Driving Towards Periodontal Health: A Simplified Roadmap for Periodontal Management

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Driving Towards Periodontal Health: A Simplified Roadmap for Periodontal Management
Oral Health & Dental Practice Magazine
July 2008

By: Cary Galler, DDS, MSD

Periodontal diagnosis and treatment planning can be a complex endeavor for the periodontal care provider. It is a difficult undertaking to assimilate the multiple variables that interplay in the manifestation of periodontal disease and to devise appropriate strategies for its management. Establishing guidelines (rules of the road) for periodontal management will greatly assist the practitioner in developing a comprehensive approach to treatment. This article proposes a treatment algorithm (road map) based on current thought in periodontics. When its logic is followed, while employing appropriate clinical judgment, the algorithm can be an invaluable aid to support the dentist's periodontal decision-making efforts.

THE PERIODONTAL SUMMARY SCORE
This author has previously published articles introducing a quantifiable periodontal scoring system, entitled the Periodontal Summary Score (PSS). The PSS summarizes the periodontal parameters of probing depths and gingival bleeding into a comprehensible aggregated frequency score that simplifies the interpretation of the present periodontal condition. This method can be of great value to the clinician in determining the severity of the disease at any point in time (Fig. 1).

Increasing PSS values signify more advanced levels of disease severity. Referencing the current PSS against an ideal target score of 10-0-10, indicative of periodontal health, highlights the present periodontal condition in a more tangible and comprehensible fashion. The PSS uses a cutoff point of 30-10-30 to differentiate between moderate and severe periodontal disease. It also classifies periodontal disease into three distinct levels of severity by assigning gradated parameter values to each severity level (Fig. 2).

The PSS can be particularly valuable when it is used to compare a patient's present score with their previous scores. The comparative analysis gleaned from multiple time point measurements helps to develop a dynamic depiction of a patient's periodontal progress, and thereby, provides constructive guidance in developing an effective treatment plan. The PSS also assists in understanding whether periodontal treatment measures performed to this date have been successful, and whether new therapeutic strategies must be introduced (Fig. 3).

The PSS is a powerful communication tool that renders the complexity of periodontal diagnosis into an easily understandable score that greatly the facilitates effective dialogue between the care provider and patient. The PSS becomes as identifiable as a blood pressure reading or cholesterol score to the patient. This simplified scoring method demystifies the concept of periodontal disease for the patient and may aid in motivating them to accept the care that is necessary to optimize their oral health.

PERIODONTAL RISK
Over the last number of years, associations between periodontal and systematic disease have been more clearly identified. 3 As a result, the profession has highlighted a number of verifiable risk factors that increase the susceptibility to periodontal disease.

It is beyond the scope of this article to delve into the above matters in substantial detail; however, it is strongly believed that certain critical factors have a significant influence in affecting the outcome of the periodontal disease process (Fig. 4).

A large number of investigations have shown that Type 1 and 2 Diabetes increase the risk and severity of periodontitis. There appear to be multiple cellular and molecular alterations taking place in the periodontium as a consequence of sustained hyperglycemia. Periodontitis has also been shown to have an effect on diabetes, although there is less evidence on the underlying mechanisms. The entrance of microorganisms and/or their byproducts into the systemic circulation and the host-inflammatory response are believed to play a role in this process.

Cigarette smoking has significant health implications. It can modify the manifestation and progression of periodontal disease and also affect the response to periodontal treatment. HIV infection has been cited as a risk factor for periodontal disease. Some forms of periodontal disease may be more severe in individuals affected with immune system disorders. All of the above factors are classified as critical factors and appear to play an essential role in affecting the pathogenesis and progression of periodontal disease.

In addition, other factors play a modifying role and in combination with one another, may also significantly alter the course of periodontal disease. These factors are categorized as contributing risk factors and are subdivided as being clinical or systemic in nature. When any one of the critical factors is identified, the risk for future periodontal disease is deemed to be high. When two or more clinical and systemic contributing factors are evident, the risk is also classified as high. Some subjectivity is involved in differentiating between a high and low risk. As such, clinical judgment must be utilized to accurately categorize the risk. Nevertheless, the risk of future disease is a pertinent concern and should certainly influence what decisions the clinician makes about future periodontal treatment.

A periodontal treatment plan should take into account the level of risk involved in a case. A high periodontal risk warrants more active intervention. In all cases, efforts should be made to modify the risk factor identified, if at all possible. Certain risks, such as tobacco smoking can be eliminated or reduced, while other systemic factors are not easily modifiable. As a result of the above, this author proposes that the Periodontal Risk Profile become a central component of the documentation regimen in a periodontal examination (Fig. 5). The periodontal disease score (PSS) when considered in combination with the periodontal risk level (Periodontal Risk Profile) should influence the direction of future periodontal care decisions.

PSS + RISK + CLINICAL JUDGMENT = PERIODONTAL TREATMENT PLAN
The level of risk should be equally considered as part of the treatment planning equation. When the present periodontal disease state (PSS) and periodontal risk level (Periodontal Risk Profile) are analyzed together, the practitioner is better positioned to determine what treatment strategies may be appropriate in a given situation. As the periodontal score increases, more advanced treatment protocols are required.

Each case presents with its own unique profile. Nevertheless, there is only one correct diagnosis. Undoubtedly, there is often more than one treatment approach that can result in periodontal success. Accordingly, judicious clinical judgment must be utilized. All influencing factors should be taken into full account and all treatment decisions should be made on a case specific basis.

TRAFFIC GUIDELINES FOR PERIODONTAL SUCCESS
There is an intimate relationship between the periodontal disease score and the periodontal risk. Both factors have a direct effect on the outcome of treatment. Consequently, both the disease score and risk should be carefully considered when developing a proper treatment plan in any given case (Fig. 6).

The Periodontal Summary Score becomes very valuable when its absolute value can be correlated to the level of disease (Fig. 7). Empirically, a score below 10-0-10 may be considered healthy. A healthy periodontal condition may demonstrate a few 4-5mm probing depths and/or gingival bleeding sites. A score of up to 30 sites of probing depth or bleeding translates to a mild periodontal condition. Any score above that level illustrates a more advanced periodontal condition.

To further assist the practitioner, a treatment algorithm is hereby proposed that categorizes periodontitis into three distinct levels of disease, and it has assigned a color-coding (green, yellow and red) to the different levels using a traffic light analogy (Fig. 8).

The Green Zone is consistent with periodontal health. There are no more than 10 sites of probing depths greater than 3mm; with no sites being greater than 5mm. Bleeding on probing is limited to 10 sites or less (Fig. 9).

The Yellow Zone indicates a mild to moderate level of disease, where there are between 10 and 30 sites of probing depth greater than 3mm, with several sites of these sites being 6mm or more. The number of gingival bleeding sites is also of significant concern (Fig. 10).

The Red Zone depicts a condition of severe periodontal disease. There are more than 30 sites of probing depth greater than 3mm, with many being 6mm or more. Bleeding on probing is also highly elevated (Fig. 11).

The central thesis of the treatment algorithm is the relationship between disease and risk and the interdependent influence they have to each other. As the disease and risk score both increase, treatment options should be expanded to reflect the more serious nature of the condition. More aggressive treatment options should be employed with increasing disease and risk severity.

Treatment in the Green Zone requires only standard conservative periodontal treatment. A default recare schedule of six months will likely to be successful in sustaining the state of health present (Fig. 12).

In the Yellow Zone more advanced treatment is required. Treatment would normally commence with scaling and root planing, but it is likely that more advanced treatment is required (Fig. 13).

Beyond scaling and root planing, one of the first options for patients with mild to moderate disease is to consider utilizing one of the several locally administered antimicrobial (LAA) agents. If there are a reasonable number of manageable sites to treat, the implementation of these agents may assist in resolving the periodontal condition to lower levels of disease. Studies have shown that the administration of locally administered agents will improve periodontal outcomes, and consequently, will assist in moderating periodontal disease scores. 20-22

The utilization of immunomodulators such as Periostat, and/or systemic antibiotics, may also be of benefit. 23-25 In many cases periodontal surgery reduces the depths of periodontal pockets, and thereby, moderates the disease by limiting the bacterial load into the subgingival environment. Ultimately, at the endpoint of periodontal disease, extraction may be the definitive cure for periodontitis and may be the most appropriate treatment when there is no predictability for the other treatment options described above. 26-29

The treatment algorithm makes no distinction xx between the treatment proposed for the Yellow and Red Zones. The hierarchy of options available for mild, moderate and severe disease is the same. However, as the severity of the disease increases, a more aggressive treatment option may be indicated. Clinical judgment should, of course, play an important role in determining the appropriate course of action in each case (Fig. 14).

BEST PRACTICES PROTOCOL
Periodontal disease does not appear to progress in a predictably linear pattern. 30 Even within the same mouth, some sites may remain quiescent, while others demonstrate random bursts of activity. This Asynchronous Multiple Burst Model of periodontal disease progression requires the clinician to maintain a constantly vigilant watch over every patient's periodontal health, so that changes in periodontal health may be promptly elucidated. 31 When this occurs, new treatment measures must be initiated to address this newly developed scenario.

When a new patient presents to the dental office, a thorough screening of the patient's periodontal condition should be included as a part of the new patient dental evaluation process. It may be performed as a cursory screening examination, such as the Periodontal Screening and Recording Examination (PSR),32 and then followed by a full examination if the condition so warrants. Alternatively, a full periodontal charting may be provided at the outset. Both methods will properly identify if a patient has existing periodontal concerns.

Where required, appropriate periodontal care should be delivered, often beginning with conservative periodontal measures, such as scaling and root planing. It is imperative, however, that the results of such treatment be thoroughly evaluated by performing a further updated periodontal examination within a reasonable period of three to 12 months time. This reevaluation process will identify if the treatment measures performed to date have been successful in resolving the previous periodontal problems. Not doing so would permit the periodontal problem to continue its progression, to the detriment of the patient. This Post Treatment Reevaluation will provide an opportunity to detail a new, more advanced care treatment plan that may have greater potential to reduce the periodontal concerns present. It is at this time that the dentist must determine if he/she has the necessary expertise and experience to handle this more involved case, or whether a referral to a periodontal specialist is indicated.

At a point in time when proper periodontal care has been successfully completed and has reduced the periodontal concerns previously present, the patient carries forward into a treatment phase that is supportive in nature. This recare (recall) or maintenance phase of treatment also requires vigilant oversight by the dental care providers (dentist and dental hygienist). It is incumbent upon every dental practitioner to devise a recare program that responsibly monitors the dynamic nature of periodontal disease.

In order for the dentist to carry out his/her responsibility for close periodontal supervision, a protocol that carefully identifies changing periodontal conditions must be adopted. It is suggested that each dental patient have a full periodontal charting performed within a given calendar year. It may be helpful for the dental practice to adopt a policy that at the first recare appointment for a patient in the new calendar year (be it January or December), the first order of periodontal business should be to update the charting records. These probing measurements may be performed by the dentist or by the dental hygienist and then verified by the dentist.

Current periapical radiographs of each periodontal site of interest must be available and present dated within a reasonable 1-2 year time period to ensure that every area of periodontal activity is appropriately chronicled. A new full mouth radiographic series may be indicated every 3-5 years. Only through a strict protocol of regular clinical and radiographic analysis can timely new treatment decisions be made. Following a responsible treatment sequence will assure best periodontal practices. Figure 15 summarizes this Best Practices Protocol.

NEW STRATEGIES FOR PERIODONTAL MANAGEMENT
When a periodontal treatment plan is first implemented, it is fully expected that it will be successful. However, due to the complex nature of the biological processes involved, a favorable treatment outcome is not always assured (Fig. 16). When this occurs, the clinician must be ready to consider what alternative treatment strategies are most suitable to execute.

The concept of locally administered periodontal antimicrobial therapy has been identified to have significant benefit in the treatment of periodontal disease. Delivering a chemotherapeutic agent directly to a site of periodontal concern in high concentration has been shown to be highly effective in eradicating offending microbial agents. There have been a large number of agents that have been utilized in this regard. Antimicrobial agents, such as Atridox, that slowly bioabsorb within the periodontal sulcus, are the best-known agents in Canada. Many of these agents have excellent therapeutic benefit and are highly appropriate to use in recalcitrant periodontal conditions. Where a periodontal condition does not improve as well as expected, or where a case begins to show relapse, the introduction of locally administered antimicrobial agents may be an excellent additional treatment strategy to consider (Fig. 17).

Recently, a novel periodontal therapy has been introduced in Canada. Periowave utilizes a non-thermal diode laser to activate a topically applied photosensitizing solution that is administered into the periodontal sulcus. The treatment is site specific, painless, non-antibiotic, safe and effective. Periowave's primary mode of action is the disruption of the microbial cell wall. This achieves a dual action by eradicating periodontal pathogens and by inactivating endotoxins and other virulence factors such as protease, collagenase and lipopolysaccharides. Studies performed to evaluate this therapy show it achieves favorable improvements in reducing probing depths and gingival bleeding and increasing clinical attachment levels. Further evidence supporting the use of photodynamic therapy continues to emerge.

Periowave is a value-added adjunct to scaling and root planing. It has been shown to potentiate the results of scaling and root planing (Fig. 18). It takes only one minute to complete the photodynamic treatment at each involved site. It is, therefore, possible to treat multiple sites in a patient in a time efficient manner. Consequently, Periowave may offer significant advantage when utilized as part of a comprehensive program of periodontal care. It may be used as an adjunctive therapeutic measure during conservative periodontal therapy or in the recare phase, at sites that have not responded as well as expected. Figure 19 highlights the indications for utilizing Periowave in an overall periodontal care plan.

The dental practice must implement a responsible periodontal protocol that properly assesses a patient's periodontal condition at the outset of therapy. There must also be routine provision to update a patient's periodontal status on a regularly scheduled basis, so as to timely identify disease changes when they occur. When a patient shows periods of quiescent periodontal activity, there may not be a need to amend the present treatment regimen. When periodontal exacerbations occur, new strategies must be adopted to deal with the changing dynamics of the disease. Utilizing a structured treatment algorithm, as described in this article, to categorize periodontal disease into three traffic light colored stages, and to suggest a hierarchy of treatment options at each color stage, helps the dental practitioner to implement the most appropriate treatment option. Accordingly, this roadmap is proposed to facilitate periodontal decision-making and to greatly improve therapeutic outcomes.

A ROADMAP TO PERIODONTAL HEALTH
The dental practice must implement a responsible periodontal protocol that properly assesses a patient's periodontal condition at the outset of therapy. There must also be routine provision to update a patient's periodontal status on a regularly scheduled basis, so as to timely identify disease changes when they occur. When a patient shows periods of quiescent periodontal activity, there may not be a need to amend the present treatment regimen. When periodontal exacerbations occur, new strategies must be adopted to deal with the changing dynamics of the disease. Utilizing a structured treatment algorithm, as described in this article, to categorize periodontal disease into three traffic light colored stages, and to suggest a hierarchy of treatment options at each color stage, helps the dental practitioner to implement the most appropriate treatment option. Accordingly, this roadmap is proposed to facilitate periodontal decision-making and to greatly improve therapeutic outcomes.

Dr. Cary Galler graduated Dentistry from McGill University. He received a Certificate in Periodontics and a Master of Science in Dentistry from the University of Washington. He is in private practice in Toronto, Ontario as well as teaching graduate periodontal students at the University of Toronto. Dr. Galler wishes to thank Dr. Marlo Galler for her valuable assistance in preparing this manuscript.

Oral Health welcomes this original article.

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