Perio page 4 The Treatment of Periodontal Disease and How patients are categorized-DoctorSpiller.com

Periodontal disease page 12345678

About Periodontal Disease

The information on this page assumes that you are already familiar with the cause and progress of periodontal disease.  It will be helpful to read my discussion of Periodontal disease if you have not already done so before proceeding further. Periodontal disease (gum disease) is classified according to its severity.  The diagram above gives a simplified view of the three stages of the disease

The diagram shows the soft tissue (gums–the gingiva) as gray, the bone as the spongy looking white material underneath it, and the teeth as white.  The black material (on the diagram) encrusting the teeth is calculus, a hard, flinty buildup of hardened plaque which tends to act like a splinter when it is in chronic contact with the gingiva.

When a patient receives his/her initial oral examination at a dentist’s office, it usually involves probing the depth of the pockets pictured in the diagram above.  This is done with a blunt instrument and is generally painless.  The measurement from the edge of the gums to the depth of the pocket is measured and recorded on a chart.   Each tooth is measured at six places around its circumference.  By examining the chart, the dentist and hygienist are able to categorize the patient into one of several periodontal classifications, and thus is able to determine the best course of treatment for that patient.

It is important to understand that the hygienist is the professional who will be handling most of the patient’s periodontal therapy.  The hygienist is a thoroughly trained specialist whose lifelong experience is recognizing and treating periodontal conditions.  Because of their training, and time spent with the patient, hygienists are generally better attuned to the patient’s periodontal needs than the dentist him/herself.

Note to dentists

A number of dentists have written to me asking exactly how periodontally involved patients are handled in my office.  The standard of care has changed significantly in the area of periodontal treatment, and general dentists have been assuming more responsibility for the treatment of their periodontally involved patients.   If you would like to know how I triage my periodontal patients when they present for general dental treatment, then please click here.

Prophylaxis, Debridement and Root planing:  The categorization of periodontal condition and how patients are treated.

Until recently, when a patient called his general dentist to make an appointment for an exam and cleaning, he generally got exactly what he expected regardless of the seriousness of his periodontal disease.  If the patient had serious problems with his gums, and if the hygiene team thought the disease could not be halted with a simple cleaning, that patient was referred to a periodontist (gum specialist).  Things are beginning to change now, and not every new patient who schedules a “cleaning” will actually receive an “ordinary” prophylaxis, which is the type of cleaning he may be used to.  Indeed, that patient may not receive a cleaning at all on the first visit.  Moreover, the “cleaning” may involve as many as five separate appointments, often with numerous shots of local anesthetic to make the scraping of the teeth tolerable.  Each office will have its own categorization of hygiene patient.  For ease of discussion, I have listed the five classifications I use in my own office.

1. The prophylaxis patient

A prophylaxis is the type of cleaning that everyone expects when they get to the dentist’s office.  It involves scaling calculus above the gum line followed by ordinary flossing, and pumice polishing using a rubber cup on a slow speed handpiece (drill).  Note that this procedure can be done only if the patient has little or no calculus below the gum line.  In other words, a prophylaxis is performed only on patients with little bone loss and only minor, localized pocketing.  When the dentist or hygienist probes the gums around the teeth in a “normal” patient, he finds the probe goes no deeper than two or three millimeters below the gum line.   A prophylaxis is not appropriate on patients who have periodontal problems beyond minor redness and bleeding.   A prophylaxis patient can expect a full dental exam, x-rays and his/her cleaning on the same initial visit.

2. The debridement patient

calculusbridgeSometimes, a new patient will present with so much plaque and calculus built up on their teeth that it is impossible to completely visualize the teeth, or to probe the depths of the patient’s periodontal pockets without pain and bleeding.  When this is the case, A normal prophylaxis is not possible, and a more aggressive procedure called a full mouth debridement is necessary.  It involves a rough scaling to remove the bulk of the calculus and plaque from the teeth, and as far down on the roots as the patient can tolerate without anesthesia.  This will make it possible for the patient’s gums to begin the process of healing, and just as importantly, it makes a thorough oral examination possible.  (Click on the image to enlarge and learn more about this “calculus bridge”).

calculusbridge2A debridement removes most of the calculus buildup.   It is quite labor intensive and is more expensive than a normal prophylaxis.  The full mouth debridement is accomplished on the initial office visit, and the official oral exam is deferred until a subsequent visit, after some healing has taken place.   If the patient’s periodontal condition has improved to the point where bleeding has stopped, and minor periodontal pocketing has begun to resolve, then a second cleaning visit (called a fine scale and prophylaxis) and the initial oral examination is performed.  If the patient’s periodontal condition remains grave, then the initial oral exam is performed, a treatment plan is outlined and the patient is scheduled for several  periodontal root planing visits in addition to appointments to repair or extract damaged teeth.

3. Incipient periodontitis

When a patient comes to the dental office with the beginnings of periodontal disease, he may present with pockets between the teeth, measuring 4 to 5 mm deep.  The pockets bleed when the dentist probes them. These patients have actually begun to lose the bone between their teeth.  If this is allowed to continue, the bone loss will progress over the course of several years until the bony support of the teeth has been undermined.   Patients who fit into this category are generally not given a normal prophylaxis on their initial visit.  The first visit is spent doing a thorough examination, including taking measurements of the pocket depths, getting a full series of x-rays, making a correct diagnosis and then explaining the diagnosis and proposed treatment with the patient.  This patient is generally brought back to the office for two separate “cleaning” visits.  The type of cleaning these patients receive is called a root planing(No, “planing” is not misspelled.  Planing the teeth is much like using a wood plane to plane a board.)   During this procedure, the patient is thoroughly anesthetized and then the teeth are planed using scalers and curettes.  For incipient periodontitis, half the mouth is root planed on each of two visits.  After this procedure, there is a good possibility that the pockets will shrink provided that the patient institutes good home care, cleaning carefully between the teeth.  This is most easily done with Stimudents (toothpicks) or Proxabrushes.

4. Moderate periodontal disease

Periodontal disease most frequently starts between the teeth because it is between the teeth that patients are most likely to neglect to clean.  Left alone, the bone loss continues until the pockets become deeper and deeper, eventually fanning around the tooth to effect the bone on the outside and inside of the teeth.  When pockets measure 4 to 6 mm between the teeth, then the patient fits into a more severe classification of periodontal disease.  He is said to have moderate periodontal disease.  The treatment for moderate periodontal disease is root planing, the same as is done for incipient periodontal disease.  But since there is more root exposed above bone line to plane, the patient’s mouth is done in two separate visits, one half of the mouth per visit.  Once the initial periodontal treatment has been carried out, these patients are frequently placed on a three or four month recall schedule to receive periodontal maintenance prophylaxis rather than the normal six months prophylaxis that non-periodontal patients are placed on.

5. Severe periodontal disease

Patients who have lost so much bone that they present with a generalized condition of 7 mm or greater pocketing are often treated at the general dentist’s office with four quadrants of root planing (one quadrant per visit, necessary because of the extent of exposed root that needs attention).  However, root planing alone is generally not sufficient to halt the disease, and these patients are often referred to a gum specialist (periodontist) for follow-up gum surgery.  These patients most often are seen twice a year by their periodontist alternating with twice a year visits to their general dentist for their periodontal maintenance prophylaxis treatments.

6. Periodontal maintenance patients

Once patients with periodontal disease have had their initial periodontal treatment, and if their periodontal disease has been halted, and they are able to maintain their teeth in a disease free state, they become more like a normal prophylaxis patient.  However, since they have much more exposed root surface to scale, their “prophylaxis” is more complicated than a regular prophylaxis done on a patient without periodontal disease.  These patients receive a type of cleaning called a periodontal maintenance prophylaxis ( ADA code 4910) which is somewhat more expensive than a regular prophylaxis, and is generally done three or four times a year instead of twice a year as is done for patients without periodontal disease.

Scaling, root planing and periodontal surgery==>>

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Periodontal triage for dentists

Periodontal disease page 12345678