Periodontitis – The framework of effective periodontal therapy includes a working diagnosis and classification of disease, the identification of pertinent etiologic factors, and a treatment plan that addresses each of the etiologic agents in a logical sequence. To ignore pertinent etiologic factors in the treatment plan will translate to under treatment and failure in periodontitis therapy. Treatment of etiologic factors that either do not exist, or that have been incorrectly identified, will produce overtreatment and unnecessary financial or physical hardships for the patient.
Problem-based periodontal therapy begins with an understanding of health and knowing what it means to diagnose and classify a periodontitis disease.
What Is Health? What Is a Normal Periodontium? What Is Meant by the Term “Disease”?
Health is the absence of disease or abnormality. Periodontal health then is defined by the absence of marginal periodontal inflammation, the absence of inflammation in the periodontal ligament, or evidence of periodontal deformities. Successfully treated and maintained gingivitis patients may be both free of disease and have a normal periodontium.
Periodontitis patients who have received successful periodontal and maintenance therapy (ie, patients who are apparently free of periodontal inflammation with no ongoing injury in the periodontal ligament) may, by definition, be considered healthy as well. However, these patients may not have a normal periodontium.
Disease is defined as a process that is characterized by a series of morbid pathobiologic events that produce clinical signs and symptoms in the affected host. The process occurs in response to known or unknown etiologic factors.
What Are the Fundamental periodontitis Disease Categories? Do These Periodontal Diseases Conform to the Definition of Disease?
The basic categories of periodontal diseases are:
• Gingivitis. The gingival diseases are periodontal diseases in which the process is gingival inflammation, the primary etiologic factors may be microbiologic, systemic diseases, or physical injury, and the signs and symptoms are gingival bleeding, increases in probing depths, and pain. Loss of periodontal attachment, tooth mobility and/or fremitus of teeth, and tooth migration are not ordinary features of gingivitis. As it is with all inflammatory periodontitis diseases, the pattern and severity of gingival inflammation in a given patient is affected qualitatively and quantitatively by local and/or systemic contributing factors.
• Periodontitis. The types of periodontitis are periodontal diseases in which the process is periodontal inflammation, the primary etiologic factor may be microbiologic, systemic diseases, or physical injury, and the signs and symptoms are gingival bleeding, increases in periodontal probing depths, destruction of periodontal attachment, pain, and tooth loss. Mobility and/or fremitus and migration of teeth are consequences of forces on teeth with reduced/lost periodontal attachment (see occlusal traumatism below). The pattern and severity of periodontal inflammation in a given patient is affected qualitatively and quantitatively by local and systemic contributing factors.
• Occlusal traumatism. Occlusal traumatism is a condition of periodontitis or is a periodontal disease in which the process is inflammation within the periodontal ligament and the alveolar bone (the lesion of trauma from occlusion), the primary etiologic factor is force acting on teeth, and the signs and symptoms are pain, tooth mobility and/or fremitus, and pathologic migration of teeth. The pattern and severity of the lesion of trauma from occlusion in a given patient is affected quantitatively and qualitatively by local and systemic contributing factors.
Each one of these categories of periodontitis conforms to the definition of disease. In each disease, there is a process, there is a series of morbid pathobiologic events that are outcomes of the process, and there is a related set of clinical signs and symptoms.
What Is Meant by the Expressions “Diagnosis” and “Classification”?
Diagnosis is the art of identifying the disease process. It is the product of a careful evaluation of the patients history, the array of symptoms presented by the patient, and the clinical signs revealed during a clinical examination. For instance, the diagnosis of periodontitis is ordinarily achieved by detecting gingival bleeding with a periodontal probe, destruction of periodontal attachment using radiographs and/or a probe, mobility and/or fremitus digitally, determining any pathologic migration and/or loss of teeth. Figure 1 represents histologically the process of marginal periodontal inflammation and the morbid outcomes (ie, loss of both alveolar bone and periodontal attachment) of periodontitis.
PROBLEM-BASED PERIODONTAL DIAGNOSIS AND DISEASE MANAGEMENT
Classification is the art of categorizing individual clinical cases of periodontitis disease according to treatment requirements. Classification systems are frequently used by third party providers to help understand treatment needs. For over 20 years, dentists have been using a classification system developed by the American Academy of Periodontology (AAP) to facilitate dialogue among dentists and between third party individuals concerning the severity of periodontal diseases, and by direct extension, treatment needs. This classification system consisted of:
• Type I. Gingivitis where gingival inflammation was present without radiographic evidence of interproximal bone loss.
Type III. Moderate periodontitis where gingival inflammation was superimposed over clinical evidence of moderate bone loss with early turcation invasions and possible tooth mobility.
• Type IV. Advanced periodontitis where gingival inflammation was superimposed over severe bone loss with extensive furcation invasions and tooth mobility. Cases of this type could display tooth loss due to periodontitis, pathologic migration of teeth, posterior bite collapse, and/or loss of occluding vertical dimension.
• Type II. Early periodonfitis where gingival inflammation was superimposed over clinical evidence of mild bone loss without furcation invasions.
While the terms that defined each type were intentionally vague, the system did provide the framework for dialogue among therapists, allied personnel, and third party payers over treatment needs for each case. For instance, a treatment plan for a Type Ill moderate periodontitis case displaying the osseous defects and furcation invasions shown in Figure 6 would be expected to include resective and/or regenerative surgical therapy. The treatment plan for a Type II early periodontitis case, such as that shown in l9gure 7, would probably not include resective or regenerative therapy
As the knowledge base about the patterns of periodontal diseases improved, this system of classification became inadequate. Models of periodontitis had emerged sugg sting that not all cases of periodontitis behaved the sane clinically, that small (<1 mm) changes in attachment iewe’ were difficult to detect clinically, and that there was &,idence that all cases of periodontitis did not respond the sarne to therapy.
An attempt to overcome many of these shortcomings occueried during the 1999 International Workshop for a classification of Periodontal Diseases and Conditions. Here, scientist and clinicians agreed upon a reclassification system to improve the understanding of periodontal diseases among scientists, clinicians, and allied dental healthcare agencies. Each new or revised category of disease was based, in part, upon its etiology and the particular healthcare requirements to control etiology.
The new system includes eight major categories of periodontitis diseases or conditions, and each of the categories is subdivided into specific etiology-based diseases or conditions. This new Classification System for Periodontal Diseases and Conditions was adopted by the AAP in 2000. To facilitate its use in every-day periodontics, the new system would be modified over time.
How Are Scientifically-Based Decisions Made in Successful Periodontics? What Is Meant by the Expression “Art of Decision-Making in Periodontal Therapy”?
Successful periodontal therapy is based upon scientifically- based decisions involving: the periodontitis disease process, the identification of all etiologic factors, a correct diagnosis, controlling the etiologic factors, and correcting deformities produced by disease.
The art of decision-making in periodontal therapy involves the synthesis of:
1. Clinical experience of the therapist
2. Technical ability of the therapist
4. Experiences of others (type III information) as reported and presented at professional forums
5. Evidence-based thinking
While the traditional components of a decision process remain important ingredients (ie, a clinician will not ordinarily make a treatment decision that will involve a technique that is beyond the scope of his/her abilities), the fact remains that the knowledge base in all aspects of periodontitis is rapidly expanding. It is incumbent that clinicians keep current with new science and technology, evaluate reports in the literature critically, and utilize new information in their practices when appropriate.
What Is Meant by the Expressions “Evidence- Based Thinking”, “Equivalence Testing”, and “Superiority Testing”?
Evidence-based thinking occurs when the therapist logically and systematically utilizes scientifically-based clinical evidence in the process of making decisions about periodontitis diagnosis, prognosis, and treatment.
Equivalence testing in clinical trials may show that a method is at least as effective as a commonly employed gold standard. Superiority testing may show that a given method will produce outcomes that will be more beneficial than another to a patient.
If there is evidence that a technique or concept of periodontitis therapy is predictably equivalent or superior in a given clinical scenario, then, within the scope of experience and ability, it should be considered as a treatment option. In doing so, the number of options available to the patient are increased, and the potential for placebo effects, personal biases, or clinical experiences of the therapist that have no controls are kept to a minimum.
The fallout of evidence-based thinking in clinical periodontitis will inevitably be an increased number of treatment options, increased patient confidence, practice growth, and improved therapeutic outcomes.
What Are the Parameters of Care?
The AAP took a leadership role in developing diagnostic and therapeutic guidelines for what might be considered the standard of care for periodontal patients. The resulting Parameters of Care describe the scope of possible active treatment plans for the following clinical situations:
• Plaque-associated gingivitis
• Chronic periodontitis with slight to moderate loss of periodontal support
• Chronic periodontitis with advanced loss of periodontal support
• Refractory periodontitis
• Mucogingival conditions
• Acute periodontal diseases
• Aggressive periodontitis
• Placement and management of the dental implant
• Occlusal traumatism in patients with chronic periodontitis
• Periodontitis associated with systemic conditions
• Systemic conditions affected by periodontal diseases
• Periodontal maintenance
The emphasis of the current parameters is treatment of periodontitis and what therapeutic entities might be appropriate for given periodontal conditions. Each parameter is inclusive so as to give the reader (clinician, patient, third party healthcare provider, etc) an appreciation of the scope of acceptable care in each category of periodontitis. The parameters do not prescribe the care that every periodontal patient in a given category should receive. The final decision over what will constitute a treatment plan in a given case remains, as it should be, in the hands of the clinician and the patient.