Measurements of Periodontal Disease
Each of these aspects of the appointment should be addressed at every recall.
- Medical and Dental History Update
- Medical History
- HealthPartners Medical/Dental History screen is updated.
- Be aware of questions relevant to periodontal disease; i.e., diabetes, acquired immune deficiency syndrome (AIDS), certain medications, etc.
- Dental History
- Record date of last professional visit at the initial exam. Does the patient comply with recommended recall intervals?
- Tobacco used:
- Record in the medical history
- Type and amount of tobacco used
- Ask patient if there is a history of periodontal disease in the family.
- Assess patient's dental knowledge regarding periodontal disease.
- Oral hygiene habits: record patient's current oral hygiene habits and frequency
- Frequency of brushing and flossing
- Use of other adjuncts
- Radiographs are essential for proper periodontal diagnosis. A panographic film and bitewing radiographs do not provide the appropriate level of detail to meet this need. Posterior vertical bitewing radiographs can be used for both diagnosis of caries and monitoring the bone level.
- Periodontal Charting
- Full-Mouth Probing (FMP)
- Each adult patient receives a FMP at their initial examination. Patients of record that have not had a full mouth probing recorded in their chart or electronic dental record (EDR) should have a baseline probing completed and recorded. All pockets, regardless of depth, are charted. Pockets that bleed on probing are circled in red. Bleeding points are noted in red in EDR. At subsequent visits, only pockets >3 mm or that bleed on probing are charted.
- Walking the probe, regulated (standardized) pressure
- Working end of probe is parallel to tooth surface.
- Record the deepest measurement in each of 6 areas per tooth (3 facial, 3 lingual).
- Periodontal Screening and Recording (PSR) may be considered an adequate probing alternative for healthy individuals.
- Attachment Level: measured in millimeters, recession is the distance between the exposed cementoenamel junction (CEJ) and the (more apically placed) gingival margin. Record most advanced area on the facial and lingual of each tooth.
- Bleeding on Probing (BOP)
- Probing should be done before the prophylaxis.
- Generally is recorded directly after probing procedure, before rinsing, and before allowing patient to wipe tongue over teeth/gingival margin.
- BOP records 6 potential areas per tooth.
- Quantity of bleeding is not recorded in the BOP index, only whether blood was elicited or not elicited. A statement regarding quantity, spontaneity, general, or localized may be recorded in the progress notes.
- Plaque Control Record or Index (PCR or PCI)
- Defined: a method of quantifying the number of tooth surfaces in a patient's mouth that have plaque on them. By identifying where the plaque is found, the care provider can focus on the positive aspects of the patient's current home care (plaque removal), and offer suggestions to improve home care in other areas of high plaque. PCR records 4 surfaces per tooth: mesial, distal, buccal, and lingual (M, D, B, L).
- Mobility
- Use two, blunt-ended instruments to visually detect buccal-lingual movement accurately (not fingers).
- Check mobility of all teeth.
- Record class of mobility according to the total amount of movement:
- <1.0 mm = 1
- 1.0 mm–2.0 mm = 2
- >2.0 mm or depressable = 3
- Furcations
- Can usually be detected accurately during the FMP procedures unless the pocket is deep in the furcation area. In this case, a Michigan probe may be useful.
- Classifying:
- Class I = detectable concavity on root trunk only, slight bone loss.
- Class II = detectable roof in any furcation area on root trunk, partial bone loss between roots.
- Class III = detectable through-and-through passage of the probe, no bone within the arch of the furcation.
- Gingival Status
- Describes in general/localized detail the appearance of attached and free gingival margin.
- Categories could include:
- Color (pink, red, cyanotic)
- Shape and form of: gingival margin (rolled, knife-edged, clefts, recession, etc.)
- Consistency and tone (edematous, friable, firm, etc.)
- Bleeding, the best diagnostic sign of inflammation (generalized, localized, spontaneous)
- Texture, least reliable (stippled, loss of stippling, etc.)
- Exudate
- Diagnosis Codes
- Determine which diagnostic code best describes patient's periodontal status and record under the Perio tab in the EDR.
- Risk Assessment
- Complete the periodontal risk assessment under the Risk tab.
Periodontal Risk Assessment
In the current research, predictors for risk of developing periodontal disease have been discovered. The goal of this section is for guidance in using these factors to assess each individual patient's risk of developing periodontal disease.
The factors should be considered collectively to determine one's risk. This is not a cookbook or an absolute diagnosis of the patients' risk of future pathology, but rather a tool that helps predict the patient's periodontal future. This should be made clear to the patient when discussing the final risk assessment.
Clinical judgment, when used in concert with this tool, will dramatically increase the accuracy of the assessment.
Four Primary Risk Factors
Smoker
Positive
Current research suggests that the degree of risk of periodontal disease is dose dependent. Patients who smoke 10 cigarettes per day or more are considered heavy smokers and should be placed at the high risk level for this category. Those who smoke fewer than 10 cigarettes per day are considered light smokers and would be placed at the moderate risk level for this category.
Many of these patients may not clinically exhibit signs or symptoms of the disease due to the systemic changes that have occurred to the periodontal supportive tissues and their immune system.
This risk category specifically addresses cigarette smoking; however, pipe, cigar and smokeless forms of tobacco also increase the risk of various oral diseases.
Negative
Nonsmokers may be placed at the low risk level for this category.
Diabetic
Positive
The level of periodontal risk depends on whether the patient's diabetes is controlled or uncontrolled.
Uncontrolled
These patients may be placed at the high risk level for any infectious disease including periodontal disease.
Controlled
Because their diabetes is controlled, these patients have fewer systemic complications and therefore may be placed at the moderate risk level for this category. If the clinical signs and symptoms are not consistent with an expected controlled status, then a medical consult would be in order to verify the disease status.
Negative
These patients may be placed at the low risk level for this category.
Immunodeficient
Positive
Immunodeficient patients have a difficult time fending off bacterial diseases, and periodontal disease is no exception. Patients who are human immunodeficiency virus (HIV)(+) or receiving immunosuppressive medications are to be placed at a high risk level for this category.
Negative
These patients may be placed at the low risk level for this category.
History of Periodontal Disease
Positive
As periodontal disease is chronic, a determination of whether the disease is stabilized or active must be made.
Active
If active, continuing with this assessment is unnecessary: Follow the treatment plan for the active disease category.
Stabilized
This patient may be at risk to redevelop active periodontal disease. Most of these patients will appropriately fall into the high-risk group. However, some patients who have established a controlled state for a significantly long period of time may be better placed in the moderate group. Check to see if the lamina dura has been re-established. Clinical judgment is the final determinant.
Negative
Only those patients with no history of periodontal disease would be placed in the low risk group for this category. A negative history's predictive value is relative to age. Younger patients may be at risk without exhibited signs or symptoms of the disease.
Five Modifying Risk Factors
These factors should be used to help determine if a patient is at moderate or high risk. The patient would also have at least one of the four primary risk factors.
Family History of Periodontal Disease
Positive
This could indicate two associations:
- The patient could have inherited traits that place them at risk.
OR
- The patient may have become infected with the bacteria responsible for periodontal disease from family members.
Both of these would place the patient at the moderate risk level in most cases. However, if periodontal disease is prevalent in the patient's immediate family, it may be more appropriate to place the patient at the high-risk level for this category.
Negative
These patients may be placed at the low risk level for this category.
Ethnicity
Certain ethnic groups appear to be at higher risk for certain periodontal diseases. (i.e., Afro-American, Asian, American Indian.)
Age
The prevalence and severity of periodontal disease increases with age.
Plaque and Calculus
This category is more indicative of the patient's motivation, knowledge or compliance. The PCR (Plaque Control Record) will measure the quantity of plaque. Of greater importance is the bacterial composition of the plaque. Calculus will contribute to the chronicity of gingivitis or periodontitis.
Professional Dental Frequency
Patient who do not regularly visit the dentist have statistically more pocketing and are at a higher risk for experiencing attachment loss than patients who regularly visit the dentist.
Overall Risk Assessment
Once all nine risk factors have been examined, look at them collectively in order to give the patient an overall risk prediction of developing periodontal disease.
Low Risk
If none of the four primary risk factors is positive, the patient should be at a low risk level for developing periodontal disease.
Moderate Risk
The moderate risk level requires the most clinical judgment since the determination between moderate and low risk in the various categories is of great importance for proper risk assessment. Other considerations in determining periodontal risk include occusal trauma and medications impacting the gingival tissues (e.g., Dilantin, calcium channel blockers, and antineoplastic medications).
High Risk
The first four categories have the most influence on predicting a high risk level:
- Patient history of periodontal disease
- Smoking (10 or more cigarettes per day)
- Immunodeficiency
- Diabetes (uncontrolled)
- Systemic diseases impacting the periodontitis
If any one of these is positive, the patient may be considered at high risk for periodontal disease.
