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Discussion Topics
When determining prognosis for individual teeth, how much importance do you place upon mobility, furcation invasions, attachment level, rate of destruction, and plaque cont
What is/are the current diagnostic scheme(s) in perio? Are there any drawbacks to this (these) particular classification system? Which is used for insurance purposes?
What are the dental plaque induced gingival diseases?
What are the non plaque induced gingival diseases?
What are the two subclassifications for chronic and aggressive periodontitis and their associated extent and severity?
How is localized aggressive distinguised from generalized aggressive?
Describe the classification of periodontitis as a manifestation of systemic diseases, necrotizing periodontal diseases, abscesses of the periodontium, and periodontitis assoicated with endo lesions?
What is the classification for developmental or acquired deformities and conditions?
Armitage G, et al: Position Paper: Diagnosis of Periodontal Disease. J Periodontol, 2003; 74: 1237 – 1247
Armitage G. Periodontal diagnoses and classification of periodontal diseases. Periodontol 2000. 2004; 34:9-21
What factors are important for fabricating a periodontal diagnosis? What is the relative importance of 1. pocket depth, 2. attachment level, and 3. radiographic bone level in developing a periodontal diagnosis.
Greenstein, G. Current interpretations of periodontal probing evaluations: Diagnostic and therapeutic implications. Compend Contin Educ Dent. 2005 Jun; 26(6):381-2, 384, 387 – 390
Page R., Martic, et al: Longitudinal validation of a risk calculator for periodontal diesease. J Clin periodontol, 2003 Sep;30(9):819-27
What does probing depth actually measure? Can PD be modified by 1. inflammed tissues 2. non-inflammed tissues 3. treated periodontal disease? What factors can improve the accuracy of probing depth?
Listgarten MA, Mao R, Robinson PG. Periodontal probing and the relationship of the probe tip to the periodontal tissues. J. Periodontol. 47:511-513, 1976.
Magnusson I, Listgarten MA. Histological evaluation of probing depth following periodontal treatment. J. Clin. Periodontol. 7:26-31, 1980.
Fowler C, et al. Histologic probe position in treated and untreated human periodontal tissues. J. Clin. Periodontol. 9:373-385, 1982.
Caton J, et al. Depth of periodontal probe penetration related to clinical and histologic signs of gingival inflammation. J. Periodontol. 52:626-629, 1981.
Persson R, Svendsen J : The role of periodontal probing depth in clinical decision-making. J Clin Periodontol 17:96-101, 1990.
Armitage G., Svanberg G., Loe H. Microscopic evaluation of clinical measurement of connective tissue attachemnt levels. J Clin Periodontol 1977;4;173-190
Greenstein G. Contemporary interpretation of probing depth assessments: diagnostic and therapeutic implications. A literature review. J Periodontol 68:1194-1205; 1997.
How much pressure should be applied to a probe when measuring BOP? Is this different for measuring around implants?
Van der Velden U, de Vries J. The influence of probing force on the reproducibility of pocket depth measurements. J. Clin. Periodontol. 7:414-420, 1980.
Gerber J, Tan W, Balmer T, Salvi G, Lang N: Bleeding on probing and pocket probing depth in relation to probing pressure and mucosal health around oral implants. Clin Oral Implants Res 2009;20;75-78
How reproducible are periodontal probing measurements?
Badersten A, Nilveus R, Egelberg J. Reproducibility of probing attachment level measurements. J. Clin. Periodontol. 11:475-486, 1984.
Alves Rde V, Machion L, Andia DC, Casati MZ, Sallum AW, Sallum EA. Reproducibility of clinical attachment level and probing depth of a manual probe and a computerized electronic probe. J Int Acad Periodontol. 7(1):27-30, 2005
Isidor F., Karring T, Attstrom R. Reproducibility of pocket depth and attachemnt level measurement when using a flexible splint. J Clin Periodontl 1984;11;662-668
What is pathologic tooth migration and how does it affect prognosis? Does root proximity have any effect on prognosis?
Greenstein G et al: Differential diagnosis and management of flared maxillary anterior teeth. J Am Dent Assoc 2008; 139(6):715-723
Brunsvold, M. Pathologic tooth migration. J Periodontol 2005 Jun;76(6):859-66
Describe the McGuire classification of prognosis. What categories are considered?
McGuire MK : Prognosis versus actual outcome: A long-term survey of 100 treated periodontal patients under maintenance care. J. Periodontol. 62:51-58, 1991.
McGuire MK, Nunn ME. Prognosis versus actual outcome. II. The effectiveness of clinical parameters in developing an accurate prognosis. J Periodontol 67:658-665,1996.
McGuire MK, Nunn ME. Prognosis versus actual outcome. III. The effectiveness of clinical parameters in accurately predicting tooth survival. J Periodontol 67:666-674, 1996.
Describe the prognostic classification by Kwok and Caton.
Kwok V, Caton JG. Commentary: prognosis revisited: a system for assigning periodontal prognosis. J Periodontol. 2007 Nov;78(11):2063-71. Review.
Molar prognosis
Miller PD Jr1, McEntire ML, Marlow NM, Gellin RG. An evidenced-based scoring index to determine the periodontal prognosis on molars. J Periodontol. 2014 Feb;85(2):214-25.
What factors do we take into account for treatment planning?
Donnenfeld OW. Therapeutic end-points in periodontal therapy. Int J Perio Rest Dent 1(4):51-60, 1981.
Lindhe J, et al. "Critical probing depths" in periodontal therapy. J Clin Periodontol 9:323-336, 1982.
Wennstrom JL, Papapanou PN, Grondahl K. A model for decision making regarding periodontal treatment needs. J Clin Perio dontol 17:217-222,1990.
Splieth C, et al: Periodontal attachment level of extractions presumably performed for periodontal reasons. J Clin Perio dontol 2002; 29: 514-518.
McGuire MK, Newman MG. Evidence-based periodontal treatment. I. A strategy for clinical decisions. Int J Perio Rest Dent 1995;15:71-83
Are there any other anatomic factors that we would consider when making treatment decisions?
Kramer GM. A consideration of root proximity. Int J Perio Rest Dent 7:9-34,1987.
Lane JJ, O'Neal RB. The relationship between periodontitis and the maxillary sinus. J. Periodontol. 55:477-481, 1984.
When making treatment decisions, how aware are patients of their own condition? When patients are referred, what do they known about their potential disease? Is there anything we can do to increase this awareness?
Croxson LJ. Practical periodontics. Awareness of periodontal disease - the patient. Int Dent J. 48(Supplement 1):256-260, 1998.
Brunsvold MA, Nair P, Oates TW. Chief complaints of patients seeking treatment for periodontitis. JADA 130:359-364, 1999
ABSTRACTS
When determining prognosis for individual teeth, how much importance do you place upon mobility, furcation invasions, attachment level, rate of destruction, and plaque cont
What is/are the current diagnostic scheme(s) in perio? Are there any drawbacks to this (these) particular classification system? Which is used for insurance purposes?
What are the dental plaque induced gingival diseases?
What are the non plaque induced gingival diseases?
What are the two subclassifications for chronic and aggressive periodontitis and their associated extent and severity?
How is localized aggressive distinguised from generalized aggressive?
Describe the classification of periodontitis as a manifestation of systemic diseases, necrotizing periodontal diseases, abscesses of the periodontium, and periodontitis assoicated with endo lesions?
What is the classification for developmental or acquired deformities and conditions?
Topic: Diagnosis of periodontal disease
Authors: Armitage G, et al: NO ARTICLE
Title: Position Paper: Diagnosis of Periodontal Disease.
Source: J Periodontol, 2003; 74: 1237 – 1247
Type: Position Paper
Rating: Good
Keywords: Diagnosis, Periodontal disease
Purpose: To provide a general overview of the important issues related to the diagnosis of periodontal diseases.
Discussion: The diagnosis and classification of periodontal diseases is based almost entirely on traditional clinical assessments. Clinicians must rely on the presence/absence of signs of inflammation (i.e BOP), probing depths, extent and pattern of attachment loss and bone loss, pt’s medical and dental histories, and presence/absence of pathologies (including plaque, calculus, pain, and ulceration).
Plaque induced periodontal diseases are traditionally divided into gingivitis (inflammation without the loss of connective tissue attachment) and periodontitis (presence of gingival inflammation at sites where there has been a pathological detachment of collagen fibers from cementum and the JE has migrated apically. Inflammatory changes associated with connective tissue attachment loss lead also to bone loss).
If sites that have been successfully treated for periodontitis develop gingival inflammation at later date, do those sites have recurrent periodontitis or gingivitis superimposed on a reduced but stable periodontium? There are no currently data to definitively answer this question. However, since not all sites with gingivitis develop periodontitis, it is also feasible for gingivitis to occur on a reduced periodontium where attachment loss is not occurring. Demonstration of the progression of attachment loss at two time intervals is required to show periodontitis progression.
In 1999 the International Workshop for Classification of Periodontal Diseases and Conditions reclassified the different forms of plaque induced periodontal diseases. There are now considered to be seven forms of plaque induced periodontal diseases:
1) Gingivitis
2) Chronic periodontitis
3) Aggressive periodontitis
4) Periodontitis as a manifestation of systemic diseases
5) Necrotizing periodontal diseases
6) Abscesses of the periodontium
7) Periodontitis associated with endodontic lesions.
‘Adult’ and ‘Early-Onset’ periodontitis are no longer used. All forms discussed in the new classification can progress either rapidly or slowly, and can be non-responsive to therapy. Gingivitis can occur on a reduced but stable periodontium.
Diagnosis of periodontal diseases is determined by analyzing information gathered at the periodontal examination. While practitioners may obtain a variety of data including microbiological samples, gingival crevicular fluid samples, etc., the diagnosis of periodontal disease is based on attachment loss. Ultimately the supplemental diagnostic tests can be used to screen (separate diseased from non-diseases) and detect sites/patients undergoing further attachment loss. The clinical value of fully validated diagnostic tests is considerable in that the results of these tests are potentially useful in identifying the presence of putative pathogens, monitoring the response to therapy, identifying sites at higher risk for progression and assisting the clinician in determining a patient-specific recall interval for periodontal maintenance therapy.
Supplemental diagnostic tests fall in 4 categories. They can be used to detect the presence of,
1) substances associated with putative pathogens
2) host-derived enzymes
3) tissue breakdown products
4) Inflammatory mediators.
There is a commercially available test that can test a patient’s genetic susceptibility to periodontitis. It is a genetic test for polymorphisms in the Interleukin 1 (IL-1) gene cluster. Approximately 30% of the Caucasians are positive for a composite genotype of IL-1A and IL-1B polymorphisms. People who carry this composite genotype may be at increased risk for bop, severe chronic periodontitis, tooth loss and reduced stability of gains of CAL after guided tissue regeneration. How best to use this genetic test and host-based tests in clinical practice remains to be determined.
Probes are most routinely used to measure variables that assess attachment loss. Computer linked controlled-force probes are available. Better diagnostic imaging systems are also becoming available to the marketplace.
Topic: Periodontal diagnoses
Authors: Armitage G ARTICLE
Title: Periodontal diagnoses and classification of periodontal diseases..
Source: Periodontol 2000. 2004; 34:9-21
Type: Clinical study
Rating: Good
Keywords: Periodontal diagnoses, classification
Purpose: To discuss periodontal diagnosis and the current classification system.
Discussion: Before arriving at a periodontal diagnosis the clinician needs to answer three questions.
1. What periodontal disease or condition does the patient have?
2. How severe is the problem?
3. Is the disease or conditions localized or generalized?
The first question is the most difficult because it requires the understanding of all the information gathered during the history taking process and the clinical examination.
Pts may have more than one disease or condition simultaneously affecting the periodontium
Severity of periodontitis divided into slight=1-2mm clinical attach loss, moderate=3-4mm attach loss, and severe=>5mm attach loss.
Severity of ginigivitis of slight, moderate and severe can be used as well, but is subjective assessment of intensity of the gingival inflammation.
Localized vs. Generalized: Localized if up to 30% of teeth are affected and generalized if >30% of teeth involved (However, in his 1999 paper he describes localized vs. generalized on per site basis)
What factors are important for fabricating a periodontal diagnosis? What is the relative importance of 1. pocket depth, 2. attachment level, and 3. radiographic bone level in developing a periodontal diagnosis.
Topic: Interpretations of periodontal probing
Authors: Greenstein, G. ARTICLE
Title: Current interpretations of periodontal probing evaluations: Diagnostic and therapeutic implications.
Source: Compend Contin Educ Dent. 2005 Jun; 26(6):381-2, 384, 387 – 390
Type: Review
Rating: Good
Keywords: periodontal probing
Purpose: Discussion paper on diagnostic and therapeutic implications of periodontal probing evaluations. Discussion:
Clinical signs of periodontal health (PD <3mm, color, consistency, etc.)
Increased PD and CAL loss: PDs >1mm, >1.5mm, and >2mm are associated with CAL loss 50%, 80%, and 90% of the time, respectively
Infiltrated CT: The probe tip will stop 0.2-0.4mm within the JE in health and 0.3mm within CT in inflammation.
Accuracy of Probing: One study said that in PDs of 3mm, 4-6mm and >7mm, CAL measurements varied with respect to duplicate measurements by 0.3mm, 0.5mm and 1.3mm respectively. Another study said that the variation is 0.23-0.28mm for PDs <5mm. For PD >6mm variation is 5-6 times greater.
Increased BOP is associated with increased PD in non-treated patients. Deeper sites tend to bleed more upon provocation. BOP tendency can be modified by anti-thrombotic drugs, increasing the incidence.
Periodontal pathogens are identified in 20-30% of sites with PD >5mm and only in 5% when PD is <3mm.
Forecasting Disease Progression: Risk ratio from 5-36 months for manifesting disease progression was 3 times greater for deep vs. shallow sites. Claffey et al, reported that at sites with initial PD <3.5mm, 4.5-6.5mm and >7mm the percentage of sites deteriorated/patient was 11%, 7% and 16% respectively, over 42 months (threshold 1.5mm). Deep sites are more prone to deterioration.
Therapeutic implications:
Impact of supragingival oral hygiene: Good oral hygiene can affect the microflora composition in shallow and moderate PD. Toothbrush can penetrate only 1mm subgingivally
Impact on Non-Surgical therapy: PDs of 4-6mm and >7mm can have PD reduction (CAL gain) after SRP of 1.29mm (0.55mm) and 2.16mm (1.29mm) respectively. Pathogenic biofilms have a 2.5mm radius of influence, and can induce disease progression when they are within 2.5mm of the attachment apparatus.
Surgical vs. Non-surgical: In general most studies agree that surgical treatment can attain greater PD reductions vs. non-surgical treatment.
Recurrence of PDs: Sites of initial PD of 4-5mm, 6-7mm and >8mm were 8.3%, 22.6% and 39.1% more likely to rebound over a 3 year period.
Statistical Evaluation: Always distinguish between statistical and clinical significance. Results are often skewed. Data from partial mouth scoring must be viewed with caution.
Conclusion: It is preferable, but not always essential, to have shallow sites around teeth to attain and maintain periodontal health. Therapeutic decisions based on probing depths are influenced by the medical and dental history of the patient, practical interpretation of the literature, and clinical experience.
Topic: Risk calculator
Authors: Page R., Martic, et al ARTICLE
Title: Longitudinal validation of a risk calculator for periodontal disease.
Source: J Clin periodontol, 2003 Sep;30(9):819-27
Type: Clinical
Rating: Good
Keywords: risk factors; periodontal diagnosis; periodontal treatment; quantification of risk
Purpose: To test the accuracy and validity of risk scores calculated using the Periodontal Risk Calculator (PRC) as predictors of periodontal status relative to actual outcomes.
Method: Clinical records and radiographs of 523 subjects (male) enrolled in the VA Dental Longitudinal Study of Oral Health and Disease, covering a period of 15 years were included. Data from records and radiographs taken at the baseline examination were entered into the PRC and risk scores on a scale of 1-5 for periodontal deterioration were calculated for each subject. Risk calculations involved a multi-step process involving mathematical algorithms that use nine risk factors including: age, smoking history, diabetes, history of periodontal surgery, PD, furcation involvements, restorations or calculus below the gingival margin, radiographic bone height, vertical bone lesions. They only calculated the deepest PD on each tooth. Patients were given a risk assessment score from 1-5 with 1 meaning no risk of future of attachment loss. Methods used to determine changes in periodontal status over time were radiographic assessment of alveolar bone using digitized radiographs, PD and tooth loss. Statistical analysis was performed to determine the association between risk prediction and actual outcome.
Results: PRC separated subjects into risk groups 1-5, each of which contained more than 100 subjects except for risk group 1 which had only 2 subjects. Risk assessment calculator grouping was very effective in predicting bone loss and tooth loss. Risk scores determined by PRC were not a reliable predictor of future increase in PD. By year 3, the incidence rate of bone loss of group 5 was 3.7-fold greater than for group -2 and by year 15 the loss of periodontally affected teeth was 22.7-fold greater than for group 2. By year 15, 83.7% of subjects in risk group 5 had lost one or more periodontally affected teeth compared to 20.2% of subjects in group 2.
Conclusion: Risk calculations using the Periodontal Risk Calculator predicted future periodontal status with a high level of accuracy and validity.
What does probing depth actually measure? Can PD be modified by 1. inflamed tissues 2. non-inflamed tissues 3. treated periodontal disease? What factors can improve the accuracy of probing depth?
Topic: Periodontal probing
Author: Listgarten MA, Mao R, Robinson PG ARTICLE
Title: Periodontal probing and the relationship of the probe tip to the periodontal tissues
Source: J. Periodontol. 47:511-513, 1976.
Type: RCT
Rating: Good
Keywords: periodontal probing, reliability, reproducibility
Purpose: To determine the most common location of the periodontal probe tip during routine measurements of periodontal pocket depth
Methods:
31 teeth scheduled for extraction due to advanced periodontal disease, orthodontics, or prosthetic indications.
Periodontal pocket depth level was measured with probe on the mesial and distal surfaces from the CEJ or reference groove (if CEJ couldn’t be clearly located) to the base of the pocket. The teeth were then extracted without the use of elevators interproximally.
The probe readings were then used to mark the estimated location of the probe tip on the tooth surface using a diamond disc. The tooth was fixed in formalin solution and then sectioned.
Sections included if at least 2 of these landmarks could be identified: Apical extent of probe (reference mark), CEJ or groove in the vicinity of CEJ, most apical extension of bacterial plaque adherent to tooth surface, most coronal extent of JE, most coronal extent of CT inserted into cementum ( representing the most apical extent of epithelial attachment). Only 38 of 62 (61%) surfaces demonstrated the desired reference points.
Results:
Mean distance of 0.2 mm separated the apical extent of plaque from the most coronal extension of the junctional epithelial cell remains
Mean width of the epithelial attachment was 1.3 mm
The location of the tip of the probe was 1.6 mm apical to the coronal end of the JE and 0.3 mm within the connective tissue attachment.
On 16 surfaces, tip of probe was located within JE and 21 surfaces apical to JE (NSSD)
BL: On average the pattern suggests that the probe tip is located at the demarcation line between the JE and the CT attachment to the root, and possibly within the CT in periodontally involved teeth.
Topic: Diagnosis
Authors: Magnusson I, Listgarten MA ARTICLE
Title: Histological evaluation of probing depth following periodontal treatment
Source: J. Clin. Periodontol. 7:26-31,
Type: Clinical Study
Rating: Good
Keywords: periodontal treatment, scaling, periodontal probe, pocket depth
Purpose: To compare probing depths from clinical and histological measurements before, and following periodontal treatment.
Methods: 40 single-rooted teeth scheduled for extraction were divided into treated and non-treated groups. Non-tx group: (26 teeth) Clinical measurements included GI, PI, and attachment levels (using a thin metal strip) (2) Notches placed at the gingival margin at MB/ML and DB/DL and metal strips gently inserted until resistance was felt. Line was prepared on the strip at the level of the apical part of the notch and was measured with calipers. Teeth were extracted with forceps and prepped for histo exam. The treated group (14 teeth) underwent SRP, curettage, and CHX for 1 month. Following, the same procedure was performed as the non-tx group.
Results: SSD was found b/w the treated and non-treated in pockets > 4 mm.
Non-treated teeth (Group I): Metal strip coronal to CT 13/39 surfaces; at CT 4/39; penetrated into CT 22/39. Strip penetrated an average of 0.29 mm into the CT apical to the JE in PD > 4mm.
Treated teeth (Group II): Metal strip coronal to CT 11/20 surfaces; penetrated into CT in 9/20. Strip penetrated an average of 0.31 mm coronal to the CT (within the JE) in PD >4mm.
Pocket depths 4 mm or less showed no difference with or without treatment (within 0.01 and 0.02mm of where CT meets JE).
No correlation was found between the degree of GI and PD
BL: In pockets >4 mm, SRP may result in reduction of probing depths due to an increase in resistance to probing and not necessarily by new CT attachment. The study also found no correlation between probing through the tissues and degree of gingival inflammation. This could be due to the fact that inflammation on histological level may exist without being detected by clinical inspection. This is particularly true if gingivitis is of chronic nature where gingival fibers are fibrotic.
Topic: probing accuracy
Title: Histologic probe position in treated and untreated human periodontal tissues.
Source: J. Clin. Periodontol. 9:373-385, 1982.
Type: clinical
Rating: good
Keywords: histology, periodontal probe, periodontal pockets, probing depths
Purpose: To histologically determine the relationship of the probe tip to the periodontal tissue in untreated periodontal pockets and periodontal pockets treated with oral hygiene and root planing.
Methods:
27 single rooted teeth condemned for extraction from 16 subjects. At least 6mm probing and 6mm attachment loss.
Gingival fluid measurements were made only in the treated group to supplement the probings and evaluate the effect of treatment. Probing recorded were taken in both groups using a Michigan #1 periodontal probe, terminal diameter 0.40mm and standardized probing pressure of 0.5N. The initial probe placement dictated the orientation of the reference groove. AL, BOP, and recession were also recorded.
Subjects in the treated group were given plaque control instructions and teeth were root planed.
Subjects were seen every two weeks until healing and stabilization (10-23 weeks).
Finally, the probe was inserted in the measured length in both groups, fix on the tooth crown and the buccal portion of teeth with the adjacent soft tissues and the periodontal probe were removed in block sections.
Histometric analysis was performed and the distances from the probe tip to the gingival margin, base of JE, alveolar bone and alveolar bone crest were recorded. Connective tissue inflammatory index was also taken.
Results: All the clinical parameters were significantly changed following the treatment phase.
PD was reduced by 2.2mm (0.8mm recession and 1.4mm gain in attachment level)
BOP was absent in 14/15 of sites comparing to 2/15 before treatment, gingival fluid was reduced (from 2.6mm2 to 0.7mm2).
In the untreated sites the tip reached the base of the JE in 11/12 specimens, mean penetration 0.45mm. Probe tip was found apical to the bone crest in 7/12 specimens and the mean distance to the nearest alveolar bone was 0.52 mm with a mean inflammatory index 67%.
In the treated specimens, the probe tip was found coronal to the base of JE in 13/15 specimens, average 0.73mm from it. Mean distance from the nearest alveolar bone was 1.25mm and mean of 34% inflammatory index.
Difference in probing is 1.2mm (0.73+0.45) close to the clinical estimated attachment gain.
Limitations: Different patients for treated and untreated sites. Results for buccal surfaces may not necessarily be valid for other aspects of the teeth. There is a possibility of error in the replacement insertion.
Conclusion: Probe tip often does not reach the base of JE in treated sites. Clinical measurements of attachment levels are not reliable in determining the true histologic level of connective tissue attachment.
Topic: Periodontal probe
Author: Caton J, et al. ARTICLE
Title: Depth of periodontal probe penetration related to clinical and histologic signs of gingival inflammation.
Source: J. Periodontol. 52:626-629,1981.
Type: Histological study
Rating: Good
Keywords: Periodontal probe; gingival inflammation; histology
Purpose: to determine if the depth of periodontal probe penetration into the sulcus was related to BOP and both clinical and histologic signs of inflammation
Methods:
-60 gingival biopsies (from the base of the midfacial periodontal pocket) in 26 healthy patients requiring surgery for pocket elimination.
-Prior to surgery, the midfacial gingival surfaces were evaluated for the presence or absence of visual signs of inflammation.
-Clinical pocket was determined using an electronic pressure-sensitive probe (0.35mm). The probe tip will be aligned parallel to the long axis of the tooth. Probing was terminated once a force of .25 gm of force was used
-Pocket depth and presence or absence of bleeding was recorded within 30 seconds.
-Gingival biopsies were obtained and processed
Results:
- 45 of the original 60 biopsies were used
-Mean sulcus depth was 1.8mm with a range of 1-3mm
-Visual signs of inflammation were present in 17 specimens and BOP was seen in 24 specimens.
-In specimens with clinical signs of inflammation, there were significantly greater distances between gingival margin and apical termination of the probe tip.
-No significant differences existed in the distances between the probe tip and the apical end of the junctional epithelium.
Discussion:
-Although clinical pocket depth was greater in the specimens with clinical signs of inflammation, this is probably due to swelling of the gingival margin in a coronal direction since the distance between the apical end of JE and the probe tip was not increased.
-Whether specimens were visibly inflamed or not, the probe tip penetration remained coronal to the apical end of the JE.
-Regardless of the bleeding status, the probe tip terminated coronal to the apical end of the JE.
-The area of inflamed CT was lateral and not apical to the probe tip showing a weak correlation.
Topic: Probing depth
Authors: Persson R, Svendsen J ARTICLE
Title: The role of periodontal probing depth in clinical decision-making
Source: J Clin Periodontol 17:96-101, 1990
Type: Retrospective study
Rating: Good
Keywords: Probing depth, clinical decision making, treatment outcome
Purpose: To evaluate the role of periodontal probing depth in clinical decision-making.
Methods: Data was collected from 123 patients with moderate to advanced periodontal disease. No anterior teeth were included in this study. Each sextant was given a score recording the PD of the worst affected site or the number of sites with PD > 6mm. Score was on a scale 0-5. Initial treatment included OHI and SRP. Re-evaluation was performed after 6-12 weeks. Based on the results of the re-evaluation, surgical or non-surgical treatment was performed. Surgical therapy consisted of open-flap debridement with osseous resection to achieve positive architecture or facilitate flap placement. Non-surgical therapy consisted of repeated root planing and prophylaxis. Patients were placed on maintenance after treatment and followed up at 1 and 3 years. Formal techniques of decision analysis were used to assign utility values and decision tree created to analyze the choice between no treatment and initial therapy and surgical and non-surgical treatment. Threshold values were created for each option.
Results: Increased disease severity at the initial exam and at re-eval (increase in number of sites with PD ≥ 6mm) was associated with an increase in surgical intervention. With increasing disease severity, there was an increase in sextants showing positive changes after initial therapy. The probability of surgical therapy decreased after a positive response to initial therapy. Surgical treatment was not more effective than non-surgical in attaining a PD < 3mm, unless 5 or more sites in a sextant exhibit PD ≥ 6 mm. Neither form of treatment could consistently achieve PD < 3mm throughout a sextant. Overall positive response was higher for surgical therapy. Non-surgical therapy was associated with continued or increased impairment of the periodontal tissues.
Conclusion: PD 4-6 mm can be treated equally well by either surgical or non-surgical therapy. PD > 6 mm are best treated surgically to achieve the greatest amount of pocket reduction.
Topic: Probing accuracy
Authors: Armitage G., Svanberg G., Loe H NO ARTICLE
Title: Microscopic evaluation of clinical measurement of connective tissue attachemnt levels.
Source: J Clin Periodontol 1977;4;173-190
Type: Discussion
Rating: Good
Keywords: Probe, connective tissue attachment, microscopic
Purpose: To determine how accurately periodontal probes measure connective tissue attachment levels in beagle dogs in teeth with clinically healthy gingiva, experimental gingivitis and advanced periodontitis.
Methods: 9 beagle dogs placed into three groups on the basis of periodontal status: clinically healthy, experimental gingivitis, and periodontitis.
The periodontitis group consisted of 3 dogs with clinical signs of advanced periodontal disease (rec, pocket formation, spontaneous hemorrhage, purulent exudate, increase mob, radiographic bone loss). 3/6 dogs that had undergone the plaque control program were placed in the clinically healthy group. The remaining three dogs were put in the experimental gingivitis group. They were allowed to develop gingivitis by with- drawing all plaque control and by placing them on a soft diet/
Plaque and gingival index scores were recorded, gingival exudate measurements were made.
In the healthy and experimental gingivitis specimens, the probes were inserted with a standardized force of 25 ponds. In periodontitis specimens, the probes were inserted with a gentle, but nonstandardized force.
After insertion, 120 plastic periodontal probes (40 in each group) were held in place by fusing them to the teeth. Blocks of periodontal tissue with the probes in situ were subsequently processed and serially sectioned.
Dogs were sacrificed after probe placement for histology. Histometric measurements were made from the sections in order to compare the level of connective tissue attachment to the level of probe penetration.
10 probe specimens were randomly selected for incisors, canines, premolars, and molars from each group of dogs.
Results:
In healthy specimens the probes consistently failed to reach the apical termination of the junctional epithelium (x = -0.39 mm).
In the experimental gingivitis group most probes came closer to the apical termination of the junctional epithelium, but on the average still fell short by x = -0.10 mm.
In periodontitis specimens the probes consistently went past the most apical cells of the junctional epithelium (x = +0.24 mm).
A significant relationship between the degree of inflammation and level of probe penetration was found. No relationship was observed between histological and clinical sulcus depths.
Histologic findings:
A slight proliferation of sulcular epithelium was routinely observed in histologic sections of the clinically healthy specimens. The inflammation was usually limited to a small area near the gingival margin. There were no histological indications that the probes passed through the sulcular and/or junctional epithelium to come in direct contact with connective tissue. In all of the clinically healthy specimens there appeared to be a layer of compressed epithelial cells between the probe and connective tissue.
In the experimental gingivitis group, inflammatory cells and epithelial proliferation were usually observed along the entire distance from gingival crest to the apical termination of the junctional epithehum. No direct contact between probe and connective tissue was microscopically observed.
The histologic picture of periodontitis specimens was characterized by a heavy inflammatory infiltrate, extensive connective tissue destruction and marked epithelial proliferation. In several specimens the probes had passed through the epithelium and were in direct contact with connective tissue. In other specimens, however, no probe-connective tissue contact was observed. Probe contact with alveolar bone did not occur.
BL:
Periodontal probes do not precisely measure CT attachment levels.
Inflammation has a significant influence on the degree of probe penetration.
Histological and clinical sulcus depths differ significantly.
Topic: Periodontal diagnosis
Authors: Greensteen G. ARTICLE
Title: Contemporary interpretation of probing depth assessments: diagnostic and therapeutic implications. A literature review.
Source: J Periodontol 68:1194-1205; 1997.
Type: Literature review.
Rating: Good
Keywords: Periodontal diagnosis, treatment, progression
Purpose: A review of the diagnostic and therapeutic implications of increased PD.
Discussion:
It is necessary to distinguish between deep, healthy sulci (non inflamed sites with PD > 3) and pockets (inflamed areas with↑ PD).
A stable periodontal pocket have BOP but disease progression has halted; whereas increasing PD reflects periodontal progression.
Increased PD usually reflects CALoss.
In healthy sites, probe tip generally stops within JE but in diseased tissue, it penetrates into CT, thereby giving you a larger PD reading.
When deep and shallow PD are compared, the data indicate that deep sites are associated with increased BOP, elevated subgingival temperatures (value of this is still questionable), higher levels of pathogens, more probing errors, a greater amount of infiltrated connective tissue, reduced ability to remove subgingival deposits with root planing, and diminished effectiveness of OH to alter the subgingival microbiota.
Both PD and CAL are necessary in the monitoring of health (or disease) since they can change independent of one another.
Clinical trials demonstrate that PD is not a good predictor of future disease progression (Claffey et al. reported that only 24% of the 7mm PDs present 3 months after treatment experienced disease progression (> 1.5 mm) during the remainder of the 42-month study). However, deep sites are usually at greater risk of disease progression than shallow sites in untreated and treated patients.
Studies have also shown that the greater the initial pocket depth, the greater the chance for rebound pocketing, but plaque control is a variable in this phenomenon.
Conclusion: Evidence indicates that it is advantageous, but not always necessary, for patients to have shallow PD. With regards to surgical reduction of PD beyond that attained with non-surgical therapy, clinicians need to consider the advantages (e.g., ease of maintenance, reduced risk of disease progression) and disadvantages (e.g., root sensitivity, cosmetic defects) of treatment procedures.
How much pressure should be applied to a probe when measuring BOP? Is this different for measuring around implants?
Topic: probing force
Authors: Van der Velden U, de Vries J. ARTICLE
Title: The influence of probing force on the reproducibility of pocket depth measurements.
Source: J. Clin. Periodontol. 7:414-420, 1980.
Type: clinical study
Rating: fair
Keywords: probing depth reproducibility
Purpose: To study the reproducibility of pocket depth measurements obtained with a pressure probe employing a constant force of 0.75 N and a conventional probe without standardized force.
Methods: 7 patients were selected that had approximately 50% bone loss in some area of the mouth (radiographically). All patients received SRP and OHI. Patients were then seen by 3 examiners, and each examiner recorded interproximal (not facial or lingual) probing depths with a pressure sensitive probe and a traditional probe. They began with the pressure sensitive probe and probed the patient twice, immediately followed by the traditional perio probe (probed twice consecutively as well). Thirty minutes after the first examiner probed, the second examiner performed the same exams in the same order, followed by the third examiner 30 minutes later.
Results: The standard probe had greater probing depths than the pressure sensitive probe in all 3 examiners for the first set of measurements (mean 0.35, 0.51, 0.98mm). In looking at the 2 sets of probing depths, with the pressure probe, all measurements were similar. There were NSSD between the probes intra-examiner. NSSD between probing depth reproducibility in deep or shallow pockets (trend toward shallow pockets having more similar measurements)
Conclusion: Results in this study indicate that a standardized probing force of 0.75 N does not lead to a more reproducible pocket depth measurement.
Comment: The pressure sensitive probe most likely probed deeper the first set of measurements since they probed twice with the pressure sensitive probe before using the traditional probe.
Topic: Probing
Authors: Gerber J, Tan W, Balmer T, Salvi G, Lang N NO ARTICLE
Title: Bleeding on probing and pocket probing depth in relation to probing pressure and mucosal health around oral implants.
Source: Clin Oral Implants Res 2009;20;75-78
Type: Clinical
Rating: Good
Keywords: bleeding on probing, oral implants, peri-implant health, peri-implant mucositis, probing depth, probing force
Purpose: To assess the BOP tendency and periodontal probe penetration when applying various probing forces at oral implants in patients with a high standard of OH practices and well-maintained peri-implant tissues.
Method: 17 patients with implants from the University of Berne in Switzerland were recruited for the study. Patients had received treatment for gingivitis or periodontitis prior to implant placement and were on regular maintenance care with a registered dental hygienist. Pts should demonstrate excellent OH and no BOP.
BOP was evaluated with two different probing forces of 0.15 and 0.25 N. These forces were applied by an electronic pressure sensitive probe with a point diameter of 0.4mm. BOP and PDs were assessed in 4 sites/implant. Contralateral teeth were also assessed for BOP and PD.
The two different probing forces were applied in a 7-day interval.
Results: 32 implants were assessed and had clinically healthy peri-implant mucosal tissues with absence of PD>5mm. Control teeth also did not have PD>5mm.
Increasing the probing force from 0.15 to 0.25N resulted in an increase of 13.7% in BOP (SSD) and 0.3mm (NSSD) in PD in implant sites.
The increase in teeth was 6.6% which was NSSD and there was no difference in PD.
When applying 0.15N there was NSSD in BOP between implants and teeth.
Conclusion: The probing force of 0.15N around implants might be the threshold pressure value to be applied to avoid false positive BOP readings.
How reproducible are periodontal probing measurements?
Topic: probing authenticity
Author: Badersten A, Nilveus R, Egelberg J. ARTICLE
Title: Reproducibility of probing attachment level measurements.
Source: J. Clin. Periodontol. 11:475-486, 1984.
Type: RCT
Rating: Good
Keywords: reproducibility, probing, probing depths, diagnosis
Purpose: To investigate the reproducibility of probing attachment level measurements.
Materials and methods:
2 groups of pts with severe advanced chronic periodontitis (16 pts in one group, 13 pts in the other group). Incisors, cuspids, premolars probed in mandible and maxilla at 6 aspects of each tooth in both groups of patients.
Two trained examiners completed the probing using
A nonstandardized probing force in one group
A standardized force of 0.75 N in the other group. Soft acrylic onlays used for reference points and were compared to the use of the CEJ.
Results:
90% of probing attachment level (PAL) measurements and probing pocket depths (PPD) were reproduced within +/-1.0 mm (found both intra- and inter-examiner)
Reproducibility of probing measurements using CEJ for a reference point was less than using the edge of acrylic onlays (reflects difficulty in accurately detecting the CEJ).
Reproducibility similar between standardized and nonstandardized forces.
Reproducibility increased after nonsurgical therapy.
Reproducibility was better for incisors compared to cuspids and premolars; for buccal surfaces compared to other surfaces of the teeth; for shallow pockets compared to deeper pockets; and for maxillary teeth.
BL: Measurements using the CEJ were less reproducible than using the acrylic stents/onlays. The reproducibility of duplicate measurements was better for incisors vs. posterior teeth, buccal vs. other surfaces, shallow vs. deeper pockets, after therapy compared to before therapy, and for maxillary teeth compared to mandibular.
Topic: Diagnosis
Authors: Alves Rde V, Machion L, Andia DC, Casati MZ, Sallum AW, Sallum EA. ARTICLE
Title: Reproducibility of clinical attachment level and probing depth of a manual probe and a computerized electronic probe.
Source: J Int Acad Periodontol. 7(1):27-30, 2005
Type: Clinical Study
Rating: Good
Keywords: conventional manual probe, florida probe, electronic probe
Purpose: To evaluate the reproducibility of a conventional manual probe (MP) and an electronic probe, the Florida Probe (FP: can detect 0.2mm increments).
Methods: 20 patients with chronic periodontitis (minimum of 4 sites on anterior teeth with PD > 5mm and BOP) were assessed for pocket depth (PD) and clinical attachment level (CAL) by one examiner. Replicate measurements were taken one hour apart with each probe, on anterior teeth, at six sites per tooth. The manual probe values were approximated to the nearest 0.5mm. Pearson's correlation test and Student's paired t-test were used for the statistical analysis.
Results: The absolute mean difference in replicate measurements of PD was 0.72 +/- 0.86 for MP and 0.66 +/- 0.68 for FP. There were NSSD in PD between the replicate measurements of both FP and MP (p > 0.05), although the correlation value was higher for FP (r = 0.97, p < 0.01) than for MP (r = 0.54, p < 0.05). Considering CAL, no differences were found between replicate measurements for both FP and MP (p > 0.05) and correlation values were similar. Although the FP showed higher correlation values for PD, no significant differences were found between duplicate measurements for both probes.
BL: Both electronic and manual probing measurements seem to be reproducible when assessing periodontal disease.
Topic: probing reproducibility
Authors: Isidor F, Karring T, Attstrom R NO ARTICLE
Title: Reproducibility of pocket depth and attachment level measurement when using a flexible splint.
Source: J Clin Periodontl 1984;11;662-668
Type: clinical
Rating: good
Keywords: probing depth; attachment loss; reproducibility; flexible splint, periodontal pocket measurements.
Purpose: To study 1) The reproducibility of measurements of PD and AL when using a flexible splint to produce readily identifiable reference points and to standardize the probing spot and the direction of probe insertion. 2) The reliability of transgingival probing.
Methods:
Lateral incisors, canines, and premolars from 17 pts with advanced periodontitis. PD > 5mm.
A flexible splint was produced and used for reproducible probing spots and directions of probe insertion.
BOP was used to evaluate the state of gingival health prior to and 3 mo after perio treatment.
PD and AL measurements were performed twice with a 3-week interval at baseline and after periodontal treatment including periodontal surgery, in order to have measurements with and without inflammation. The bone level was measured twice, one time with bone sounding and then during surgery after flaps were elevated.
Results: Although before treatment splints were placed in a proper position, after treatment none of the splints fit exactly but after light pressure they could be placed properly on each tooth.
Sites without bleeding increased from 24.7% to 75% 3 months after treatment.
95% of the sites measurements differed 1mm or less and never exceeded 3mm.
NSSD were observed between the reproducibility of measurements before and after surgeries, and the depth of the pocket as well as the site of the teeth were found to have no influence.
In 60% bone sounding and measurements during surgery were identical and in 90% the difference was 1mm or less, and never more than 3mm. The measurements performed before elevation tended to be lower.
Conclusion: PD and AL were measured with a reproducibility of 1mm for approx. 95% of examined tooth surfaces.
The state of periodontal health has no influence on the reproducibility of measurements.
Transgingival measurements of bone height were slightly lower than those measured during surgery.
What is pathologic tooth migration and how does it affect prognosis? Does root proximity have any effect on
Topic: Flared maxillary teeth splinting
Author: Greenstein G., et al. ARTICLE
Title: Differential diagnosis and management of flared maxillary anterior teeth.
Source: J Am Dent Assoc 2008; 139(6):715-723
Type: Review
Reviewer: Phillip Crum
Rating: Good
Keywords: Tooth; oral pathology; occlusion; occlusal splints
Purpose: Discuss diagnosis and treatment of spreading anterior maxillary teeth
Discussion:
-The periodontium in a normal state, they boney support for a tooth is found within 0.33 to 2.36 mm of the CEJ
- Occlusal trauma (primary/secondary), and posterior bite collapse are the main causes of pathological migration of the maxillary anterior teeth. Occlusal trauma can be caused by occlusal prematurities (high restorations), extrusion of teeth, poorly fitting prostheses, parafunction, a habit (biting on a pipe) and orthodontic movement. Posterior bite collapse is often associated with overclosure, which can result in the maxillary incisors’ being forced towards the buccal.
Treatment: Identify contacts and habits. If the teeth are not in contact in centric occlusion or during functional movements then the possible reason for migration is a habit. The habit needs to be identified and eliminated, or at least help the patient to do so.
In case of excessive occlusal forces, occlusal adjustment needs to be done to eliminate any prematurities and remove any fremitus. In the case of secondary occlusal trauma, periodontal therapy needs to be initiated. Teeth might move to their natural position spontaneously (Gaumet 1999,) or with orthodontic movement. If the periodontium is reduced and mobility persists due to bone loss, splinting of the teeth is often advocated, with a temporary (<6 months), provisional (several months to years) or permanent splint (Serio 1999).
Posterior bite collapse: When there is posterior bite collapse the clinician needs to re-establish the occlusal vertical dimension, which will probably result in disclusion of the anterior teeth. The migrated teeth may retract on their own, owing to forces generated by the lips, once the displacing forces are eliminated, or by orthodontic movement. Additional scenarios of migration might be, size discrepancy between maxillary and mandibular anterior teeth, or a naturally occurring deep overbite.
Conclusion:
-A multidisciplinary approach to therapy often is needed
-Spontaneous correction of migrated teeth is possible in the early stage, however once spaces are greater than 1mm this occurrence is unpredictable.
-In general clinicians can prevent migration of teeth if he or she controls periodontal disease and establishes a stable posterior occlusion.
**Good flow charts in review to help with treatment decision making.
Types of Splints
|
Type of Splint |
Duration of Use |
Examples (Materials) |
|
Temporary |
<6 months |
Bonded composite, resin-reinforced ribbons |
|
Provisional |
Months to years |
Bonded composite, resin-reinforced ribbons |
|
Permanent |
Indefinite; is stable across the long term use |
A-Splints (wire with composite or acrylic), resin bonded bridge (that is, a Maryland bridge), conventional fixed prosthesis |
Topic: Tooth migration
Authors: Brunsvold, M ARTICLE
Title: Pathologic tooth migration
Source: J Periodontol 2005 Jun;76(6):859-66
Type: Literature review
Rating: Good
Keywords: Periodontal diseases/adverse effects; review literature; tooth migration/pathogenesis; tooth migration/prevention and control; tooth migration/therapy
Purpose: To review information on the prevalence, etiology, treatment, and prevention of pathologic tooth migration.
Conclusion: Pathologic tooth movement (PTM) is defined as a change in tooth position that occurs when there is disruption of the forces that maintain teeth in a normal relationship.
Prevalence: PTM among periodontal pts is 30.03-55.8%, with 9% of patients including tooth migration as part of their chief complaint.
Etiology: The etiology of PTM is multifactorial. Major factors that influence tooth position are inflammation and loss of periodontal tissues, occlusal factors, soft tissue pressures of the cheek, tongue and lips, oral habits.
• Periodontal and Periapical Inflammation: Periodontal inflammation often leads to pathologic tooth migration, possibly because the equilibrium of forces is disrupted. Tooth movement has been described in a direction opposite of the deepest part of the pockets. Hydrodynamic and hydrostatic forces within the blood vessels and inflamed tissues in the periodontal pocket have also been suggested in the etiology of PTM.
• Occlusal Factors can contribute to PTM include posterior bite collapse, loss of arch integrity (interproximal contacts), class II malocclusion, occlusal interferences, protrusive pattern of mastication, bruxism, and shortened dental arches. Extrusion is a common form of PTM.
• Soft Tissue Changes: Forces as light as 1g produced by facial muscles when at rest are sufficient to displace the incisors
• Habits: Lip and tongue habits, fingernail biting, thumb sucking, pipe smoking, bruxism, and playing with instruments can lead to tooth movement. Duration of force is more important than the force magnitude.
Treatment: Correction of PTM is dependent on what stage at which it is diagnosed and the extent to which it has progressed. Techniques to correct include spontaneous correction following periodontal therapy, extraction and replacement of severely migrated teeth, limited or adjunctive orthodontic therapy, or conventional orthodontic treatment. When PTM is treated in its early stages periodontal therapy alone is sometimes effective in producing spontaneous correction. This is true even for advanced cases such as drug induced gingival hyperplasia with PTM. Most cases of moderate to severe PTM require a team approach often requiring possible extractions, orthodontic, and prosthodontic treatment. Cases involving extruded teeth might require light orthodontic intrusion forces with frequent recall visits to control inflammation. Most cases of PTM could be prevented through early diagnosis of periodontal disease and contributing factors.
Describe the McGuire classification of prognosis. What categories are considered?
Topic: Prognosis
Authors: McGuire MK ARTICLE
Title: Prognosis versus actual outcome: A long-term survey of 100 treated periodontal patients under maintenance care.
Source: J. Periodontol. 62:51-58, 1991.
Type: Retrospective study
Rating: Good
Purpose: To determine if it is possible to predict the long-term prognosis of individual teeth based on common clinical criteria.
Methods: 100 patients (65F/35M) with at least 5 years of maintenance care were selected. Age at initial exam ranged from 22 to 71 years. All had been diagnosed initially as having chronic generalized moderate to severe periodontitis. Mean length of maintenance care was 7 years. All patients followed similar course of treatment and data was collected in a routine fashion. Initial exam followed by SRP and OHI. Occlusal adjustment was limited to removal of fremitus and biteguards were recommended to patients with parafunctional habits. Re-eval at 4-6 weeks. All patients received surgical therapy, generally pocket elimination with osseous resection, in some cases open flap debridement with osseous grafts was performed. Approximately 1 month after surgery, re-evaluation was performed and light scaling and patient was assigned a maintenance interval (1-3 months). During maintenance period if PDs increased, patients were treated with SRP or surgery on rare occasions.
Prognosis as good, fair, poor, questionable, hopeless was assigned after the active phase of periodontal therapy and prior to placing patient on maintenance. Prognosis was based on clinical, surgical and x-ray findings. Prognosis repeated at 5 and 8 years into maintenance. These assessments were blind to previously assigned prognoses.
Good: Adequate periodontal support and control of the etiologic factors to assure the tooth would be relatively easy to maintain, assuming proper maintenance.
Fair: Attachment loss to the point that the tooth could not be considered to have a good prognosis and/or Class I furcation involvement. The location and depth of the furcation would allow proper maintenance with good patient compliance.
Poor: Moderate attachment loss with Class I and/or Class II furcation involvement. The location and depth of the furcation would allow proper maintenance but with difficulty.
Questionable: Severe attachment loss resulting in poor crown to root ratio. Poor root form. Class II furcation involvement not easily accessible to maintenance care or Class III furcations. Mobility class 2 or greater. Significant root proximity.
Hopeless: Inadequate attachment to maintain tooth in health, comfort and function.
Teeth deemed hopeless at the initial examination and extracted during the initial active periodontal therapy were not included in the study.
Results:
2,484 teeth, 51 lost, giving 2.1% loss for population. 26.6% of questionable teeth lost.
While the average prognosis of the teeth studied at each interval remained relatively stable, the prognosis categories themselves changed frequently.
Ultimate fate of teeth labeled as hopeless varied significantly: 25% retained and subsequently labeled as fair or good.
Questionable teeth became better or were lost. They never stayed as questionable. The fair and good categories improved.
Projections were ineffective in predicting any prognosis other than good, and prognoses tended to be more accurate for single-rooted than for multi-rooted teeth.
To project prognoses, frequent periodontal maintenance and re-evaluation are essential.
BL: It is a fact the periodontal therapy is effective. Periodontally involved teeth can be retained for years in health, comfort and function. If the tooth has little periodontal involvement and is initially assigned a good prognosis, it appears that we are generally correct with our projection. When other prognosis categories are assigned, we find that often our projections are incorrect. Until we are better able to project prognosis, frequent periodontal maintenance and re-evaluation visits are essential.
Topic: Prognosis
Authors: McGuire MK, Nunn ME. ARTICLE
Title: Prognosis versus actual outcome. II. The effectiveness of clinical parameters in developing an accurate prognosis.
Source: J Periodontol 67:658-665,1996.
Type: Clinical study
Rating: Good
Purpose: To further evaluate data derived from the previous article to explore the relationship of the traditionally taught clinical factors to their prognosis assignment, and to determine which clinical parameters are the most important in developing an accurate prognosis.
Method: 100 pts from previous study and at least 5 yrs maintenance care 2-3 months interval. All pts w/ initial diagnosis of mod-severe adult periodontitis and were considered well maintained. Prognosis (Px) assigned initially, at 5 and 8 years compared by regression analysis.
Results:
Factors significantly correlated w/initial prognosis are: Hx of perio disease in a sibling, hx of parafunctional habit, percentage of overall bone loss, deepest PD, presence and severity of furcation involvement, mobility, unfavorable crown/root ratio, unfavorable root formation, malposition, fixed prosthesis abutment.
For the 5 and 8 years data, the regression model accurately predicted 81% of the actual prognosis, worse prognosis noted in 4% and better prognosis in 14%.
The model is more accurate for anterior teeth.
Overall accuracy for teeth w/less than when good prognosis was excluded was 43% at 5 yrs and 35% at 8 yrs.
Good OH increased the probability of improving prognosis, while initial teeth mobility decreased the likelihood of improving prognosis.
Smoking decreased the likelihood of improvement by 60% and doubled the likelihood of worsening in prognosis at 5 yrs.
Conclusion: Some clinical factors appear to be more accurate than others in the assignment of prognosis. Traditional prognosis assignment seems to be ineffective for teeth w/initial prognosis less than good. A more effective method based on clear and objective clinical criteria is needed.
Critique: The article downplays initial endodontic involvement as a significant factor for affecting change in prognosis. They mention it but do not emphasize the importance of utilizing initial endo involvement in classification of prognosis.
Topic: Prognosis
Authors: McGuire MK, Nunn ME. ARTICLE
Title: Prognosis versus actual outcome. III. The effectiveness of clinical parameters in accurately predicting tooth survival.
Source: J Periodontol 67:666-674, 1996.
Type: retrospective study
Rating: Good
Keywords: periodontal prognosis
Purpose: To determine the effectiveness of commonly taught clinical parameters utilized in the assignment of prognosis in accurately predicting tooth survival.
Methods: 100 treated perio patients (2,509 teeth) with at least 5-years maintenance care selected from one clinician’s appointment book over a 2-year period. Survival analysis was used to evaluate the relationship of these common clinical parameters to an actual end point, tooth loss.
Results: Average time of survival for teeth that were lost was 5.79 years (range 0.33-12.33yrs; median 6.25yrs). 5.2% tooth loss over average of 10 yrs. 63% of teeth lost had poor C:R ratio vs 17% of survivors w/ poor C:R ratio; 19% of teeth lost had poor root form vs 7% of survivors; 90% were in pts with fair-poor OH vs 80% of survivors; 62% of teeth lost were in smokers, vs 36% of survivors; 23% of lost teeth were in pts with excellent compliance vs 27% of survivors; 57% of lost teeth were in pts with parafunctional habits (44% did not wear biteguard) vs 40% of survivors (24% survivors without biteguard use). 62% of teeth lost were in smokers.
Conclusion: The effect of these clinical parameters on teeth survival is only partially reflected in the assigned prognosis initially, and some of the clinical parameters should be weighted more heavily than others when assigning prognosis. Further studies are needed to develop a more accurate method for the assignment of prognosis. This system is likely more accurate for anterior than posterior teeth.
Describe the prognostic classification by Kwok and Caton.
Topic: Prognosis
Authors: Kwok V, Caton JG. ARTICLE
Title: Commentary: prognosis revisited: a system for assigning periodontal prognosis.
Source: J Periodontol. 2007 Nov;78(11):2063-71
Type: Review
Rating: Good
Keywords: Dentistry; diagnosis; periodontics; prognosis; treatment.
Purpose: To describe a prognostication system that uses periodontal stability as the primary outcome.
Discussion: Although arbitrary studies usually were described as long term when they lasted more than 5 years. Therefore, it may be logical to define long term prognosis as 5 years or more and short term as <5 years. Prognosis can change after treatment as well as after recurrent disease activity. Therefore reprognostication occurs after each examination of the patient.
Proposed prognostication system:
1. Favorable: The periodontal status of the tooth can be stabilized with comprehensive periodontal treatment and periodontal maintenance. Future loss of the periodontal supporting tissues is unlikely if these conditions are met.
2. Questionable: The periodontal status of the tooth is influenced by local and/or systemic factors that may or may not be able to be controlled. The periodontium can be stabilized with comprehensive periodontal treatment and periodontal maintenance if these factors are controlled; otherwise, future periodontal breakdown may occur.
3. Unfavorable: The periodontal status of the tooth is influenced by local and/or systemic factors that cannot be controlled. Periodontal breakdown is likely to occur even with comprehensive periodontal treatment and maintenance.
4. Hopeless: The tooth must be extracted.
Factors that affect prognosis:
General factors: patient compliance in an effective maintenance program, smoking, diabetes and other systemic factors (Neutrophil dysfunction usually manifests with severe aggressive periodontal breakdown, and this is associated with Chediak-Higashi syndrome, chronic granulomatous disease, chronic neutropenias, leukocyte adhesion deficiency, Papillon-Lefevre syndrome, Down syndrome, immunologic dysfunctions among others).
Local factors: Deep PD (>5mm) and attachment loss, anatomic plaque-retentive factors (furcation involvement, enamel pearls, CEPs, palatogingival grooves, crowding, root-proximity, open contacts, overhangs), trauma from occlusion and parafunctional habits, and mobility.
Conclusion: The proposed prognostication system, based on stability and evidence-based modification factors, may be more predictable and facilitate communication between clinicians and patients.
Molar prognosis of Miller-McEntire
Topic: Miller-McEntire Index
Author: Miller PD Jr, McEntire ML, Marlow NM, Gellin RG. NO ARTICLE
Title: An evidenced-based scoring index to determine the periodontal prognosis on molars.
Source: J Periodontol. 2014 Feb;85(2):214-25.
Type: RCT
Rating: Good
Keywords: prognosis factors, smoking, furcations, mobility, molar type, age
Purpose: to evaluate six prognostic factors and to determine the periodontal prognosis on molar teeth.
Methods:
102 patients mean age 42 y/o
33.3% were smokers
Six prognostic factors examined: Age, # of furcations, smoking, PD, Mobility, Molar type
Results:
Smoking had the largest hazardous effect
Second was increased PD, followed by mobility and furcation involvement.
The Miller–McEntire score for all molars showed a 38% increase in risk for molar extraction with every unit increase in score
Conclusions
Smoking had the most negative impact (24,6% greater chance of losing their teeth), far exceeding the impact of PD, mobility, or furcation involvement.
Molar type had a lesser impact, and age had the least impact
What factors do we take into account for treatment planning?
Topic: Diagnosis
Authors: Donnenfeld OW. ARTICLE
Title: Therapeutic end-points in periodontal therapy.
Source: Int J Perio Rest Dent 1(4):51-60, 1981.
Type: Clinical Study
Rating: Good
Keywords: scaling, root planning, occlusion, maintenance therapy
Purpose: To discuss therapeutic end-points that can serve as guidelines for measuring levels of success in the treatment of periodontal disease.
Discussion:
Control of plaque and sulcular depth:
1. Ensure pts are skilled in plaque control procedures
2. Control, modify or eliminate all stressors that can affect pts systemic resistance
3. Establish self-cleansing sulci, after SRP
Role of occlusion:
Important to identify the signs of occlusal trauma and to make appropriate judgments for its elimination subsequent to the resolution of the inflammatory process.
Splinting due to occlusal trauma should be done when the signs of occlusal trauma becomes progressive. Occlusal trauma has the ability to alter bone levels, and in the presence of inflammation to increase bone resorption.
Overcontouring an artificial crown can cause harmful effects rather than underconturing which demonstrated no changes in the tissues. Assess the axial contours of the crowns!!!
Ideal therapeutic end-points for a successfully treated periodontal case:
1. No color changes
2. No BOP
3. PDs in the vicinity of 3 mm
4. Mobility patterns stabilized if not reduced.
Objective directed toward the pt’s priorities and ability to sustain and maintain a normal functioning dentition, thus the above ideal end-points must be compromised sometimes such as; age, systemic disease, dental needs, anatomical considerations, economics and compliance.
Guidelines for maintenance therapy:
1. Ascertain gingival status: color, BOP, oral hygiene status and perform SRP if necessary, go over OHI
2. Record PD, recession, MG defects, mobility and occlusion once a year
3. Young pts with high incidence of dental caries index, bitewings should be taken annually. Other pts FMX should be taken once a year following therapy of moderate-severe periodontitis and follow-ups 2-3 months after.
Topic: Critical probing depths
Authors: Lindhe J, ARTICLE
Title: "Critical probing depths" in periodontal therapy.
Source: J Clin Periodontol 9:323-336, 1982.
Type: clinical
Rating: good
Keywords: critical probing depth, surgical/non-surgical periodontal therapy, oral hygiene, periodontal disease.
Purpose: 1) To calculate the critical probing depth values for Surgical & non Surgical periodontal therapy, 2) to monitor, during SPT, sites that were > 4 mm after active treatment with regard to gingival inflammation and AL changes, and 3) to evaluate the effect of oral hygiene status on pocket depth & AL during SPT on pts with prophylaxis every 3 months.
Methods: 15 patients with advanced periodontal disease received a baseline examination and oral hygiene instruction. Split-mouth design involving either SRP alone or SRP + MWF. Healing phase was 0 6 months and the maintenance phase was 6 24 months. During healing, a prophy was given every 2 wks, and in the maintenance phase, a prophy was given every 3 months. Reevaluations were at 6, 12, and 24 months after active treatment. Regression analysis was performed.
Results: Treatment resulted in a loss of clinical attachment in sites with initially shallow pockets, while sites with initially deep pockets gained clinical attachment. From regression analysis, the critical probing depth for SRP alone was 2.9 mm & for Modified Widman with SRP was 4.2 mm. Surgical treatment resulted in more attachment loss in initially shallow sites as compared to non surgical treatment. In sites with initial probing depth greater than the critical probing depth, more gain in attachment occurred following Widman flap surgery than following SRP. The SRP + MWF group established more sites with PD < 4mm. However, the mode of therapy used during active tx did not significantly influence the alteration of the AL during the maintenance phase. Sites which during the Maintenance period were found to be free from supragingival plaque were associated with shallow pockets and maintained attachment levels. Sites which harbored plaque exhibited increasing probing depths & further attachment loss (only 30-50% of sites which had plaque belonged to the < 4mm category).
Conclusion: The critical probing depth for SRP alone was smaller than the value for SRP + MWF. Shallow sites responded better to SRP alone and deeper sites responded better to MWF and SRP.
Topic: Decision-making
Author: Wennstrom JL, Papapanou PN, Grondahl K. ARTICLE
Title: A model for decision making regarding periodontal treatment needs.
Source: J Clin Perio dontol 17:217-222,1990.
Type: Review
Rating: Good
Keywords: dental radiology; periodontal disease; alveolar bone height
Purpose: To present a tentative model for decision making regarding periodontal treatment needs, based on the amount of remaining periodontal bone support.
Methods:
n=194 individuals aged 25-70 years.
Full mouth series of radiographs were obtained from 2 examinations approximately 10 years apart.
Based on the calculated mean bone loss data, a rate factor was determined for each tooth site and used in the final description of the alveolar bone level for each particular tooth site at ages 30, 35, 40,…, up to 70 years.
A maintained alveolar bone height at the age of 75 years of one third of the root length was chosen as a reasonable goal in the trial model set up.
Maximal bone loss allowed at each age group was calculated.
Results:
In the initially 25 yo individuals, the mean distance between the CEJ - alveolar bone crest was 1-1.94mm.
When the mean bone loss for the 5 – year intervals was calculated and added to the mean bone level at 25 years, it was found that the total bone loss did not exceed the tolerable amount of bone loss which was considered as the maximum allowed at the age of 75, for most teeth and tooth sites (except for the distal of maxillary 2nd premolars and 2nd molars).
The lowest rate of destruction was shown in mandibular first premolars.
The calculated ABL for each tooth site describes the level at which therapeutic intervention has to be made in order to secure the maintenance of one third of the bone level at the age of 75.
In the upper arch, the highest rate of bone loss was noted between 70-75 years. A similar pattern was shown in the lower premolars, lower first molars 35-40 years and incisors and canines between 55-60 years.
The model implies that if a tooth site shows a bone level apical to that acceptable for the age of the patient, in addition to having persistent BOP and PD >6mm, further periodontal treatment is needed in order to secure the maintenance of the tooth throughout life. It can also be used to evaluate periodontal treatment needs on a population level.
Conclusion: According to this model, the goal of periodontal therapy in a certain society could be defined as the control of the development of destructive periodontal disease in order to prevent loss of function of the dentition throughout life.
Topic: Periodontal attachment level
Authors: Splieth C, et al ARTICLE
Title: Periodontal attachment level of extractions presumably performed for periodontal reasons.
Source: J Clin Periodontol 2002; 29: 514-518
Type:
Rating: Good
Keywords: Extraction, dental, periodontal attachment, reason, epidemiology, tooth loss
Purpose: To analyze the residual periodontal attachment in teeth extracted in order to determine a possible forceps level for extractions that were periodontally indicated.
Methods: 500 teeth were randomly selected for analysis. Teeth likely extracted for orthodontics and wisdom teeth were excluded for a final count of 432 teeth. Caries and state of fillings in teeth were recorded). Plaque was removed from the teeth, which were then stained with 1% Fuchsin solution to visualize the remaining periodontal ligament. Attachment values (mm2) and minimal relative proportion of residual periodontal attachment (%) were computer calculated for the whole root surface and proximal root surface.
Results: For teeth without carious defects or fillings, the mean residual attachment (50.5%) was significantly lower than for teeth with carious defects or fillings (64.7%). There was an increase in extractions in teeth with ≤70% residual attachment. Teeth with pulpal involvement showed residual periodontal attachment 77.9%.
Conclusion: The results of this study indicate that teeth are extracted too early for periodontal reasons with respect to the slow natural progression of periodontal disease. Level of attachment in “periodontal” extractions is too high and undifferentiated, which calls for improvement in the knowledge of periodontal diagnosis and treatment.
Topic: Evidence based periodontal treatment.
Authors: McGuire MK, Newman MG. ARTICLE
Title: Evidence-based periodontal treatment. I. A strategy for clinical decisions
Source: Int J Perio Rest Dent 1995;15:71-83
Type: Discussion
Rating: Good
Keywords: Evidence based approach, evidence based treatment.
Purpose: To describe evidence-based periodontal treatment
Discussion: This article is the first in a series of reports describing a new approach and strategy for evaluating information and innovations associated with periodontal treatment.
Evidenced based approach: places much more importance on the clinician’s use of quantitative, unbiased data (evidence) to support specific treatment decisions. Also, it requires that specific and explicit rules of evidence be used to help quantify the clinician’s recommendations to the patient. When scientific evidence is available, the clinician is obligated to incorporate this knowledge into patient care. This information may be used by clinicians to modify their treatment decisions based on the available evidence. The author talks about how the uncertainty of practitioners can be explained partly by the discrepancy between personal clinical experience, and the ‘excellent results’ seen in both the literature and CE course presentations. Clinically useful information comes from two sources: the pt and research.
Evidence-based Treatment: Based on current relevant literature found in a MEDLINE search which is used along with a practitioner's prior educational background, clinical limitations and pt expectations. A decision pathway is presented. Randomized clinical trials (RCT) & unbiased, controlled data collection are needed in current research protocols so that results can be analyzed, digested, and used by the practicing clinician. The importance of compliance is addressed, and compliance is paramount in the treatment sequence regardless of the type of treatment performed. The authors suggest the use of clinical algorithms, which serve as a written guide for stepwise management and a way to organize thoughts in a visible way. These algorithms are used to inform and educate pts and invite them in a shared decision about their treatment.
Conclusion: Ultimate treatment decisions should be based on a combination of clinical experience, research evidence, expert opinion, and pt expectations. Evidence-based treatment encourages clinicians not to rely totally on the clinical experience but seek the literature for pertinent information. The author suggests practicing periodontists to use research in providing optimum pt care.
Are there any other anatomic factors that we would consider when making treatment decisions?
Topic: Root proximity
Authors: Kramer GM ARTICLE
Title: A consideration of root proximity.
Source: Int J Perio Rest Dent 7:9-34,1987.
Type: Discussion article
Rating: Good
Keywords: Root proximity, anatomy
Discussion: Root positions are determined by genetic guidelines as well as environmental and iatrogenic factors. Factors such as proximal wear, tooth loss, orthodontic treatment, periodontitis, occlusal trauma and proximal caries can change the original root positions.
Papillary form is affected by the size of the alveolar bone, interproximal shape, and contact position of the crowns.
In proximal periodontal disease, papillary volume, form, and proximal bone configuration eventually become the structural battle zone where plaque bacteria and immune defenses contest for supremacy. This interplay should be visualized against the background of the proximal anatomy. This will help understand the direction, degree, and form of tissue changes in a variety of circumstances and assist in planning and carrying out prevention and /or treatment.
Three structural entities, which may be influenced by root proximity, are important in understanding the pathways of inflammation and the resultant anatomical changes that may evolve when plaque-induced periodontal disease occurs. These entities are:
1. The number of, compactness, and direction of the interdental connective tissue fibers coronal to the osseous crest.
2. The density or trabecular nature of the proximal bone.
3. The location of proximal blood vessels, especially as it relates to their emergence from the osseous crest.
Fiber defense principle” hypothesis by the author: The most reliable defense structure is the connective tissue complex. Dissolution of this collagen fiber system is essential to apical migration of epithelial attachment.
The therapist may need to increase the inter-root distance in order to correct the periodontal or carious lesions and to prevent their recurrences. This can be accomplished by (1) selective extraction of tooth or roots (2) tooth (crown/root) preparation and (3) orthodontic treatment.
Conclusion: Root proximity and its influence on the anatomy of the papilla and proximal bone become important in the diagnosis, treatment planning and treatment of periodontal disease, and execution of proximal restorative dentistry. Tight root proximity situations present double jeopardy: more difficult to treat and more vulnerable to breakdown.
Topic: Periodontitis and the maxillary sinus
Authors: Lane JJ, O'Neal RB. NO ARTICLE
Title: The relationship between periodontitis and the maxillary sinus.
Source: J. Periodontol. 55:477-481, 1984.
Type: Review
Rating: Good
Keywords: maxillary sinus
Purpose: A review describing the relationship of periodontal disease and the maxillary sinus.
Discussion:
The maxillary sinus is present in the newborn and expands as the maxilla develops until bony growth and development of dentition is completed (16-18 years old).
The marked radiographic increase in size of the sinus may appear to occur after removal of premolar or molar; however this is probably due more to the decrease in the quantity of bone following alveolar remodeling rather than an actual increase in sinus size.
Maxillary sinus is usually pyramidal in shape with the apex extending into the zygoma and the base being the nasal antral wall.
The sinus is lined with pseudostratified ciliated columnar epithelium similar to that in nasal passage, only thinner
2 case reports show there is a close relationship between molar roots and the sinus suggesting that sinusitis may develop from the extension of periodontal disease into the maxillary sinus do not establish periodontal disease as a cause of maxillary sinusitis but they do suggest, given the proximity of the sinus to the roots, that periodontal disease may be a factor in the development of sinusitis.
Conclusion: During evaluation, all patients with extensive furcation involvements, especially if the sinus is in close proximity to the teeth, should be asked about sinus problems. Although the incidence of this type of problem is probably rare, careful evaluation and proper diagnosis could avoid complications for these patients.
When making treatment decisions, how aware are patients of their own condition? When patients are referred, what do they known about their potential disease? Is there anything we can do to increase this awareness?
Topic: Patient awareness
Authors: Croxson LJ ARTICLE
Title: Practical periodontics. Awareness of periodontal disease - the patient
Source: Int Dent J. 48(Supplement 1):256-260, 1998.
Type: Clinical
Reviewer: Marlon Foote
Rating: Good
Keywords:
Purpose: To look at awareness by the public and our patients’ knowledge of periodontitis, what it means to them, how they interpret this information and whether they seek care as a result of such knowledge.
Method: In 1986, 747 responses interviewed personally and in 1997, 500 randomly selected in New Zealand for phone interview and asked 3 questions: What causes gum disease? Do your gums bleed? And if you went to a dentist tomorrow, do you think they would find something wrong with your gums?
Results: Increase in pt’s awareness that gum disease is related to no dental care, diet, infection, plaque/calculus. Females showed slightly greater awareness than males, and 25-34 years old group has the greatest awareness. But the lack of awareness of bleeding gums (20-30% will see dentist if gum bleeds; 70% would put up with it) and lack of concerns with signs of disease (10% believe dentist will find something wrong) means the public is not perceiving the problem as important, or not realizing it in their own mouths.
Conclusion: Improving the awareness of the public is difficult and even the best SRP will not succeed without a partnership between the patient and practitioner and a sharing of management of the disease process.
Topic: Patient Chief Complaints
Author: Brunsvold MA, Nair P, Oates TW. ARTICLE
Title: Chief complaints of patients seeking treatment for periodontitis.
Source: JADA 130:359-364, 1999
Type: RCT
Rating: Good
Keywords: prognosis factors, smoking, furcations, mobility, molar type, age
Purpose: To determine the most common chief complaints (CCs) of patients with periodontitis.
Methods: Dental records of 191 patients treated in the Dpt of Periodontics at the UTHSC in San Antonio were examined.
96 of the subjects were women and 95 men. Most of the patients were referred by a member of their dental health team (GPs, periodontists, Dental Hygiene Dpt). CCs were recorded and statistical analysis was performed.
Results/BL: There were 21 different CCs, the average number per patient was 1.75 and the maximum number of CCs in one patient was 5. 5 patients did not report any chief complaint and 14/21 of those complaints were considered related periodontitis symptoms.
-The most common complaint expressed was related to information given to subjects about their periodontal disease by a member of the dental health team.
-29.3% complained relating to tooth or gingival pain or to infection. These complaints are generally considered dental emergencies.
-25.6% of subjects had complaints related to esthetic aspects of their gingiva or anterior teeth.
-Complaints associated with the desire to fix or save teeth and esthetic concerns were more common among older subjects (>40 years old) comparing to younger and more common amongst women compared to men.
-Fear of losing their teeth is a strong motivating factor in seeking periodontal treatment.
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