contact relationships:

        -   Open contacts can subject the periodontal tissues to the
            direct irritation of food impaction.

    -   Defective restorations:

        -   Marginal openings are a refuge for bacteria.

        -   Overhanging margins alter tissue contours, retain bacteria,
            and frustrate hygiene efforts.

    -   Tooth malposition:

        -   Tipped teeth can produce pseudopocketing and interbony
            defects.

        -   Root approximation hinders hygiene efficacy and can result
            in accelerated bone loss in the presence of inflammation.

    -   Perio-endo relationships:

        -   Localized deep defects should be evaluated for possible
            perio-endo relationship.

        -   Long standing endo defects become periodontal pockets, and
            require periodontal maintenance.

    -   Occlusion:

        -   Should be evaluated when mobility is identified

    -   Tooth morphology:

        -   Invaginations can result in severe localized periodontal
            defects.

        -   Multirooted variants of non-molars introduce possible furcal
            invasion and reduce prognosis.

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2.  **Systemic factors**

    -   Systemic medical conditions:

        -   Diabetes

        -   Corticosteroid therapy

        -   Chemotherapeutic agents

        -   Hematological disorders

        -   Tobacco habit

        -   Drug abuse

        -   Pregnancy and other endocrine factors

        -   Medications that cause tissue hypertrophy

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3.  **Referrals for Systemic Issues**

    -   Smoking or oral tobacco use:

        -   Clinic based smoking cessation

    -   Medications:

        -   Physician referral to explore alternative therapies with
            less periodontal impact

    -   Host response:

        -   An apparent failure of host response in patients with a
            diagnosed or suspected metabolic disorder may suggest a
            referral for medical evaluation.

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4.  **Is an Adequate Response to Therapy Likely?**

    -   Factors that increase the likelihood of resolution:

        -   Edematous tissues at initial examination

        -   Horizontal versus vertical pattern of bone loss

        -   Absence of furcal invasions and concave root surfaces

        -   Indication of patient interest in treatment and improvement
            of oral health

    -   Factors that decrease the likelihood of resolution:

        -   Mucogingival problems

        -   Interbony defects

        -   Furcation involvement

        -   Heavy occlusal or restorative loading (bridge and partial
            abutments)

        -   Hyperplastic tissues

        -   Minimal calculus at initial instrumentation

        -   Excellent oral hygiene at initial exam

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5.  **Scale and Root Plane**

    -   Criteria:

        -   End point is to affect a change in the microbacterial
            distribution within the pocket and surrounding tissue; not
            strictly calculus removal.

    -   Treatment:

        -   Ultra-sonic instrumentation, when combined with hand
            instrumentation, provides improved instrumentation where
            access is poor (i.e., furcations, deep pockets, posterior
            teeth).

        -   Generally requires local anesthesia.

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6.  **Re-evaluation for Response to Therapy**

    -   Performed at 4-6 weeks after last quadrant treated

    -   Review oral hygiene.

    -   Repeat periodontal probing for furcal invasions, attachment and
        pocket depths.

    -   Review mobility, bleeding, and suppuration.

    -   Examine root surfaces for smoothness.

    -   Remove residual calculus.

    -   Expect resolution of 1-2 mm pocket depth.

    -   Expect resolution of signs of active disease.

    -   Clinical judgment is critical in determining whether treatment
        was successful.

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7.  **Compromise Therapy**

    -   Less than complete periodontal control may be unavoidable in
        some instances:

    -   Advanced age

    -   Chronic illness

        -   May contraindicate therapy

    -   Extremely poor prognosis

        -   For the dentition for periodontal or other reasons

    -   Economic considerations may dictate compromise therapy

        -   Patients may not be able afford or chose not to pursue
            periodontal therapy because of the expense of treatment.

    -   Patient refuses specialist care:

        -   Patient must be informed of potential consequences including
            tooth loss.

        -   Documentation must include treatment options presented to
            the patient, and that the patient made an informed decision
            to not comply with a recommended referral.

    -   Adjunctive therapy:

        -   Use of systemic or topical medications in a general dental
            practice, without exhausting conventional therapy and
            referral is a compromise therapy.

        -   There is evidence that use of nonsteroidal
            anti-inflammatories can slow bone loss in adult
            periodontitis.

        -   Antibiotics, especially metronidazole and doxycycline have
            been shown to change bacterial flora and slow the
            progression of attachment loss.

        -   Irrigation may serve as an adjunctive therapy in pockets
            that are not accessible to conventional oral hygiene
            devices.

        -   Localized antibiotic therapy (currently Atridox, Periochip,
            or Arestin) has been shown to temporarily reduce pocketing
            and increase attachment levels.

**Adult Periodontitis with Advanced Loss of Periodontal Support:
Algorithm Annotations**

1.  **Local factors**

    -   Calculus:

        -   Provides both a physical irritant and a refuge for bacteria
            and bacterial toxins

        -   Effective removal of calculus is important in altering the
            bacterial flora of the periodontal pocket.

    -   Contact relationships:

        -   Open contacts can subject the periodontal tissues to the
            direct irritation of food impaction.

    -   Defective restorations:

        -   Marginal openings are a refuge for bacteria.

        -   Overhanging margins alter tissue contours, retain bacteria,
            and frustrate hygiene efforts.

    -   Tooth malposition:

        -   Tipped teeth can produce pseudopocketing and interbony
            defects.

        -   Root approximation hinders hygiene efficacy and can result
            in accelerated bone loss in the presence of inflammation.

    -   Perio-endo relationships:

        -   Localized deep defects should be evaluated for possible
            perio-endo relationship.

        -   Long standing endo defects become periodontal pockets and
            require periodontal maintenance.

    -   Occlusion:

        -   Should be evaluated when mobility is identified

        -   Temporary or long term fixed splinting may be indicated when
            attachment loss leaves teeth uncomfortable or unstable.

    -   Tooth morphology:

        -   Invaginations can result in severe localized periodontal
            defects.

        -   Multirooted variants of non-molars introduce possible furcal
            invasion and reduce prognosis.

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2.  **Systemic Factors**

    -   Systemic medical conditions:

        -   Diabetes

        -   Corticosteroid therapy

        -   Chemotherapeutic agents

        -   Hematological disorders

        -   Tobacco habit

        -   Drug abuse

        -   Pregnancy and other endocrine factors

        -   Medications that cause tissue hypertrophy

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3.  **Compromise therapy**

    -   Treatment to provide less than complete periodontal control may
        be unavoidable in some instances:

    -   Advanced age

    -   Chronic illness

        -   May contraindicate therapy

    -   Extremely poor prognosis

        -   For the dentition for periodontal or other reasons

    -   Economic considerations may dictate compromise therapy

        -   Patients may not be able afford or choose not to pursue
            periodontal therapy because of the expense of treatment.

    -   Patient refuses specialist care:

        -   Patient must be informed of potential consequences of tooth
            loss.

        -   Documentation must include treatment options presented to
            the patient, and that the patient made an informed decision
            to not comply with a recommended referral.

    -   Adjunctive therapy:

        -   Use of systemic or topical medications in a general dental
            practice, without exhausting conventional therapy and
            referral is a compromise therapy.

        -   Antibiotics, especially metronidazole and doxycycline have
            been shown to change bacterial flora and slow the
            progression of attachment loss.

        -   Irrigation may serve as adjunctive therapy in pockets that
            are not accessible to conventional oral hygiene devices.

        -   Localized antibiotic therapy, (currently Atridox, Periochip
            and Arestin), has been shown to temporarily reduce pocketing
            and increase attachment levels.

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4.  **Scale and Root Plane**

    -   Criteria:

        -   End point is to affect a change in the microbacterial
            distribution within the pocket and surrounding tissue; not
            calculus removal alone.

    -   Treatment:

        -   Ultra-sonic instrumentation, when combined with hand
            instrumentation, provides improved debridement where access
            is poor (i.e., furcations, deep pockets, posterior teeth).

        -   Generally requires local anesthesia

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5.  **Re-evaluation for Response to Therapy**

    -   Performed at 4-6 weeks after last quadrant treated

    -   Review oral hygiene.

    -   Repeat periodontal probing for furcal invasions, attachment and
        pocket depths.

    -   Review mobility, bleeding, and suppuration.

    -   Examine root surfaces for smoothness.

    -   Remove residual calculus.

    -   Expect resolution of 1-2 mm pocket depth.

    -   Expect resolution of signs of active disease.

    -   Clinical judgment is critical in determining whether treatment
        was successful.

**Supportive Periodontal Treatment: Algorithm Annotations**

1.  **Successfully Treated Gingivitis and Early and Moderate
    Periodontitis**

    -   Considerations for maintenance therapy exclusively in the
        general dental office

        -   Good response to initial therapy (minimal residual pocket
            depth)

        -   Good compliance with oral hygiene and treatment
            recommendations

    -   Considerations for maintenance therapy shared between the
        general dental office and the periodontist

        -   Mixed response to initial therapy (pockets remain)

        -   Inadequate oral hygiene

        -   Evidence of compromised host response

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2.  **Successfully Treated Advanced Periodontitis**

    -   Considerations for maintenance therapy exclusively in the
        general dental office

        -   History of stable attachment for several years

        -   Periodontal therapy has left minimal pockets and boney
            defects.

        -   Good compliance with oral hygiene recommendations

    -   Considerations for maintenance therapy shared between the
        general dental office and the periodontist

        -   Questionable response to initial therapy or compromised
            areas (residual pocketing, Furcal involvement)

        -   Poor compliance with oral hygiene recommendations

        -   Extensive restorative treatment required

    -   Considerations for maintenance therapy exclusively in the
        periodontist\'s office

        -   Possible or previous rapidly progressing periodontal patient
            compromise initial therapy (trial maintenance)

        -   Extensive remaining defects

        -   Further active therapy is likely

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3.  **Refractory**

    -   Considerations for maintenance therapy exclusively in the
        periodontist\'s office

        -   Generally allows for earliest detection and intervention
            should there be recurrence

    -   Considerations for maintenance therapy shared between the
        general dental office and the periodontist

        -   Loss of dentition is deemed inevitable.

        -   High restorative need

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4.  **Radiographic Interval**

    -   The periodontal recall interval for radiographs for a patient in
        supportive periodontal therapy should not exceed two years for
        bite-wing radiographs that show the boney crest and are of
        acceptable horizontal angulation. More frequent radiographs are
        appropriate when there are questions of the adequacy of control,
        when there are intraboney defects, and when bone grafting or
        guided tissue regeneration were elements of recent active
        therapy. For patients with episodes of active disease, or where
        control is questionable a five year interval for a full mouth
        series is indicated.

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5.  **Comprehensive Periodontal Recording**

    -   Periodontal records at each supportive periodontal therapy visit
        should include:

        -   Current radiographs

        -   Full mouth probing and attachment loss records (record
            pockets of \>3 mm depth, bleeding, suppuration, and any
            attachment loss)

        -   Notation of furcal invasion

        -   Mobility recording

        -   Bleeding and suppuration points

        -   Plaque control disclosing and evaluation (may be omitted if
            patient consistently demonstrates excellent plaque control,
            and a note to that effect is in made)

        -   Notation of oral hygiene difficulties, and the
            recommendations to allow improved oral hygiene

        -   Problem areas

        -   Next visit purpose

        -   Recall interval (if the patient is to remain on S.P.T.)

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6.  **Is Periodontal Disease Controlled?**

    -   For a patient to be considered for continued supportive
        periodontal therapy both the periodontal record and clinical
        signs must be used to establish a clinical judgment that the
        disease is not progressing. Recordings of attachment level show
        variability of 2-3 mm without a true change in attachment level.
        Radiographs show level of boney support, not attachment level,
        and 2-3 mm of change are required to demonstrate change with
        standard radiographic techniques. While the truest measure of
        active periodontal disease, significant damage can occur without
        documentation by these modalities. The clinical signs of active
        disease (erythema, edema, bleeding or suppuration on probing)
        are less specific for active periodontal disease, but are
        timelier.

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7.  **Supportive Periodontal Treatment**

    -   Fluoride therapy in furcal areas

        -   Furcal caries are often unrestorable.

        -   Open furcations are at risk for furcal caries.

        -   The maintenance visit presents an opportunity to place
            topical fluoride agents in this high risk area.

    -   Desensitization therapy

        -   Root sensitivity is common in periodontal maintenance
            patients.

        -   Sensitivity can interfere with home care efforts.

        -   Topical agents are available that can provide limited
            desensitization.

        -   The maintenance visit provides an opportunity to place these
            medications when indicated (history of post therapy
            sensitivity).

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8.  **Retreat or Referral**

    -   Performed at 4-6 weeks after last quadrant treated

    -   Review oral hygiene.

    -   Signs of active disease indicate need for active therapy.

    -   If etiology is unclear or requires surgery to remedy, refer.

    -   Repeated scaling and root planing (two year intervals) are
        required to maintain some patients.

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9.  **Recall Interval**

    -   Generally 3 months initially

    -   Adjust according clinical judgment of patient\'s response

**Periodontal Therapy Appointment Management: Algorithm Annotations**

1.  **Radiographs**

    -   A periodontal assessment should be performed to determine
        radiographs necessary beyond bite wings

    -   Full mouth series:

        -   Necessary for diagnosis and treatment planning in
            generalized periodontal disease

    -   Bite wings:

        -   Must show crestal bone to be diagnostic

    -   Panographic radiograph:

        -   May serve as an screening film in addition to selected
            periapicals and bite wings in localized periodontitis

        -   Generally not indicated if full mouth periapicals are made

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2.  **Initial Debridement**

    -   May be completed at the time of the screening exam if localized

    -   May be combined with oral hygiene instructions if tenderness and
        bleeding are not pronounced

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3.  **Comprehensive Periodontal Exam**

    -   Plaque disclosing

    -   Complete charting

    -   Radiographs available to correlate with charting

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4.  **Compromise Therapy**

    -   For economic or other reasons a patient may refuse the
        recommended therapy, but agree to a routine prophylaxis
        appointment; document:

        -   Patient\'s understanding of periodontal condition, treatment
            recommendation, and

        -   Likely outcome of noncompliance

        -   Problem areas that were addressed and to what extent

        -   Those areas that were not addressed

        -   Plan for next visit

    -   Treatment plan:

        -   Emphasis should be place on those teeth that treatment will
            likely make a difference.

        -   Teeth without evidence of periodontitis are of low priority.

        -   Visits may emphasize sides, quadrants or individual teeth.

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5.  **Scale and Root Plane, Initial Visit**

    -   Generally performed within one week

    -   Evaluate plaque control.

    -   Review oral hygiene.

    -   Evaluate response in previously treated quadrants.

    -   Scale and root plane target quadrant, usually with anesthetic.

    -   Consider adjunctive antibiotics.

    -   Discuss rational and agenda for next periodontal visit.

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6.  **Additional Scaling and Root Planing Visits**

    -   Performed urgent operative care and after periodontal diagnosis

    -   Evaluate plaque control.

    -   Review oral hygiene.

    -   Reinforce treatment reasoning and plan.

    -   Scale and root plane target quadrant, usually with anesthetic.

    -   Discuss and agenda for next periodontal visit.

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7.  **Revaluation for Response to Therapy**

    -   Generally performed at 4-6 weeks after last quadrant treated

    -   Evaluate oral hygiene.

    -   Review oral hygiene.

    -   Comprehensive periodontal exam, including periodontal probing
        for furcal invasions, attachment and pocket depths; recording of
        mobility, bleeding, and suppuration

    -   Examine root surfaces for smoothness and remove residual
        calculus.

    -   Polish if necessary.

    -   Discuss future periodontal therapy required.

**Refractory Periodontitis**

The term refractory periodontitis refers to that small percentage of
treated patients with whom mechanical therapy including surgery fails to
stop the loss of periodontal attachment. The pathogenesis of refractory
periodontitis is poorly understood and these patients demonstrate a
continued lack of response to conventional periodontal therapy. A
clinical diagnosis of Refractory Periodontitis is generally made on this
distinction.

**Definitions and Descriptions**

Refractory periodontitis has been associated with abnormal
polymorphonuclear leukocyte (PMN) phagocytosis, an abnormal response by
inflammatory mediators, chemotactic defects in PMNs, and cigarette
smoking. Chemotactic defects in PMN may be an intrinsic chemotactic
response (cellular or serum related) or may be the result of substances
elaborated by bacteriological pathogens in the periodontal pocket. Data
suggests refractory patients may have the potential for a more vigorous
response by inflammatory mediators (cytokines) and that they appear to
have a decreased CD4/CD8 ratio. Research reveals smoking causes defects
in neutrophil function, impaired serum antibody responses to periodontal
pathogens, and potentially diminished gingival fibroblast function. One
study showed that subjects with refractory disease have higher levels of
certain groups of pathogens and they differ in combinations of
predominant species. Three major microbial complexes were observed:

1.  *Tannerella forsythensis, Treponema denticola, Actinobacillus
    actinomycetemcomitans*

2.  *Staphylococcus intermedius, Porphyromonus gingivalis, P micros*

3.  *S intermedius, Fusobacterium nucleatum* with or without
    *Porphyromonus gingivalis*

Other data show no difference in the amount of plaque present in stable
sites or sites losing attachment. Frequently few, if any, of the
classical pathogens are detected in the plaque samples taken at the time
progressive disease is diagnosed. This may indicate no clear or well
defined microbial profile exists in refractory patients. Also,
refractory periodontitis in some instances may represent re-infection
from untreated significant others.

**Treatment/Therapy**

Preliminary analysis has indicated that at least two patterns or rates
of attachment loss may be associated with refractory periodontitis and
that each pattern may be indicative of a different micro flora. The
pattern associated with a relatively rapid loss of attachment was
characterized by a gram-negative flora which contained spirochetes*, P.
intermedia*, and fusobacterium species. A slow, continuous rate was
associated with a predominantly gram-positive flora containing a high
proportion of *S. intermedius* and/or a *S. intermedius*-like organism.

Refractory periodontitis in systemically healthy adults can show a great
variety or oral and non-oral organisms. The frequent occurrence of
unusual periodontal organisms in certain patients may be due to a
weakened host response and/or usage of various chemotherapeutic
regimens.

A clinical case report in the literature demonstrates patients termed
refractory to treatment (including surgeries) showed remission to the
disease progress for a minimum of 2 1/2 years. This was accomplished
after extensive micro-biological analysis and sensitivity testing was
performed to determine appropriate antibiotic therapy, along with
conservative therapy of several sessions of root planing and scaling.

Results indicate that a substantial number of microorganisms associated
with refractory periodontitis are variably resistant to commonly-used
antibiotics. Diagnostic microbiology must be considered an essential
adjunct to the therapist faced with periodontal lesions refractory to
conventional treatment.

In patients who have not responded well to conventional treatment,
cultural analysis is strongly recommended in order to select the
appropriate antibiotic. The tetracyclines, metronidazole, augmentin, a
combination of metronidazole and amoxicillin, and clindamycin have all
been shown to be of benefit in treating some of these patients. However,
the appropriate antibiotic can only be determined by the identification
and susceptibility-testing of the individual patient\'s flora. No one
antibiotic will successfully treat all cases of recurrent or refractory
disease since the patients have different clinical and microbiological
profiles. Treating these patients without microbial testing increases
the risk of treatment failure and the potential for causing an
overgrowth of resistant pathogens and an exacerbation of the disease.

While the patient is under control or in the maintenance phase of the
disease process, a three month periodontal recall with a periodontist is
recommended.

Every attempt should be made to maximize continuity or care. As a
result, patients should be seen by the same providers and periodontist
(doctor of dental surgery \[DDS\] and registered dental hygienist
\[RDH\]). The general dentist is responsible for determining the caries
exam recall.

**Early Onset Periodontal Disease**

The term Early Onset Periodontitis (EOP) refers to a number of
overlapping diseases of the periodontium characterized by early age of
onset and aggressive nature. Included in this constellation of diseases
are prepubertal periodontitis, juvenile periodontitis (localized and
generalized), and rapidly progressive periodontitis (Type A and Type B).
These diseases result in rapid destruction of the periodontal tissues in
otherwise generally healthy individuals. The age of onset varies from
very early childhood (Generalized Prepubertal Periodontitis) to around
age 35 (Type B form of Rapidly Progressive Periodontitis). As there
tends to be familial patterns with EOP, a review of the family history
of periodontal disease is key in reaching a diagnosis. A review of
radiographs for abnormal patterns of bone loss is also critical in
establishing a diagnosis. A clinical diagnosis of EOP is generally made
on the basis of distribution of bone loss and age of onset.

**Definitions and Descriptions**

*Prepubertal Periodontitis*

Prepubertal periodontitis has been defined as either localized or
generalized and affects the primary dentition. Both forms of the disease
are characterized by defects in the polymorphonuclear leukocytes and/or
monocytes. Prepubertal periodontitis is quite rare (the exact incidence
of the disease was not stated in the literature reviewed). This form of
periodontitis appears to affect males and females equally. One author
has suggested that division of periodontal disease during childhood and
adolescence into prepubertal and juvenile periodontitis may sometimes be
a matter of when the diagnosis made rather distinct disease entities.

The localized form occurs in otherwise healthy children and has an age
of onset around 4 years of age. The localized form may affect only a few
teeth showing no particular pattern. It features little or no gingival
inflammation and the tissue destruction is not as severe as seen in the
generalized form. The localized form is usually responsive to good
plaque control, curettage, and antibiotic therapy. Due to age of onset,
tetracycline should not be used.

The generalized form occurs in children that generally are afflicted
with systemic diseases (e.g., frequent bouts of otitis media and
frequent upper respiratory infections). The age of onset with the
generalized form coincides with the eruption of the primary teeth.
Tissue inflammation is pronounced and destruction severe in this form
and it may lead to advanced bone loss in the permanent dentition. These
cases are difficult to treat successfully. Early diagnosis and referral
to a periodontist for both localized and generalized prepubertal
periodontitis is very important. Frequent recall intervals are indicated
(every 2-3 months).

*Aggressive Periodontitis*

Juvenile periodontitis appears in two forms: localized and generalized.
The age of onset of both forms is the circumpubertal period (11 to 14
years of age). There appears to be a familial tendency for this disease
and there may be functional defects associated with the PMNs and/or
monocytes. Localized juvenile periodontitis (LJP) is relatively rare
with a reported incidence ranging from .1% to 3.4% of patients in a 10
to 19 age range. There is a reported female to male ratio of 3: 1 for
this form of juvenile periodontitis. It has been suggested that this
could be due to females having an earlier onset and diagnosis of the
disease. The bone loss pattern is classically described as vertical
around the first molars. Frequently there is also bone loss seen around
the incisors. The bone loss pattern is most often symmetrical. It has
been suggested that the first molars and incisors are affected because
they are the first permanent teeth to erupt. (*Actinobacillus
actinomycetemcomitans* \[Aa\] is able to colonize the teeth before other
bacteria that inhibit Aa are able to establish a niche.) The current
thinking is that Aa is spread among family members. There may also be
inherited defects with the PMNs and/or monocytes that contribute to the
individual\'s susceptibility. With proper treatment, this disease is
stable in most individuals and has even been shown to \"burn\" itself
out. This is the only form of Early Onset Periodontitis that has a
specific bacterium associated with its etiology. Aa is found in over 95%
of patients diagnosed with LJP as opposed to 17% of healthy subjects.
Patients afflicted with LJP are otherwise healthy and there is generally
very little plaque or gingival inflammation seen around the affected
teeth. This further supports the notion of the importance of family
history for this disease and a review of the radiographs for abnormal
bone loss patterns.

Treatment for LJP involves meticulous plaque control, localized scaling
and root planing, periodontal surgery, and antibiotic therapy. The
primary treatment goal for root planing is the elimination of Aa from
the affected site. Bacterial DNA testing for Aa is useful in confirming
the diagnosis and in testing for a successful end point of treatment.
This bacterium has demonstrated the ability to invade the connective
tissue of the gingival pocket. As a result, conventional scaling and
root planing are insufficient in eliminating the infection. Periodontal
surgery to remove tissue from the periodontal pocket as well as
treatment with tetracycline is very important in arresting this disease.
Tetracyclines possess a collagenase-inhibiting activity which may help
reduce tissue breakdown and promote repair.

Aa has been shown to produce a number of potent virulence factors. Among
these are a leukotoxin, a chemotaxis-inhibiting factor, a collagenase
and an epithelio-toxin to assist it in penetrating the gingival
epithelium. It has also been shown to produce a fibroblast toxin to
prevent repair of damage it has caused. It is unknown which of these
factors actually plays a role in tissue destruction in LJP. Several
studies have shown that neutrophils from gingival lesions of LJP
patients have reduced phagocytic capacity compared to neutrophils
cultured from, similar lesions in patients with gingivitis or adult
periodontitis. Early recognition and referral to a periodontist are very
important in minimizing the effects of LJP.

The generalized form of juvenile periodontitis (GJP) occurs less
commonly than the localized form (about half as frequently). GJP is
characterized by rapid, severe bone loss around many or all of the
permanent teeth with more pronounced gingival inflammation than is seen
in the localized form. Plaque samples have been shown to have a high
percentage of Gram negative rods including *Porphyromonas gingivalis*.
The localized and generalized forms of juvenile periodontitis may have
common underlying etiologies, however, differences in bacterial flora
and immune responses have been shown. Several studies have demonstrated
increased serum IgG antibody activity against Aa in patients with LJP
but low titers against *P. gingivalis*. Patients diagnosed with GJP and
adult onset periodontitis have demonstrated high titers against *P.
gingivalis* and low titers against Aa. This further supports the notion
that LJP and GJP are distinct diseases from a microbiological view. The
rarity of this form of juvenile periodontitis makes it difficult to
study.

As with the localized form, early detection and referral to a
periodontist is very important. Treatments include scaling and root
planing, antibiotic therapy and frequent recall (every 2-3 months). The
prognosis for this disease is poor.

*Rapidly Progressive Periodontitis (RPR)*

These forms of periodontitis occur later in life than the disease
described above. The Type A form generally occurs during the late teen
to early 20\'s while the Type B form has an age of onset of the late
20\'s to mid-30\'s. Estimates of the prevalence of RRP vary greatly,
possibly because of differences in examination procedures and criteria,
and the use of clinical studies of select population groups rather than
random sampling in epidemiologic studies. In general, RRP is relatively
rare. Studies based on radiographic evidence and probing assessments
report prevalence values of 0.2% for Norway, 0.1% for Finland and 0.5%
for Brazil. Several studies point to 1:2 male to female ratio with some
variability associate with age.

In most patients with rapidly progressive periodontitis, the PMNs do not
function properly. Microbes are the primary pathogenic causative agents
with a general distribution reported as 75% gram negative anaerobes and
25% gram positive microbes. RPP may be found in patients with systemic
diseases (e.g., diabetes mellitus, Down\'s syndrome, or other diseases)
or in otherwise healthy individuals.

Type A, or \"classic\" RPP exhibits rapid, generalized bone loss.
Commonly, there is very little plaque or calculus. Depressed neutrophil
function is found in about 2/3 of patients. The disease process is
cyclic showing periods of acute inflammation followed by periods of
dormancy. It is not uncommon to see a patient is his or her early 20s
with 50% or greater of bone loss. Females are affected at a ratio of 3:1
over males.

RPP Type B is found in an older age group than Type A. Bone loss is
generalized and significant. Bone loss is rapid relative to adult
periodontitis but not as rapid as seen in Type A. It is common to find
significant amounts of plaque and calculus with these patients. No sex
predilection has been established and neutrophil chemotaxis is normal or
depressed.

As with other EOP disease entities, early detection and referral to a
periodontist is very important. Treatments generally consist of scaling
and root planing, antibiotics, and surgery to correct anatomical
defects. Usually tetracycline is used; however, metronidazole has been
shown to be very effective. Removal of defective restorations and caries
control is very important. The prognosis is guarded.

**Inadequate Attached Gingiva**

When a tooth has a minimal zone of attached gingiva on either its facial
or lingual aspect, a potential mucogingival problem exists. Frenum
and/or muscle attachments in the presence of inadequate attached gingiva
should be viewed as a potential cause of future recession. Rather than
being a fixed number of millimeters of attached gingiva, it is a
clinical judgment of the adequacy of the attached gingiva on a tooth or
teeth to remain stable and healthy under conditions imposed by any
planned dental treatment or in the absence of dental care.

A.  A simple guideline for deter-mining whether a pure mucogingival
    problem exists is to record all areas with less than 2 mm of total
    gingiva (free gingival margin to mucogingival junction) as being
    potential problems because they will have 1 mm or less attached
    gingiva when crevice depth is subtracted from the total gingiva.

B.  For teeth with less that 1 mm of attached gingiva, the patients age
    should be considered. A younger person will be expected to retain
    their teeth for a longer period. The fact that a potential
    mucogingival exists early, represents a site-specific
    susceptibility. Generally speaking, the younger the patient, the
    greater the reason to consider grafting.

The permanent mandibular incisors and first molars are the first teeth
to erupt and about 12% of incisor teeth have less than 1 mm of attached
gingiva; half of these teeth may have recession within 6 months of
eruption.

If the patient is a child or young adult with no root exposure,
prophylactic grafting may be considered to prevent recession. If root
exposure already exists but appears stable, grafting still should be
considered because a graft placed on a periosteal bed has a better
predictability of success than does grafting to cover an exposed root.

If a maxillary canine or premolar has an inadequate zone of attached
gingiva, the potential exists for an esthetic problem. Mandibular
canines or premolars do not usually present a cosmetic concern.

When a tooth is predisposed to recession due to a lack of attached
gingiva, the situation can be stable. But if restorative or orthodontic
treatment could create recession, prophylactic gingival grafting should
be considered. If no such treatment is planned, the patient should be
informed of the potential for recession and the need for regular
evaluation of the situation.

Decisions regarding treatment will be a clinical judgment. If indecision
exists, referral to a periodontist should be considered.

**Root Exposure**

Root exposure is a frequent finding and considerable difference of
opinion exists regarding the need for reparative or preventive surgical
treatment within dentistry. If recession has occurred, the number of
millimeters of exposure should be recorded for future reference in
determining if the recession is active or stable. Where 2 mm or less of
total gingiva (free margin to mucogingival junction) is present, a pure
mucogingival problem exists and surgical treatment should be considered.

The skill of the dentist in determining the sequence of events in a
patient\'s dental history will usually determine the etiology. If root
exposure is present, earlier records including casts and/or orthodontic
models are helpful to determine if the situation is active or stable.
Usually no records exist and in that case a patient\'s opinion can be
helpful and should be considered when making a treatment decision. If
the patient believes the root exposure occurred in the past and is
stable, document the findings and continue to observe for change at
recall, keeping in mind that future dental treatment can alter the
situation. If indecision exists, but it is apparent that further
recession would result in a less than satisfactory situation, grafting
should be suggested. An example would be a shallow vestibule where
further exposure would result in insufficient room to place a graft.

Factors that should be considered in a patient\'s dental history are the
following:

1.  Injuries may occur in sites predisposed to recession by the presence
    of inadequate attached gingiva. Such injuries may result from
    mastication, i.e., crusty bread and apples. Vigorous use of a
    toothbrush may result in generalized recession, but be more
    extensive on teeth with little attached gingiva or teeth in a
    prominent position with little labial buccal bone (especially
    canines, first premolars and mandibular central incisors).

2.  Restorative procedures such as subgingival use of rotary
    instruments, taking an impression subgingivally and the cementation
    or polishing of a restoration in the presence of inadequate attached
    gingiva may cause recession.

3.  Periodontal surgical and non-surgical procedures may cause
    generalized and/or localized recession. Evaluation of past
    periodontal therapy should always be considered.

4.  The extraction of a tooth, especially in the presence of attachment
    loss may be followed by localized recession on adjacent teeth.

5.  Abnormally positioned frenum and/or muscle attachments especially in
    the presence of a narrow zone of attached gingiva may contribute to
    recession. Frenum and/or muscle attachments may have increased
    effect in the presence of a shallow vestibule.

The criteria for deciding whether to treat or refer a patient to the
periodontist should be based upon the severity of the diagnosed
periodontal problem. The assessment of whether the problem is beyond the
skill or management level of the individual dentist or dental hygienist
and the extent to which treating the patient\'s problems will require a
multi-disciplinary approach.

**Maintenance of the Ailing Implant**

**Peri-Implant Disease**

As implants have swept their way into dentistry\'s standard of care, so
has the need for their maintenance, and the ability to diagnose and
treat the peri-implant diseases that develop around them. The vast
majority of implants that dentists will encounter will be of the
endosseous type and to better understand peri-implant disease dentists
must know how they differ from natural teeth.

**Natural Teeth**

A periodontal ligament (PDL) is present where the gingival fibers
(Sharpeys fibers) are arranged perpendicular to the root surface and
attached to the cementum, forming a crestal barrier between the oral
environment and the supporting bone tissues.

**Implant**

Here, no periodontal ligament is present, but rather its collagen fibers
are arranged parallel to the implant collar with little to no attachment
to the implant. Only a weak hemidesmosornal epithelial attachment may be
present which is probably of no clinical significance. An implant is
functionally ankylosed. This lack of an attachment barrier along with a
minimal vascular network within the collagen fiber collar suggests that
the implant may be at increased risk to trauma and infection as compared
to the natural tooth. Studies comparing plaque associated lesions around
teeth and implants have shown that lesions around the implants become
more pronounced and occupied a larger volume of connective tissue,
suggesting that soft tissue inflammation around implants may have more
serious implication than the marginal inflammation around teeth. To
successfully treat the peri-implant lesion, the diagnosis must be based
on the etiologic cause of the disease.

**Diagnosis/Etiology**

There are few qualitative differences in the bacterial flora surrounding
implants and teeth, and as in periodontitis around natural teeth, the
clinical findings of the ailing implant are quite similar.

-   Gingival Inflammation

-   Increased probing depths

-   Progressive alveolar bone loss

-   Peri-implant radiolucencies

-   Increased mobility

The diagnostic evaluation should include:

-   Radiographs - Periapicals and vertical bitewings films (interval
    same as the natural dentitions)

-   Probing depths measured with a plastic probe

-   Evaluation of:

    a.  Bleeding

    b.  Color/contour/consistency (tone)

    c.  Occlusal Factors - Lateral forces or prematurities

    d.  Prosthesis fit or movement so that the screw or cement seal
        remains tight.

    e.  Individual implants in multiple unit prosthesis to evaluate for
        mobility -- requires removal of the prosthesis (recommended
        every 2-3 years). Recommended be done by the dentist who
        originally placed the prosthesis.

NOTE: An increase in probing depths of 0.5-1.0 mm in the first year is
to be expected and a 0.06-0.08 mm per year after is considered within
normal limits.

The two major etiology factors found to be associated with break down of
the coronal supportive tissues around an implant are bacterial infection
(infectious failure) and biomechanical factors associated with an over
load site (traumatic failure).

A.  **Infectious Failure**: Two stages exist:

    1.  Peri-Implant Mucositis - (early stages) When the inflammation
        around an implant is confined to the soft tissues.

    2.  Peri-Implantitis - (advanced stages) When the inflammation has
        gone through the connective tissues into the bone. Typically
        associated with many of the clinical characteristics of
        periodontitis around natural teeth, including the micro flora.

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B.  **Traumatic Failures**

    1.  Retrograde Peri-Implantitis - When micro-fractures within the
        bone occur due to:

        a.  Premature implant loading

        b.  Over loading

        c.  Trauma

        d.  Lateral forces

The clinical characteristics are periapical radiographic bone loss
without the initial gingival inflammation seen with infection failure.
The microflora are also more consistent with a periodontal healthy site.

Signs and symptoms of the over loaded implant vary with the implant
system used. With the cylinder-type implant, the marginal areas develop
more bone loss which creates a crestal cupping, whereas with the
thread-type implant, the bone loss is predominantly at the thread/bone
interface.

C.  **Combination**: Traumatic with infectious failure occurs when the
    traumatic result is present and is untreated. With the absence of a
    predictable peri-mucosal seal, the implant is more susceptible to
    the infectious results, and when both are present they lead to rapid
    bone loss and mobility.

D.  **Treatment**: This section refers to sites with slight-to-moderate
    breakdown around the implant, and employs conservative therapeutic
    procedures to restore the health of the peri-implant tissues.

*Infectious Failure: Two Phases*

[Phase One]{.underline} - To gain control of the acute bacterial
infection and reduce the inflammation in the tissues.

1.  Review POH: since implants are more susceptible to plaque associated
    infections, the patient\'s home care must be at its optimum.

2.  Mechanical debridement at local factors. (see Appendix A:
    Maintenance of Dental Implant Guideline in the original guideline
    document.)

3.  Subgingival irrigation to reduce pathogenic environment within the
    sulcus (i.e., chorohexidine).

4.  Possible use of antibiotic local delivery systems such as
    doxycycline.

5.  Systemic antibiotics such as amoxicillin or other stronger
    combinations (i.e., ciprofloxacin/metronidazole). Most studies
    suggest evaluation of the bacterial culture and sensitivity via
    microbiologic testing.

All the above is done in order to establish a healthy peri-implant site
prior to going on to Phase 2.

[Phase Two]{.underline} - Restoration of peri-implant soft tissue
pocketing and/or to regenerate bony defects around the implant.

1.  Surgery (oral surgery referral)

*Traumatic Failures* (Retrograde peri-implantitis): Two Phases

[Phase One]{.underline} - Analysis of:

1.  Prosthesis fit

2.  The number and position of the implants

3.  Occlusal relationships

Change in any of the above factors can arrest the progression of the
peri-implant tissue breakdown, and must be done prior to going to the
next phase.

[Phase Two]{.underline} - The surgical correction of the peri-implant
soft tissue pockets and/or to regenerate bone in osseous defects around
the implant.

**The Failed Implant**

When the osseointegration has been severely reduced and the bone loss
extends into the apical one-third of the implant, or has involved the
apical vent holes, then the implant is deemed failed or nonrestorable
and should be removed. Also, when an implant demonstrates mobility
(which only occurs in the late stages) upon individual testing, then it
too is deemed failed and also should be removed.

**Recall Intervals Post Peri-Implantitis Therapy**

Once a patient has exhibited peri-implantitis, they are at high risk for
recurrence, and should be treated as a high risk patient.

Suggestions:

1.  3-4 month recalls

2.  Alternating visits between the specialist and the general practice
    clinicians

Recall intervals may be lengthened or shortened based on the stability
of the peri-implantitis condition and risk.

#### CLINICAL ALGORITHM(S)

Clinical algorithms are provided in the original guideline document for:

-   Overall Perio Disease Flow

-   Adult Plaque Related Periodontal Disease

-   Plaque Related Gingivitis

-   Adult Periodontitis with Slight/Moderate Loss of Periodontal Support

-   Adult Periodontitis with Advanced Loss of Periodontal Support

-   Supportive Periodontal Treatment

-   Periodontal Therapy Appointment Management

-   Refractory Periodontitis -- Diagnostic Criteria

-   Early-onset Perio Diseases

-   Patient with a Tooth Predisposed to Recession

-   Patient with Recession

-   Peri-implant Disease

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting the recommendations is not specifically
stated.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Decreased prevalence of periodontal diseases in HealthPartners
    Dental Group (HPDG) patients

-   Reduced variability in how periodontal diseases are treated in the
    HPDG patient population

-   Improved monitoring of patient outcome data resulting in improved
    care delivery

-   Improved education of patients and providers

#### POTENTIAL HARMS

Development of antibiotic resistance and side effects of systemic
therapy

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   Chronic illness may contraindicate some types of periodontal
    therapy.

-   During prophylaxis of patients with dental implants, proper
    instrumentation should be chosen so as not to compromise the
    biocompatible surface of the implant. Hand stainless steel curettes
    and ultrasonic devices are contraindicated for maintenance therapy.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Audit Criteria/Indicators\
Clinical Algorithm

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

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

HealthPartners Dental Group and Clinics guidelines for the diagnosis and
treatment of periodontal diseases. Minneapolis (MN): HealthPartners;
2006 Mar 9. 85 p.

#### ADAPTATION

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

#### DATE RELEASED

2006 Mar

#### GUIDELINE DEVELOPER(S)

HealthPartners Dental Group - Professional Association

#### SOURCE(S) OF FUNDING

HealthPartners Dental Group

#### 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: None available

Print copies: Available from HealthPartners, 8170 33^rd^ Avenue South,
P.O. Box 1309, Minneapolis, MN 55440-1309; Phone: (952) 883-5151; Web
site: [http://www.healthpartners.com](http://www.healthpartners.com/)

#### AVAILABILITY OF COMPANION DOCUMENTS

A list of potential measures is available in the original guideline
document.

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI Institute on August 7, 2007. The
information was verified by the guideline developer on August 28, 2007.
This summary was updated by ECRI Institute on July 28, 2008 following
the U.S. Food and Drug Administration advisory on fluoroquinolone
antimicrobial drugs.

#### COPYRIGHT STATEMENT

No restrictions regarding downloading and use.

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/3/2008