Patient Consultation Guide

Gingival Health

Pigmented gingiva

Gingival Health
Clinical Gingival Healthon an Intact Periodontium

Clinical Gingival Healthon a Reduced Periodontium:

Clinical Gingival Healthon a Reduced Periodontium:

BOP <10%PD ≤ 4mm(no site ≥4mm with BOP)
Probing Attachment Loss – yes
RBL – yes

BOP <10%PD ≤3mm
Probing Attachment Loss – yes
RBL – possible

Stable Periodontitis Patient

Clinical Characteristics
BOP <10%PD ≤3mm
Probing Attachment Loss – noRBL – noNon-Periodontitis Patient(ie. recession; crown lengthening, etc.)

Gingivitis

Pigmented gingiva

Gingivitis
Gingivitis IntactPeriodontium
Clinical Characteristics
BOP ≥ 10%
PD 0-3 mm
CAL – none
RBL – none

Gingivitis withReduced
Periodontium
Stable Periodontitis Patient

BOP ≥10%PD ≤ 3mm
CAL – yes
RBL – yes

Gingivitis with Reduced
Periodontium

Non-Periodontitis Patientie. recession; crown lengthening, etc)

BOP ≥10%PD ≤ 3mm
CAL – yes
RBL – possible

Periodontitis Stage I

Periodontitis Stage I
Clinical Characteristics
BOP – yes (>10%)PD ≤ 4 mm
CAL 1-2 mm
RBL < 15% & generally horizontal
Biofilm – slight - heavy

No tooth loss due to periodontitis
Moderate rate of progression
If Smoker < 10 cigs/day
If Diabetic HbA1c < 7.0%

Periodontitis Stage II

Periodontitis Stage II
Clinical Characteristics
BOP – yesPD ≤ 5 mm
CAL 3-4 mm
RBL – 15%-33% & mostly horizontal
Biofilm – slight - heavy

No tooth loss due to periodontitis
Moderate rate of progression
If Smoker < 10 cigs/day
If Diabetic HbA1c < 7.0%

Periodontitis Stage III

Pigmented gingiva

Periodontitis Stage III
Clinical Characteristics
BOP – yesPD ≥ 6 mm
CAL ≥5 mmRBL ≥50% horizontal≥ 3mm vertical
Biofilm – slight - heavy

Tooth loss due to periodontitis ≤ 4 teeth
Furcation involvement – Class II or III
Moderate ridge defect
If Smoker < 10 cigs/day
If Diabetic HbA1c < 7.0%

Periodontitis Stage IV
Generalized

Generalized

Localized

IV Grade C

Periodontitis Stage IV
Clinical Characteristics
BOP – yesPD ≥ 6 mm
CAL ≥5 mm
RBL ≥50% horizontal≥ 3mm vertical
Biofilm – slight - heavy

Tooth loss due to periodontitis ≥ 5 teeth
Furcation involvement = Class II or III
Moderate ridge defect
If Smoker < 10 cigs/day
If Diabetic HbA1c < 7.0%
Need for complex rehabilitation

Periodontitis Staging
Periodontitis

Stage IStage IIStage III

Stage IVInterdental CAL atsite of greatest loss

1-2mm

3-4mm

≥5mm

≥5mm

Radiographic
Bone Loss

Coronal third(<15%)

Coronal third(15%-33%)

Extending to mid-thirdof root and beyond

Extending to mid-thirdof root and beyond

Tooth Loss

No tooth loss
due toPeriodontitis

No tooth loss
due toPeriodontitis

Tooth loss
due to Periodontitisof ≤4 teeth

Tooth loss
due to Periodontitisof ≥5 teeth• Maximum ProbingDepth ≤ 4mm• Mostly horizontalbone loss• Maximum Probing
Depth ≤ 5mm• Mostly horizontalbone loss

In addition toStage II complexity:• Probing depth≥ 6mm• Vertical bone loss
≥3mm
• Furcation involvement(Class II or III)• Moderate ridge defectIn addition toStage III complexity:
Need for complex
rehabilitation due to:• Masticatory dysfunction• Secondary occlusal trauma(tooth mobility degree ≥2)• Severe ridge defect• Bite collapse, drifting, flaring• Less than 20 remaining teeth(10 opposing pairs)

SeverityComplexity
Local

Extent anddistributionFor each stage, describe extent as localized (<30% teeth involved), generalized, or molar/incisor pattern

Adapted from Tonetti et al. J Periodontal. 2018;89(Supp 1):S159-S172)

Grade Determination
Progression

Primarycritera

Direct evidenceof progression

Wheneveravailable,
directevidence
should beused

Indirect
evidence ofprogression

Risk factors
Grademodifiers

Grade A: Slow rate

Grade B: Moderate rate

Grade C: Rapid rate

Radiographic
bone loss or CAL

No loss over 5 years<2 mm over 5 years≥10 mm over 5 years% bone loss / age<0.250.25 to 1.0> 1.0

Case phenotype

Heavy biofilm
depositis with lowlevels of destruction

Destruction commensurate with biofilm
deposits

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

Smoking

Non-smoker<10 cigaretes/day≥10 cigarettes/day

Diabetes

Normoglycemic / nodiagnosis of diabetes

HbA1c<7.0% inpatients with diabetes

HbA1c≥7.0% in patientswith diabetes

Grade Modifiers

SmokingDiabetes

StageBoneLossI>15%

Grade A (slow)

Grade B (moderate)

Grade CII 15-33%
III >50%(rapid)

VIAge 20354555

657585

Tables from Tonetti, Greenwell, Kornman. J Periodontol 2018;89 (Suppl 1): S159-S172.

Peri-implant Mucositis and Peri-implantitis
ClinicalCharacteristics
BOP – yes
PD – increase
RBL – noVisual inflammation – yes
Biofilm – yes
Mobility – noClinicalCharacteristics
BOP &/or suppuration – yes
PD – increase/correlated
to bone loss
RBL – yes
Biofilm – yes
Visual inflammation – yes
Mobility – yes
More rapid progression thanfound in periodontitis

Risk Indicators
History of severe periodontitis
Poor biofilm control
No regular maintenance care2018 Classification of Periodontal and Peri-Implant Diseases      ­              

Adapted from Caton et al. J Periodontol 2018.

The Oral Microbiome: More than Meets the EyeResistancetocolonization

Maintainsa healthy
digestive
tract

Antiinflammatory
factors

Antioxidant
activity

Supporthost
defenseImbalanced
bacteria
Amplifies
diseaseCalculus
PlaqueActivates cells
that degradebone

Regulates
cardiovascularsystem

Releases
toxinsSymbiosis
Host-microbiome

Triggers
immuneresponse

Diabetes

Smoking
Genetics

Poor
oralhygieneDysbiosis

Antibiotics/
antimicrobial
agentsPoor
dietSalivary
factors

Immunefactors

Primary and Permanent Dentition
Permanent Eruption Dates

Primary Eruption Dates

125253
C

5451 61

62

D E F G
H64

IB

55

Lateral incisors: 9-11 mos
63

A

J

65

Canine: 16-22 mos
1st Molar: 13-19 mos
2nd Molar: 25-33 mos

Mandibular
T

85

S

84
83

KL
M
R
QPO N

82 81 71

72

75

61474

1st Molar: 14-18 mos
Canine: 17-23 mos
73
Lateral incisor: 10-16 mosCentral incisor: 6-10 mos

9 10Central incisor: 7-8 yrs
Lateral incisor: 8-9 yrs

22

24

111225

41326

314

215

11632

1716
1748

2nd Molar: 22-31 mos

7 851518

Maxillary212313Central incisor: 8-12 mos

114746311830

19294544432325 2442 41

383735212231 32

283620282726273433

Canine: 11-12 yrs
1st Premolar: 10-11 yrs
2nd Premolar: 10-12 yrs
1st Molar: 6-7 yrs
2nd Molar: 11-13 yrs
3rd Molar: 17-21 yrs

3rd Molar: 17-21 yrs
2nd Molar: 11-13 yrs
1st Molar: 6-7 yrs
2nd Premolar: 11-12 yrs
1st Premolar: 10-12 yrs
Canine: 9-10 yrs
Lateral incisor: 8-9 yrs
Central incisor: 7-8 yrs
FDI World Dental FederationInternational NumberingDental Decay

EONo lesion

E1

Lesion within theouter half of enamel

E2

Lesion within the
inner half of enamel

D1

Lesion within theouter third of dentin

D2

Lesion within the
middle third of dentin

D3

Lesion within the
inner third of dentin

Location of caries:

Pit & fissure

Interproximal

Smooth surface

Cervical / Root

Anusavice KJ. Present and future approaches for the control of caries. J Dent Educ. 2005 May;69(5):538-54. PMID: 15897335.

Tips to Prevent Dental Decay+Sugar

RiskFactors+forms
Bacteria• Sugary foods that cling to your teeth• Frequent snacking or sipping• Bottle to Bed /Feeding after final brushing• Reduced or poor manual dexterity• Dry Mouth• Not getting enough fluoride• Dexterity (young and old)

Decalcification (or weakening) ofenamel is the early sign of tooth decay.
Reduce sugars and increase fluoride.

AcidAcidforms

Tooth & PlaqueDecay

Balance risk factors with prevention
SugarBacteria

Pit &Fissure
Sealants:

SalivaFluorideRestorative Options
BridgeFillingWhite

Implant

SilverCrown
Abutment

Implant

CrownVeneers

Restorative Options

Adhesives

Biggest advantages for denture wearers:• Patient confidence• Strong long-lasting hold• Movement reductions• Food seal

Full DenturePartial DentureErosive Tooth WearHealthy

SevereTeeth Natural contours with slightfeature: grooves & imperfections
Assessment: BEWE 0(Basic Erostive Tooth Wear Exam)No erosive tooth wear

Smooth & more translucent
along the gumline

Dull & concave areas begin
to form

Yellow as underlying dentin
begins to show

BEWE 1
Initial loss of surface texture

BEWE 2
Hard tissue loss
involving <50% surface area

BEWE 3
Hard tissue loss
involving ≥50% surface area

Acid softened enamel is more susceptible to wear from physical abrasion and attrition.
Erosion is irreversible.
Bartlett, D., Ganss, C. & Lussi, A. Basic Erosive Wear Examination (BEWE): a new scoring system for scientific and clinical needs. Clin Oral Invest 12, 65–68 (2008). https://doi.org/10.1007/s00784-007-0181-5

Prevention and Management of Erosive Tooth Wear
pH of common
food and drinks
pH (acid scale)

22.6

3.3

3.7-4.2

5

6.5

6.77Lemonjuice

FizzydrinksOrangejuice

BeerBanana

AvocadoSalivaWater

12345678Acid Scale Danger Zone

Drink water

Chewsugarless gum

Dairy after acidic foods

Brush with a
Stannous Fluoride toothpaste

Stannous Fluoride is recognized as being more effective
than Sodium Fluoride in the prevention of dental erosion.

Use a straw foracidic beverages

Stannous Fluoride
Mechanism of Action

Therapeutic Benefit
Anticaries

CariesEnhances Remineralization
Inhibits Demineralization

Bleeding

Gingivitis

Patients are 3.7x more likely to transition togingival health using a stabilized, bioavailable
Stannous Fluoride toothpaste versus sodium
fluoride or MFP1.

Reduces biofilm
Reduces bleeding gums

Biofilm

Prevents erosion

SnFSnFFF

F

Sodium Fluoride protects topH <5.5 while Stannousprotects against dietary acidsin the enamel danger zone

Has the potential for slowing theprogression of erosive tooth wear

SnFErosion

Sn
F

Reduces sensitivity
External
Stimulus(European Fed of Conservative Dentistry)F

Stannous Fluoride
CausesMovement

Stannous Fluoride

Pain Signal
Transmission

Stimulates
Fluids inDentin
Tubules

FSnFNerve
Receptor

TransientToothPainOccludes dentinal tubules

Reduces halitosis
Halitosis

1. Biesbrock A, et al. The Effects of Bioavailable Gluconate Chelated Stannous Fluoride Dentifrice on
Gingival Bleeding: Meta-Analysis of Eighteen Randomized Controlled Trials. J Clin Periodontol. 2019 Sep 28.

Brushing Instructions
PowerManualInterdental Cleaning
Flossing

Other methods
Floss holder

Power interdental

Irrigator

Interdental brushTongue cleaner

Tips for Orthodontic Patients

Improve Your Smile by Removing Plaque Effectively

Decalcification (or weakening) of enamel
is caused by plaque around brackets and wires

A dental CE library provided exclusively by Procter & Gamble’s
Crest + Oral-B lets you choose from more that 150 FREE
on-demand dental continuing education courses.

At Crest + Oral-b, we’re committed tohelping you educate your patientson oral health conditions, dental
procedures, and proper oral hygiene
techniques. Visit dentalcare.com toregister today!