Periodontal Treatment Protocol (PTP) for the General Dental


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Periodontal Treatment Protocol (PTP) for the General Dental Practice
Larry A. Sweeting, DDS; Karen Davis, RDH, BSDH; Charles M. Cobb, DDS, PhD

Introduction
Hujoel et al1 estimated a 31% decrease in the prevalence of periodontitis between the years 1955 and 2000. Further, these authors estimate an additional 8% decrease by the year 2020. In spite of the decreased use of smoking tobacco,2 better understanding of the pathogenesis of periodontal diseases, and more refined and goal directed therapies, there remains evidence that dentistry is not consistently achieving a timely diagnosis and appropriate and timely treatment of existing periodontitis.3,4 Although the evidence is limited, there is a strong suggestion that use of a periodontal probe for diagnosis and recording of periodontal status in treatment records in general dental practices has yet to achieve the level of a routine and consistent habit.5-9 Indeed, McFall et al8 determined that except for radiographs, most private practice patient records were so deficient in diagnostic information that periodontal status could not be established. It should be self-evident that treatment requires a definitive diagnosis, ie, a disease cannot be adequately treated unless first diagnosed. In this regard, it is interesting to note that at least one study has reported a disconnect between dentists’ perception of treatment rendered and actual treatment as recorded in patient records.10 As an example, prophylactic procedures outnumber periodontal procedures by a ratio of 20:111,12 and yet the prevalence of chronic periodontitis (slight, moderate, and severe) is estimated to range from a low of 7% (aged > 18 years)13 up to 35% (aged > 30-90 years)14 of the US adult population.
Cobb et al.3 compared the pattern of referral of periodontitis patients in 1980 vs 2000 using patient record data from 3 geographically-diverse private periodontal practices. Results showed the following trends occurring over the 20year time span: decreased use of tobacco; increase in the percentage of cases exhibiting advanced chronic peri-

Abstract
A sequence of interrelated steps is inherent to effective periodontal treatment: early and accurate diagnosis, comprehensive treatment, and continued periodontal maintenance and monitoring. A primary goal of periodontal therapy is to reduce the burden of pathogenic bacteria and thereby reduce the potential for progressive inflammation and recurrence of disease. Emerging evidence of possible perio-systemic links further reinforces the need for good periodontal health. In the private practice setting, the treatment of patients with periodontal disease is best accomplished within the structure of a uniform and consistent Periodontal Treatment Protocol (PTP). Such a protocol would reinforce accurate and timely diagnosis, treatment needs based on a specific diagnosis, and continual assessment and monitoring of outcomes. This is best achieved if everyone in the practice setting has a general understanding of the etiology of periodontal diseases, the benefits of treatment, and potential consequences of nontreatment. Communication skills and patient education are vital components of effective therapy since slight and even moderate stages of the disease often have few noticeable symptoms to the patient. Accurate documentation and reporting of procedures for dental insurance reimbursement, coupled with scheduling considerations, assist general practice settings in effectively managing the increasing volume of patients that can benefit from early diagnosis and treatment of periodontal diseases. This article presents the essential elements of a PTP including diagnosis, treatment planning, implementation of therapy, assessment and monitoring of therapy, insurance coding, introduction of the patient to periodontal therapy, and enhanced verbal skills. In addition, considerations for implementation of adjunctive local delivery antimicrobials is presented.
Key Words: periodontal diseases, periodontal diagnosis, treatment protocol, periodontal maintenance, periodontal assessment, patient education

odontitis with a concomitant decrease in the percentage of mild-moderate disease cases; increase in the average number of missing teeth per patient; and increase in the average number of teeth scheduled for extraction per patient. A similar study by Docktor et al4 based on patient records from 3 private periodontal practices located within a major metropolitan area reported the following: 74% of referred cases were considered advanced periodontitis, of which 30% were treatment planned for extraction of 2 or more teeth; periodontal treatment provided by the general

dental office did not vary because of disease severity; and the average number of periodontal maintenance visits/patient/year in the general dental office was less than the standard of care according to severity of disease, eg, 68% of advanced periodontitis cases reported between 0 and 2 periodontal maintenance visits per year rather than the recommended every 3 months. Viewed in aggregate, the trends reported by Cobb et al3 and Docktor et al4 support the assertion that timely diagnosis and appropriate and timely treatment of chronic periodontitis have

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not significantly improved over time. A major reason for the reported scarcity of timely diagnosis and appropriate treatment may be the lack of a well-established office protocol for the diagnosis, treatment, maintenance, and monitoring of periodontal disease, and involvement of the patient through education. Obviously, this requires dedication of energy, resources, effective communication skills, and a change in practice philosophy.
The Periodontal Treatment Protocol (PTP)
Diagnosis
Regardless of recent advances in our understanding of the etiology and pathogenesis of the periodontal diseases, the assessment of traditional clinical parameters remain the foundation for periodontal diagnosis.15 Generally, such clinical parameters include probing depth (PD), bleeding on probing (BOP), clinical attachment level (CAL), degree of furcation involvement, extent of gingival recession, tooth mobility, and plaque score. Clinicians typically utilize the results from the periodontal exam, radiographs, and the patient’s medical and dental histories to establish a diagnosis and evolve a goal/diagnosis-directed treatment plan. It has been clearly demonstrated that different interpretations of the same diagnostic information can have a dramatic impact on treatment decisions.16 For this reason, a standardized approach to periodontal assessments and a working protocol as to treatment parameters would fill a logical need in the average general practice setting. However, due to extensive overlaps in most classification systems, any standardized approach is subject to variations in both clinical assessments (eg, variations in probing depth among clinicians) as well as the interpretation thereof.
All effective treatment protocols begin with a thorough and timely diagnosis. Six-point probing to measure PD and BOP is the standard of care. Based on the needs of the patient, current radiographs should be evaluated to determine the location and percentage of bone

Table 1. Modified Version of the American
Academy of Periodontology Suggested Guidelines for a Comprehensive Periodontal Examination.18
Assessment of medical history
Assessment of dental history
Assessment of periodontal risk factors 1. Age 2. Gender 3. Medications 4. Presence of plaque and calculus (quantity and distribution) 5. Smoking 6. Race/Ethnicity 7. Systemic disease (eg, diabetes) 8. Oral hygiene 9. Socioeconomic status and level of education
Assessment of extraoral and intraoral structures and tissues
Assessment of teeth 1. Mobility 2. Caries 3. Furcation involvement 4. Position in dental arch and within alveolus 5. Occlusal relationships 6. Evidence of trauma from occlusion
Assessment of periodontal soft tissues including peri-implant tissues 1. Color 2. Contour 3. Consistency (fibrotic or edematous) 4. Presence of purulence (suppuration) 5. Amount of keratinized and attached tissue gingiva 6. Probing depths 7. Bleeding on probing 8. Clinical attachment levels 9. Presence and severity of gingival recession
Radiographic evaluation of alveolar bone loss, bone density, furcations, root shape, and proximity, etc.

loss. The presence, location, and extent of furcation invasions should be noted, as well as the location of the gingival margin or CAL. Also, the patient’s age is an important factor, especially in cases of rapidly progressing disease and determining overall long-term prognosis.
A modified version of the American Academy of Periodontology (AAP) proposed guidelines for a comprehensive periodontal examination is presented in Table 1.17 However, with respect to a functional PTP for the gen-

eral dental practice, only the following principal diagnostic criteria can be addressed: age, PD, CAL, BOP, tooth mobility, furcation involvement, and percentage of radiographic bone loss. It must be emphasized that these criteria represent the minimal parameters for determining a periodontal diagnosis. There are many other important risk and modifying factors that will impact development and progression of disease and all such factors must be taken into consideration when establishing a defin-

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itive diagnosis and a diagnosis-driven treatment plan.18
Age is of relative value in that advanced amounts of periodontal destruction at an earlier age tend to indicate a more aggressive form of periodontitis. In contrast, chronic periodontitis may slowly progress towards severity over several years or decades. Young age combined with moderate to severe bone loss presents a tenuous long-term prognosis and requires more aggressive therapy compared to the older patient presenting with a chronic form of periodontitis.19
Probing depth (PD) is defined as the distance from the gingival margin to the base of the gingival crevice.20 The periodontal pocket, represented by a probing depth > 3 mm, is the principle habitat for gram-negative, anaerobic pathogenic bacteria.20 Deeper pockets tend to represent more extensive destruction of the underlying periodontium and, therefore, a potentially greater pathenogenic burden.
Clinical Attachment Level (CAL) is defined as the distance from the CEJ to the base of the probable crevice/pocket. In cases of gingival recession, the amount of recession is added to the PD to yield the total amount of CAL. Although more difficult to obtain, it is a better measure of the total extent of damage to the underlying periodontium.20-22
Mobility is best measured by the blunt end of 2 instruments alternating pressure in a facial-lingual direction and an apical direction to assess abnormal movement of the tooth. Simply assessed: Grade I mobility is slightly more than normal; Grade II is moderately more than normal; Grade III is severe mobility facial-lingually plus apical displacement.23 Mobility patterns are suggestive of possible occlusal trauma, severe inflammation, and/or loss of supporting alveolar bone.
Furcations represent bone loss between the roots of multi-rooted teeth. A deeply invasive furcation lesion is the equivalent of a poor long-term prognosis for the involved tooth. Simply put, a Grade 1 furcation involvement is incipient bone loss only; a Grade 2 is partial loss of bone producing a cul-de-sac; a Grade 3 is total bone loss with throughand-through opening of the furcation; and a Grade 4 is similar to a Grade 3, but with gingival recession that visually exposes the furcation opening.24

Radiographic Evidence of Bone Loss is best determined with adequate and current radiographs,17 most typically a full-mouth periapical survey, including vertical bite-wings, or a panographic radiograph supplemented with vertical bite-wings and selected periapical films. By definition, true periodontitis does not begin until bone loss occurs.25 Radiographic evaluation of the distribution and severity of bone loss, bone density, root anatomy, and approximation to other teeth provides specific information that will help in determining a proper diagnosis, treatment plan, and prognosis.
Bleeding on Probing (BOP) is a simple assessment of the inflammatory status of the gingiva.15,26 In patients with deeper pockets and/or loss of clinical attachment, the chances of disease progression are greater as the percentage of bleeding sites increase.27 Conversely, lack of BOP is highly correlated with stability and a lack of inflammation.28 This latter statement, however, does not apply to smokers as they tend to bleed less when compared to nonsmokers with equal amounts of disease.29
In addition to the usual clinical parameters, the clinician is well advised to consider other risk factors and their potential impact on the development and progression of plaque-induced periodontal diseases.18 Risk factors that are sometimes overlooked in the diagnosis, treatment plan, and prognosis equation include, among others: diabetes, smoking, osteoporosis, compromised immune system, drug-induced gingival conditions, hormonal changes, and genetics. Patients at risk for periodontal disease are often allowed to “slip between the cracks” during a routine visit because they may be in the early stages of the disease. Risk factors increase a patient’s chance of developing periodontitis. The presence of one or more of these risk factors may also indicate a benefit from specialty referral in some patients.
Case Types and Periodontal Diagnosis
As part of a PTP it is necessary to establish diagnostic guidelines that will provide a framework for organizing the treatment needs of the patient. Guidelines are not meant to replace clinical knowledge or skills, nor do they imply a one-size-fits-all treatment plan for peri-

odontal disease. It is recognized that each dental practice setting is different. Consequently, guidelines are intended to be used in a manner that best meets the needs of the specific patient.
Generally speaking, plaque-induced periodontal diseases have historically been categorized into gingivitis versus periodontitis based upon whether attachment loss has occurred. The 1999 International Workshop for Classification of Periodontal Diseases21 reclassified the plaque-induced periodontal diseases into 7 different classifications. In consideration of a working PTP that addresses only the common periodontal diseases, this paper will address health, gingivitis, chronic periodontitis (formerly adult periodontitis), and aggressive periodontitis (formerly early-onset periodontitis). The first 7 entries in Table 2 (see back cover) constitute a set of clinical criteria (PD, BOP, percent bone loss, tooth mobility, degree of furcation involvement, and CAL) that will facilitate differentiation of health from gingivitis and between the various levels of severity of chronic periodontitis. Further, Table 2 can aid the clinician in differentiating between chronic and aggressive periodontitis.
Some practice settings may prefer a system of “Periodontal Case Types” for purposes of diagnosis and record keeping. Table 3 presents the diagnostic clinical criteria as applied to Case Types for health, gingivitis, chronic periodontitis (slight, moderate, and severe), and aggressive periodontitis. These criteria and Case Types are generally appropriate but should be considered as guidelines only and not as a definitive diagnosis. As mentioned before, there are numerous modifying and risk factors to consider prior to evolving a diagnosis and a diagnosis-driven treatment plan.
Treatment Planning
Development of a logical and properly sequenced treatment plan is a derivative of the periodontal assessment and diagnosis. Periodontal therapy is diagnosis-driven and, to the extent possible, should address all modifying factors and risk factors that impact development and progression of plaque-induced periodontal disease. An overview of a typical periodontal treatment plan is presented in Table 4.30

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Table 3. Clinical Criteria Assigned to Periodontal Case Types of
Health, Gingivitis, Chronic Periodontitis (slight, moderate, and severe),
and Aggressive Periodontitis.

Case Type

PD (mm)

BOP (Yes/No)

Bone Loss (%)

Mobility (Grade)

Furcations (Grade)

CAL (mm)

Visual Inflammation

0 (Health)

0-3

No

0

None

None

0

No

I (Gingivitis)

0-4

Yes

0

None

None

0

Yes (localized or

generalized)*

II (Slight Chronic Periodontitis)† 4-5

Yes

10

I

1

1-2 Yes (localized or

generalized)*

III (Moderate Chronic Periodontitis)† 5-6

Yes

33

I and II

1 and 2

3-4 Yes (localized or

generalized)*

IV (Severe Chronic Periodontitis)† > 6

Yes

> 33

I, II, or III 1, 2, 3, or 4 > 5 Yes (localized or

generalized)*

V (Aggressive Periodontitis)†_ (age is significant factor)

>6

Yes

> 33

I, II, or III 1, 2, 3, or 4 > 5 Yes (localized or

generalized)*

* Localized disease is defined as < 30% of sites are involved; and generalized disease infers >30% of sites are involved.21 † Specialty referral may be indicated for additional treatment beyond initial therapy. †_ Specialty referral should be considered.

Table 4. General Overview of the Major Steps in a Typical Periodontal
Treatment Plan.3
Sequence of Major Phases
1. Address acute periodontal problems and/or pain 2. Review and update medical and dental histories 3. Assessment of systemic risk factors and refer for medical consultation as needed 4. Extraoral examination 5. Oral cancer evaluation 6. Assessment of periodontal risk and modifying factors 7. Periodontal examination to include dental implants 8. Dental examination to include occlusal relationships and dental implants 9. Radiographic examination 10. Establish a definitive diagnosis 11 Generate a diagnosis-driven periodontal treatment plan and sequence of treatment 12. Determine required adjunctive restorative, prosthetic, orthodontic, and/or endodontic treatments and
sequence 13. Execute Phase I therapy (aka anti-infective or nonsurgical therapy) with consideration given to adjunc-
tive use of chemotherapeutic agents 14. Re-evaluation (assessment) of Phase I therapy 15. If end-points are not achieved, consider selective retreatment, need for surgical therapy, specialty refer-
ral, or use of adjunctive diagnostic aides, eg, microbial, genetic, medical lab tests, etc. 16. Determine interval for periodontal maintenance and continued assessment of periodontal status

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Implementation of Therapy
There are a wide variety of treatment options to be considered when confronted with gingivitis or chronic or aggressive periodontitis. However, thorough scaling and root planing (SRP) is still considered the gold standard in periodontal therapy. Beyond SRP, no one treatment modality is the answer in every case. However, the clinician must have specific endpoints or goals that therapy should achieve. If such endpoints are not achieved, then therapy must be re-evaluated and a decision made concerning retreatment or specialty referral for consideration of more advanced therapy options. Treatment options that should be considered include:30
• Patient education including plaque control and counseling in management of periodontal and systemic risk factors
• Scaling and root planing
• Consideration of adjunctive chemotherapeutic agents, eg, locally or systemically administered antibiotics and host response modification agents.
• Re-evaluation
• Consideration of referral to a specialist is an option that must be considered for both legal and ethical reasons.31 There are a variety of reasons to consider referral to a periodontist, such as, SRP in the presence of extreme amounts of dental calculus or SRP with complications of systemic disease, gingival overgrowth and/or inflammatory hyperplasia, resective surgery, regenerative procedures for soft and hard tissues, periodontal plastic surgery, occlusal therapy, pre-prosthetic surgery, dental implants, management of perio-systemic complications, phobic patients requiring conscious sedation, etc.
Periodontal Maintenance Therapy and Continual Assessment
In general, data suggests that patients who have undergone definitive therapy for either localized or generalized peri-
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odontitis should be managed by periodontal maintenance (PM), performed at an interval of 3 months for an indefinite period of time following active therapy.32 The 3-month interval is critical (and the standard of care for moderate and severe chronic periodontitis and aggressive periodontitis) as it has been repeatedly shown to be effective in reducing disease progression, preserving teeth, and controlling the subgingival bacterial burden.33-35 Nonetheless, the PM schedule should be individualized and tailored to meet the needs of each patient. Factors such as home care, previous level of disease, tendency toward refraction, stability indicators, etc, should be used in making this assessment. More fragile patients may need intervals of 2 months or less, and conversely, patients intercepted in early disease states who demonstrate consistent stability may need less frequent intervals of 4-6 months. Regardless of the interval between appointments, the periodontal status of each patient should be re-evaluated at every maintenance appointment. Only through close monitoring can disease recurrence be detected and the maintenance interval adjusted accordingly. Continual assessment of the periodontium during maintenance affords the best opportunity for assuring long-term stability or providing interceptive care.34,35
Insurance Coding
The American Academy of Periodontology’s Parameters of Care 200036 and the American Dental Association’s Current Dental Terminology37 are available to clinicians to guide decision-making related to providing therapeutic peri-

odontal treatment and subsequent reporting of services for insurance reimbursement. In terms of nonsurgical periodontal therapy, familiarity with dental insurance codes provides a clear method to document treatment and select appropriate procedures to maximize insurance reimbursement for the patient.
Table 5 presents a modified description of the ADA insurance codes most commonly used in Phase I periodontal therapy (aka anti-infective therapy or nonsurgical therapy). The descriptions are intended to reveal distinctive differences between procedures, and guide the clinician in reimbursement procedures.
To simplify decisions made by patients, dental insurance should be referred to as “reimbursement,” “benefit,” or “assistance” by the clinician and other staff members rather than “coverage” since the word implies complete. Most patients with dental insurance will find it necessary to supplement whatever insurance benefit they receive toward lifetime periodontal care, as many plans have contract limitations for the percentage of reimbursement associated with various procedures and/or the length of time those benefits apply. For example, limitations of some insurance plans assign benefits for PM following SRP but only for 24 months following active therapy. As another example, exclusions found in other insurance plans assign benefits for SRP for generalized periodontal disease but not for localized infection. Many patients are reticent to proceed with treatment unless their insurance will “pay for it.” Consequently, it is advantageous for practices to have clear explanations about the reality of dental insurance. Figure 2 presents a sample explanation of dental insurance that can

Understanding Dental Insurance
1. Dental insurance is a contractual agreement between the employer and insurance company. The percentage of reimbursement varies greatly dependent upon the premiums paid for a particular plan and limitations of the agreement.
2. Maximum payable benefits around $1000 - $1500 commonly found today with dental insurance plans are almost identical to the annual maximum benefit of dental insurance plans 40 years ago.
3. Dental insurance is a benefit designed to help defray the costs of quality dental care, but is not all-inclusive of what an individual may need or desire to obtain optimal dental health for a lifetime.

Figure 2. Facts about dental insurance to share with patients.

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Table 5. Modified Description of ADA Insurance Codes
Commonly Used for Phase I Periodontal Therapy
(aka anti-infective therapy or nonsurgical therapy).

Code Number D0180
D1110 D4355 D4341 D4342
D4381
D4999 D4910

Treatment Procedure
Comprehensive Periodontal Evaluation

Description
Indicated for new or established patients showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking or diabetes. It includes evaluation of periodontal conditions, probing and charting, evaluation and recording of the patient’s dental and medical history and general health assessment. It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships and oral cancer evaluation.

Adult Prophylaxis

Includes the removal of plaque, stain and calculus from tooth structures and is intended to control local irritation to gingival tissues, thereby preventing disease initiation.

Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis

Initial removal of plaque and calculus that interfere with the ability to perform a comprehensive oral evaluation. This preliminary procedure is generally followed by a comprehensive periodontal evaluation for diagnosis and subsequent therapeutic periodontal procedures.

Scaling and Root Planing Generalized per Quadrant

Involves therapeutic treatment of 4 or more periodontally involved teeth per quadrant through definitive removal of subgingival plaque biofilm and root preparation in order to halt the disease from progressing, thereby creating an opportunity for healing. To be reported per quadrant inclusive of updated periodontal charting and radiographs for reimbursement.

Scaling and Root Planing Localized per Quadrant

Involves therapeutic treatment of 1 to 3 periodontally involved teeth per quadrant through definitive removal of subgingival plaque biofilm and root preparation in order to halt the disease from progressing, thereby creating an opportunity for healing. To be reported per quadrant with identification of specific teeth being treated inclusive of updated periodontal charting and radiographs for reimbursement.

Localized Delivery of Antimicrobial Agents via a Controlled Release Vehicle into Diseased Crevicular Tissue

Subgingival insertion of antimicrobial medications of a therapeutic concentration into periodontal pockets that are released over a sufficient length of time in order to suppress the pathogenic burden, and are intended to enhance the clinical results of scaling and root planing alone. To be reported per tooth, identifying multiple treatment sites per tooth, if indicated, inclusive of a narrative describing systemic considerations for reimbursement such as tobacco usage, diabetes, or heart disease.

Unspecified Periodontal Procedure, by Report

In the absence of a specific ADA code for complete periodontal re-assessment following definitive periodontal therapy, this procedure code is being utilized to determine healing response and future treatment recommendations.

Periodontal Maintenance

Follows the completion of active therapy to treat periodontal infection for the lifetime of the dentition or implant replacements and includes removal of plaque biofilm and calculus from supra and subgingival surfaces. It may also include site specific scaling and root planing for areas of localized disease recurrence. It is intended to keep periodontal diseases under control; therefore a patient may move from active therapy to periodontal maintenance and back to active therapy and/or referral during the lifetime of the dentition or implant replacements. It is not synonymous with prophylaxis, and is required at varying intervals to manage periodontal diseases and modify risk factors. To be reported by both general and periodontal practices on patients having undergone active therapy irrespective of where the procedure is performed. Current periodontal charting documenting the patient’s on-going periodontal status should be submitted for reimbursement.

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be shared with patients, assisting them in making independent decisions about treatment, regardless of the insurance reimbursement schedule.
Patient Education and Introduction to Periodontal Therapy
Effective implementation of the aforementioned concepts requires expertise in effective patient education and introduction of periodontal therapy so that patients are prepared to make wise health decisions. Being proficient in SRP procedures has little value to the patient who assumes they are visiting the dental hygienist for a “routine cleaning.” This is particularly true if the patient already has a developing or existing periodontal infection and does not understand the need for therapeutic intervention. Chronic periodontal diseases often provide few noticeable symptoms, especially in earlier stages of development. Thus, the need for effective communication, education, and listening skills are of particular importance to today’s dental patient.
The incidence of moderate and severe generalized chronic periodontitis in the US appears to affect only 5% to 15% of the adult population, whereas slight disease affects approximately 35% of the adult population.13,14,38 Thus, most new patients and even many existing patients will ultimately be diagnosed with periodontal diseases. To be effective at enrolling patients into active therapy everyone in the practice setting must have a basic understanding of the etiology of periodontal diseases, treatment options, consequences of nontreatment, and direct benefits of therapy. Patients are more motivated to accept treatment recommendations when a clear diagnosis has been established, they are given the opportunity to see infection in their own mouths, their questions have been answered, and they understand the value of treating periodontal infection in relation to their overall health.
Many clinicians inform patients of their periodontal status while working in their mouths with sharp instruments, or give a summary of findings at the end of the visit. Most patients are visual learners. Consequently, patients need to see the condition of their own mouth. At the beginning of every appointment,

during data collection and tissue assessment, the patient should be provided a mirror to visualize with the clinician the evidence of periodontal disease, caries, gingival recession, tooth mobility, furcation involvement, etc. (Figure 1). During periodontal probing, the patient should hear the pocket measurements as data is being collected and recorded. In a similar manner, during examination of the radiographs, the patient should be shown evidence of permanent bone loss, and contrast that to areas without bone loss. Involving the patient in the discovery process visually and audibly is a powerful tool to help patients take ownership in their own health.

Enhanced Communication Skills
Each clinician will develop his/her own style of case presentation for periodontal therapy and will individualize the message to different patients. However, there is significant advantage if the entire office staff has continuity in key words that are used when discussing periodontal therapy with patients. Equally important is the avoidance of minimizing messages such as “just a little bit of bleeding,” or “a little bone loss,” or “just a little bit of plaque.” It is advisable to use language that does not trivialize conditions that are not yet severe. Terms such as “slight

Figure 1. Dental hygienist showing patient periodontal conditions in patient’s own mouth.

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

bleeding,” “early bone loss,” or “slight plaque” accurately describe findings without overstating them. Periodontal disease is a bacterial infection leading to a host immune response that is characterized by inflammation and degradation of periodontal tissues.22 When informing patients of periodontal disease, using the word “infection” is more powerful than “gum inflammation” and can create a sense of urgency regarding treatment. The word “hemorrhage” indicates heavy bleeding and implies a condition outside healthy parameters. When the patient’s gingival tissues hemorrhage easily upon provocation, “hemorrhage” rather than “bleeding gum tissue” should be verbalized to the patient. The words “scaling and root

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Guide for Use of Locally Delivered Antimicrobials

Where to use locally delivered antimicrobials:
➢ Pockets > 5 mm with bleeding on probing (BOP). • The locally delivered antimicrobial may be used at the time of scaling and root planing (SRP) or at the re-evaluation appointment 4-6 weeks following SRP. If used first at the re-evaluation appointment, the site must have additional SRP to remove biofilm and hard deposits that may have re-accumulated.
➢ Residual pockets of > 5 mm with BOP or any site > 6 mm following initial SRP. • Determined at re-evaluation appointment. • If > 4 residual pockets in a given quadrant then consider either retreatment (SRP) with locally delivered antimicrobial or surgical intervention.
➢ Sites treatment planned for osseous grafting. • Locally delivered antimicrobial placed 3 weeks prior to surgical procedure.
➢ Periodontal abscess ➢ Probing depth at the distal-facial line-angle of 2nd
molars related to 3rd molar extractions where surgical intervention will yield a compromised result. ➢ Ailing/failing dental implants (peri-implantitis) where surgical intervention is not indicated or will yield a compromised result. ➢ Grade II furcation involvements (shallow or deep) when surgical intervention is not planned.

Who might benefit from use of locally delivered antimicrobials:

➢ Periodontal maintenance

patients with isolated

probing depths of > 5 mm

that exhibit BOP or any

pocket > 6 mm (Figure 3).

➢ Patients wanting to avoid

periodontal surgery.

➢ High risk surgery patients.

• Poorly controlled (brit-

tle) diabetic patients

Figure 3. Pre-treatment

• Patients with a history clinical presentation

of recent or recurrent coronary or cere-

showing PD of 6 mm

brovascular events.

• Patients with a compromised immune system due to

disease or medications.

• Kidney dialysis patients.

• Heavy smokers (>1/2 pack/day)

• Patients with physical disability that impacts oral

hygiene efficiency

• Mentally handicapped patients

➢ Patient’s with marginal oral hygiene that is not likely to

improve and thereby represent a poor surgical risk.

➢ Please note that locally applied antimicrobials may need

to be placed more than one time to achieve the desired

result.

How to apply locally delivered antimicrobials:
➢ For optimal effect from locally delivered antimicrobials the following must be achieved: • Oral hygiene instructions and patient compliance regarding the necessary oral hygiene procedures, ie, tooth brushing, use of interdental hygiene aids such as dental floss and proxabrushes, and use of antimicrobial oral rinses. • Supragingival scaling and polishing. • Definitive subgingival SRP (generally under local anesthesia). • Place locally delivered antimicrobial according to manufacturer’s directions. For example, in the case of minocycline microspheres, place one pre-measured dose per pocket. If the tooth has 2 pockets that need local delivery, 2 full doses should be administered. • The pocket should be as biofilm and deposit free as possible prior to insertion. • Insert the locally delivery product to the base of the pocket. In the case of minocycline microspheres, the tip should be placed as far into the pocket as possible before activating the syringe/handle (Figures 4 and 5).

Addendum:
➢ If probing depths are < 4 mm, the clinician should consider a conventional adult prophylaxis coupled with oral hygiene recommendations and/or reinforcement. • If the patient exhibits multiple probing depths of 4 mm a periodontal maintenance interval of 3-4 months should be considered until it can be determined if the patient’s periodontal status is stable and/or improving.

Figure 4. Initial Insertion of the pre-measured tip for administration of minocycline microspheres

Figure 5. Tip placement to base of pocket for administration of minocycline microspheres.

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planing” may sound confusing to patients or imply discomfort. The words “periodontal therapy” are effective semantic choices when informing patients about necessary periodontal treatment. “We now know” are words that can introduce patients to new ideas or treatment options to explain why information may be different than what they have heard in the past, or expected to hear at their current visit. “Halting” or “arresting disease” can be used to describe a measurable goal for treating periodontal diseases that should be obtained through intervention. “Daily disease control” communicates to the patient that they share in the role in the effective removal of plaque bacteria beyond what it achieve through periodontal treatment.
Even though some states require written consent, effective communication between the clinician and the patient is the important consideration of informed consent,39 not the completion of a form. Therefore, deliberate semantic choices should be shared by all members of the office staff to optimize patient understanding of their periodontal conditions.

Suggestions for Implementation of a Periodontal Treatment Protocol in the General Practice Setting
• General dentists and dental hygienists should schedule a meeting with referring periodontists and their dental hygienists to share philosophies of periodontal treatment and establish clarity for referrals.
• Schedule a team meeting workshop to bring all office staff up-to-date regarding periodontal assessments, diagnosis, case types, periodontal risk factors, individualized treatment of periodontal diseases, consequences of nontreatment (tooth loss and possible systemic involvement), and the value of periodontal maintenance.
• Establish continuity of the verbal skills and terminology the office staff will utilize to communicate effectively to patients about periodontal conditions.

• Include assessments and diagnosis of periodontal diseases in all new patient visits, routine prophylaxis appointments, and ongoing periodontal maintenance to insure no patient is overlooked regarding diagnosis of developing periodontal disease or recurring disease.
• Select appropriate ADA Insurance Procedure Codes for reporting periodontal procedures in order to maximize the patient’s benefit.
• Share insurance information with patients to assist them in reducing their dependence on dental insurance benefits, thereby enabling them to make independent health decisions related to treatment of periodontal diseases.
Disclosure
Dr. Sweeting, Ms. Davis, and Dr. Cobb are scientific advisors for OraPharma, Inc.

References
1. Hujoel PP, Bergström J, del Aguila MA, DeRouen TA. A hidden periodontitis epidemic during the 20th century? Community Dent Oral Epidemiol 2003;31:1-6.
2. Mendez D, Warner KE. Adult cigarette smoking prevalence: Declining as expected (not as desired). Am J Pub Health 2004;94:251-252.
3. Cobb CM, Carrara A, El-Annan E, et al. Periodontal referral patterns, 1980 versus 2000: A preliminary study. J Periodontol 2003:74:1470-1474.
4. Dockter KM, Williams KB, Bray KS, Cobb CM. Relationship between pre-referral periodontal care and periodontal status at time of referral. J Periodontol 2006:77:1708-1716.
5. Bader JD, Rozier G, McFall WT, Jr., Sams DH, Graves RC, Slome BA, Ramsey DL. Evaluating and influencing periodontal diagnostic and treatment behaviors in general practice. J Am Dent Assoc 1990;121:720-724.
6. Cury PR, Martins MT, Bonecker M, De Araujo NS. Incidence of periodontal diagnosis in private dental practice. Am J Dent 2006;19:163-165.
7. Heins PJ, Fuller WW, Fries SE. Periodontal probe use in general practice in Florida. J Am Dent Assoc 1989;119:147150.
8. McFall WT, Jr., Bader JD, Rozier G, Ramsey D. Presence of periodontal data in patient records of general practitioners. J Periodontol 1988;59:445-449.
9. Brown LJ, Johns BA, Wall TP. The economics of periodontal diseases. Periodontol 2000. 2002;29:223-234.

10. Helminen SE, Vehkalahti M, Murtomaa H. Dentists’ perception of their treatment practices versus documented evidence. Int Dent J 2002;52:71-74.
11. Blair, C. The economic impact of the under diagnosis of periodontal disease in general practice. Triage 2005;1:21-25.
12. American Dental Association, Survey Center. 1999 Survey of Dental Services Rendered. Chicago IL: American Dental Association; 1999.
13. Borrell LN, Burt BA, Taylor GW. Prevalence and trends in periodontitis in the USA: The NHANES, 1988 to 2000. J Dent Res 2005;84:924-930.
14. Albandar JM, Brunelle JA, Kingman A. Destructive periodontal disease in adults 30 years of age and older in the United States, 1988-1994. J Periodontol 1999;70:13-29.
15. Armitage GC. Periodontal diseases: Diagnosis. Ann Periodontol 1996;1:37-215.
16. Papapanou PN, Wennstrom JL, Sellen A, Hirooka H, Grondahl K, Johnsson T. Periodontal treatment needs assessed by the use of clinical and radiographic criteria. Community Dent Oral Epedimiol 1990;18:113-119.
17. American Academy of Periodontology. Parameter on comprehensive periodontal examination. J Periodontol 2000;71(Suppl.);847-848.
18. Krebs KA, Clem DS, III. American Academy of Periodontology. Guidelines for the management of patients with periodontal diseases. J Periodontol 2006;77:1607-1611.
19. Novak KF, Goodman SF, Takei HH. Determination of prognosis. In: Newman MG, Takei H, Klokkevold PR, Carranza FA, eds. Clinical Periodontology, 10th ed. Philadelphia: Saunders/Elsevier; 2006; pp. 614-625.

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The Journal of Dental Hygiene

Special supplement

20. Carranza FA, Camargo PM. The periodontal pocket. In: Newman MG, Takei H, Klokkevold PR, Carranza FA, eds. Clinical Periodontology, 10th ed. Philadelphia: Saunders/Elsevier; 2006, pp. 434-451.
21. Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999;4:1-6.
22. American Academy of Periodontology. Position paper: Diagnosis of periodontal diseases. J Periodontol 2003;74:1237-1247.
23. Carranza FA, Takei HH. Clinical diagnosis. In: Newman MG, Takei H, Klokkevold PR, Carranza FA, eds. Clinical Periodontology, 10th ed. Philadelphia: Saunders/ Elsevier; 2006, pp. 540-560.
24. Carranza FA, Takei HH. Bone loss and patterns of bone destruction. In: Newman MG, Takei H, Klokkevold PR, Carranza FA, eds. Clinical Periodontology, 10th ed. Philadelphia: Saunders/Elsevier; 2006, pp. 452-466.
25. Armitage GC. Clinical evaluation of periodontal diseases. Periodontol 2000 1995;7:39-53
26. Haffajee AD, Socransky SS, Lindhe J, Kent RL, Okamoto H, Yoneyama T. Clinical risk indicators for periodontal attachment loss. J Clinical Periodontol 1991;18:117-125.
27. Claffey N, Egelberg J. Clinical indicators of probing attachment loss following initial periodontal treatment in advanced periodontitis patients. J Clin Periodontol 1995;22: 690-696.
28. Lang NP, Adler R, Joss A, Nyman S. Absence of bleeding on probing – an indicator of periodontal stability. J Clin Periodontol 1990;17:714-721.
29. Muller HP, Stadermann S. Multivariate multilevel models for repeated measures in the study of smoking effects on the

association between plaque and gingival bleeding. Clin Oral Invest 2006;10:311-316. 30. American Academy of Periodontology. Position paper. Guidelines for periodontal therapy. J Periodontol 2001;72:1624-1628. 31. American Dental Association. Principles of ethics and code of professional conduct. January 2005. Available at: http://www.ada.org/prof/prac/law/code/index.asp. Accessed August 28, 2008. 32. American Academy of Periodontology. Position paper. Periodontal maintenance. J Periodontol 2003;74:1395-1401 33. Greenwell H, Bissada NB, Wittwer JW. Periodontics in general practice: Perspectives on periodontal diagnosis. J Am Dent Assoc 1989:119:537-541. 34. Hirschfeld L, Wasserman B. A long-term survey of tooth loss in 600 treated periodontal patients. J Periodontol 1978;49:225-237. 35. Tonetti MS, Muller-Campanile V, Lang NP. Changes in the prevalence of residual pockets and tooth loss in treated periodontal patients during a supportive maintenance care program. J Clin Periodontol 1998;25:1008-1016. 36. American Academy of Periodontology. Parameters of care. J Periodontol 2000;71: 847-880. 37. American Dental Association. Current Dental Terminology. 2007-2008;3-27. 38. American Academy of Periodontology. Position paper. Epidemiology of periodontal diseases. J Periodontol 2005;76:1406-1419. 39. American Academy of Periodontology. American Academy of Pediatric Dentistry. Guideline for periodontal therapy. Pediatr Dent 2005-2006;27(7 Reference Manual):197-201.

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Periodontal Treatment Protocol (PTP) for the General Dental