Screenings, Indices

Their influence on the treatment plan (Berne concept)

1.

2.

3.

4.

Garguilo AW, Wentz FM, Orban B.

Dimensions and relations of thedentogingival junction in humans.

J Periodontol 1961; 32:261-267.

UNC 15 – WHO probe

Periodontal probes

Nabers probe

Periodontal charting

• Probing pocket depth - PPD

• Gingival recession - GR

• Clinical attachement level/loss– CAL

• Furcation involvement- F

• Tooth mobility - MOB

• Bleeding on probing – BOP/FMBS

• Plaque index- FMPS

REC

PPD

REC + PPD = CAL

CAL

6 surfaces around each

tooth

Periodontal charting

Pocket basis

Free gingival

margin

Cemento-

enamel junction

(crown margin)

PPD

4 mm

REC

4 mm

CAL

8 mm

Technique of periodontal probing

Which Factors influencing the probing ?

The force of the probing

The direction of the

probing

Calculus, plaque retentive

factors

Periodontal indexes

• BPE

(Basic Periodontal Examination) (BSP)

• CPITN

(Community Periodontal Index of Treatment Needs) (Ainamo et al. 1982)

• PSR

(Periodontal Screening and Registration) (AAP)

• Scoring codes: 0-4

Current guidelines for complex treatment of patients with periodontal disease

WHO probe

http://www.bsperio.org.uk/members/BPE2011.pdf

Scoring codes: per sextant0 No pockets >3.5 mm, no calculus/overhangs, no

bleeding after probing 1 No pockets >3.5 mm, no calculus/overhangs, but

bleeding after probing 2 No pockets >3.5 mm, but supra- or subgingival

calculus/overhangs 3 Probing depth 3.5-5.5 mm 4 Probing depth >5.5 mm * Furcation involvement

BPE

0 No need for periodontal treatment 1 Oral hygiene instruction (OHI) 2 OHI, removal of plaque retentive factors, including all supra- and subgingival calculus 3 OHI, root surface debridement (RSD) 4 OHI, RSD. Assess the need for more complex treatment; referral to a specialist may

be indicated. * OHI, RSD. Assess the need for more complex treatment; referral to a specialist may

be indicated.

Recommended therapy

Self performed oral hygiene!

Atraumatic cleaning of the

sulcus

Modified Bass technique

Cut the edge

of the pyramid!

Motivation

Plaque staining

Debris index (Green & Vermillion 1964)0 = No plaque

1 = Plaque covering 1/3 tooth

2 = Plaque covering 2/3 tooth

3 = Plaque totally covering tooth

Simplified Oral Hygiene Index | OHI-S

Objective: epidemiological examinatin,

monitoring, studiing on effectivity of tooth

brushes or pastes

Oral Hygiene IndicesOral Hygiene Index (Greene and Vermilion,

1960)

Plaque index (Silness & Loe 1964) – recording both

soft debris, mineralized deposits

!

Gingival indicesGingival Index (GI) Löe-Silness

Papillary Bleeding Index (PBI)

Gingival Bleeding Index

Modified gingival index (Loe 1967)

0 = Healthy gingivae

1 = Gingivae look inflamed, but don’t bleed when probed

2 = Gingivae look inflamed and bleed when probed

3 = Ulceration and spontaneous bleeding

Furcation involvement

Grade I-III.cal

Plaque index (PI) and bleeding on probing (BOP)

at the level of the gingival margin

0 - plus

1 – minus (negative)

II. Clinical part

„Berne concept”

Claus P. Lang

Phases of periodontal treatmentI.) Initial phase therapy (cause related treatments, hygienic phase)

II.) Corrective phase

III.) Sipportive periodontal care

Treatment phases

1. BPE index

2. Treatment of MH and acut lesions (e.g. abscess, NUG/NUP)

3. Full perio chart: PPD, REC, CAL, FMPS, FMBS, furcation (I-III), mob (1-3)

4. Tooth by tooth prognosis (secure, doubtful, hopeless)

5. Case presentation, consequences of no treatment

6. Oral hygiene instructions, smoking cessation counseling

7. Root surface debridement, elimination of plaque retentive factors, temporary

splinting, fluoride application, monitoring/improving OH

8. Re-assessment at 6-8 weeks (full perio chart), Corrective Tx plan

9. Periodontal surgeries (PPD≥5mm)

10. Re-assessment (perio chart PPD should be ≤4mm)

11. Definitive prosthetic, implant, ortho Tx

12. Periodontal supportive care (risk analysis)

of comprehensive periodontal therapy

Supportive

Initial

Corrective

Systemic / Acute

Diagnostics – step by step

1. Complains of the patient: discoloration (redness), gingival bleeding, gingiva

recession – tooth sensitivity, foetor ex orem, pain, tooth mobility, swelling…

a) ACUTE LESIONS!

2. General health – anamnesis – medical / social / familial history

3. Dental anamnesis/history

4. Clinical investigation: extra- intraoral

a) Inspection (tumor, dolor, calor, rubor, functio laesa)

b) Palpation

c) Percussion

d) Pulp sensitivity test – endo status

e) Mobility test

f) Occlusion - premature contact, overerupted teeth, deep traumatic overbite etc.

g) Radiological examinations: PX, long cone technique

h) Microbiological and haematological tests

Classification system: AAP 1999

Acute lesions1. Viral infection: HHV

2. ANUG/ANUP

Acute lesions3. Periodontal abscess

Acute lesions4. Pericoronitis

5. Acute traumatic occlusion

Decision tree in oral diagnostics

Inflammed – primary / secundary / tertiary preventionHealthy

Primary prevention

Gingivitis

4PPD≤5mm, BOP +Secundary prevention

OHI

Professional cleaning

PeriodontitisPPD≥5mm, BOP +

Secunder – tertiary prevention

SevereComprehensive periodontal

therapy

MildInitial phase therapy

„cut the edge of the pyramid”

Case I.

Periodontal status (parallel technique – no distortions)

After the initial phase therapy

Case II.

Case III.

Case VI.

4* 4 4*

4 4 4

BPE:

Case V.

Ramon Y, et al. Gingival hyperplasia caused by nifedipine – a preliminary report.Int J of Card. 1984; 5:195-204

Ellis JS et al. Prevalence of gingival overgrowth induced by calcium channel blockers: a community-based study. J Periodont 1999; 70:63-67

RABIT: Risk-Assessment Based Individualized Treatment

The key element

Periodontal supportive care

Succesfull complex periodontal treatment

Adequate individual motivation and oral hygiene

Regular professional mechanical cleaning in every 2-6 monthsdepending on the clinical case, risk factors, individual oralhygiene and manuality

Motivation and instruation every time!

Concept of recall:

Risk analysis (Lang & Tonetti 2003)

Periodontal supportive care

Risk analysis (Lang & Tonetti 2003)

Low risk patientControl in every 6 months

High risk patientControl in every 2-3 months

Supportive periodontal care

• Successful comprehensive periodontal therapy

• Adequate self oral hygiene and motivation

• 2-6-12 months intervals – professional dental care

• In every session: monitoring (at least PPD and PI) and feedback

Recall - lifelong: why and when?

In the daily practice

(Lang, Brägger, Salvi, Tonetti 2008)

Monitoring, evaluation,

diagnose 10-15 min

Motivation, instructions 5-7 min

Scaling and polishing 30-40 min

Root surface

debridement (if needed)

Polishing, fluoride application.

Booking of the following

appointment 10 min