Periodontal Diagnosis Case Classification and Potential Treatment Guide

This treatment planning guide was originally created in 1989 by Dr. Ron Van Swol to help standardize

periodontal treatment at Marquette University School of Dentistry. With the changes that have

occurred in periodontics since that time, an update has become necessary. This document has been put

together to provide non-periodontal faculty and all students of Marquette University School of

Dentistry with an overview of the philosophy of periodontal treatment at Marquette. It is not meant to

cover every possible clinical situation or replace sound clinical judgment that may require alternative

approaches for unique cases.

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PERIODONTAL DIAGNOSIS / CASECLASSIFICATION

AND POTENTIAL TREATMENT GUIDE

1989 Dr. Ronald Van SwolRevised 2002 Dr. Andrew Dentino

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American Academy of PeriodontologyDisease Classifications (Annals ’99)

I. Gingival DiseasesII. Chronic Periodontitis

A. Localized (< 30% of involved sites)B. Generalized (> 30% of involved sites)

III. Aggressive PeriodontitisA. LocalizedB. Generalized

IV. Periodontitis associated with systemic diseaseV. Necrotizing periodontal disease

A. Necrotizing ulcerative gingivitisB. Necrotizing ulcerative periodontitis

VI. Abscess of the periodontiumVII. Periodontitis associated with endodontic lesionsVIII. Developmental or acquired deformities and conditions

Chronic or Aggressive PeriodontitisA. Localized <30% sitesB. Generalized >30% sites

Severity :Slight 1-3mm CALModerate 4 -5 mm CALSevere > 5mm CALAggressive PeriodontitisPreviously classified as…

Prepubertal Periodontitis (preteens)Juvenile Periodontitis (teens)Rapidly Progressive PeriodontitisRefractory Periodontitis

ADA Case ClassificationsCase Type I: Gingivitis

Case Type II: Early Chronic Periodontitis

Case Type III: Moderate Chronic or Aggressive Periodontitis

Case Type IV: Advanced Chronic or Aggressive Periodontitis

Case Type V: Refractory Chronic or Aggressive Periodontitis

MUSoD Basic Diagnostic and Clinical Management Guidelines for Different forms of Periodontitis

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CASE TYPE I

Clinical Features:

- More generalized gingivitis

- Most sulcus depths are 1-3 mm with the possibility of an occasional 4 mm pseudopocket

- Some bleeding upon probing

- Normal mobility—less than 0.5 mm

- No furcation involvements

- No active bone loss

- No active loss of periodontal attachment

PERIODONTAL MANAGEMENT

I. Periodontal examination, charting; formulation of a diagnosis, prognosis, and treatment plan

II. Periodontal treatment

A. Systemic Phase (PRN)

B. Acute Phase (PRN)

C. Disease Control Phase

1. Oral Hygiene Instruction

2. Prophylaxis (Code D1110; AKA Scale & polish)

3. Re-evaluation in 2 weeks for oral hygiene monitoring and pocket reduction. If appropriate, case

completion. If disease is not eliminated, continue treatment; i.e., repeat A, B, and C.

D. Definitive (Periodontal Surgical Therapy)

1. Usually none

2. Elective surgery, if indicated: Free Gingival Graft, Frenectomy, crown lengthening, distal

gingivoplasty, etc.

E. Maintenance

1. Preventive Maintenance (D1110)

2. Generally every 6 months, depending on patient’s plaque control, and overall risk profile

CASE TYPE II (almost always Chronic / on rare occasions Aggressive)

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Clinical Features:

- Gingivitis with early periodontitis

- Periodontitis may be localized (< 30% of sites) or generalized ( > 30% of sites)

- Moderate pocket depths (4-5 occ. 6 mm pockets)

- Early/slight attachment loss (1 – 3 mm from CEJ to base of pocket)

- Moderate bleeding upon probing, and more generalized than Type I

- Early to very moderate bone loss (10-20%), usually localized and primarily of the horizontal type.Radiographically, one would see loss of crestal radio-density characterized on the X-ray by localized fuzzy orbroken crestal lamina dura.

- Most mobilities normal, but is possible to record some Class I’s.

- No furcation involvement or an isolated Grade I

- Gingiva may present rolled margins with enlarged papillae, this being either localized or generalized.


Periodontal examination, charting; formulation of a diagnosis, prognosis, and treatment plan

I. Periodontal treatment

A. Systemic and Acute Phases p.r.n.

B. Disease control phase

1. Oral hygiene instruction / Counseling for smoking cessation (D1320)

2. Caries Control for “NON-routine, large, or investigative lesions” - pulp test first!

3. Periodontal Scaling, Root Planing, Polish, 1 to 4 sessions depending on deposits & PD

(NO INITIAL PROPHY! – move right to D4341 by quad or half mouth)

a. Accomplished on clinic floor for chronic cases.

b. Accomplished in the Surgical Services clinic for aggressive cases.

c. Any case requiring simple extractions should also be done in Surgical Services so

that both S/RP and extractions can be rendered in one visit by quadrant or half

mouth at instructor’s discretion.

Other possible treatment procedures in this phase:

4. Exodontia done in conjunction with S/RP in Surgical Services as noted above

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5. Endodontics and/or Vitality Testing

6. Minor Orthodontics, p.r.n.

7. Localized Occlusal Adjustment, p.r.n. for periodontal reasons

8. Re-evaluation— 4 – 6 weeks after last treatment (See Comments below)

C. Definitive (Surgical Periodontal Therapy)

Possible Modalities:

1. Full-thickness, replaced gingival flap

a. AKA Modified Widman flaps, or open debridement

2. Full thickness, apically positioned mucogingival flaps with or w/o osseous

3. Gingivectomy or Gingivoplasty, Frenectomy or D-Wedge Procedure

4. Reconstructive Gingival Surgical Procedures

5. Post- operative care— BID Chlorhexidine rinsing, discretion of attending periodontist

D. Maintenance:

1. Periodontal Maintenance (D4910):

a. Maintenance category should be specified!

i. Post-treatment maintenance

ii. Trial maintenance

iii. Compromised maintenance

2. Every 3, 4, or 6 months depending on patients plaque control and overall risk profile

COMMENT: True early generalized or localized chronic periodontitis can often be managed successfully without surgery,

particularly on single rooted teeth. However, particular attention must be given to the patient’s response to treatment to

ensure that appropriate endpoints of therapy have been reached. The following questions can help guide the decision.

Is bleeding on probing reduced? (goal 0 –15%)

Have probing depths decreased to maintainable levels? (goal 1 – 4 mm)

Have clinical attachment levels improved?

CASE TYPE III (chronic or aggressive)

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Clinical Features:

- Moderate periodontitis; this of a generalized nature with the possibility of localized severe periodontitis

- Chronic cases will tend to have more local factors such as plaque, calculus and more DMF surfaces thanaggressive cases

- Pocket depths are generally 4-6+ mm

- Moderate clinical attachment loss (4 – 5 mm from CEJ to base of pocket)

- Moderate bone loss (20-40%); this primarily horizontal in nature particularly for chronic cases. There is thepossibility of localized vertical bone loss.

- Generalized bleeding upon probing

- Unsatisfactory gingival and/or osseous topography

- Slight (1) to moderate (2) tooth mobility

- Grade I and early Grade II furcation involvements


I. Periodontal examination, charting; formulation of a diagnosis, prognosis, and treatment plan.

II. Periodontal Treatment

A. Systemic and acute phases (PRN)


1. Oral Hygiene Instruction / Counseling for smoking cessation (D1320)

2. Caries Control for NON-routine, Large or investigative lesions – pulp test first!

3. Periodontal Scaling & Root Planing, w/ final polish, 1 or 4 sessions

i. Antiseptics such as 0.5% Povidone Iodine as an irrigant during ultrasonic

debridement can be useful for aggressive cases and should be scheduled in surgical

services such that debridement is done within a 48 hour time frame

ii. Systemic antibiotic coverage for aggressive cases –start just prior to debridement

Other possible treatment procedures in this phase:

4. Exodontia should be done in combination with S/RP in the Surgical Services clinic

5. Endodontics and/or Vitality Testing


7. Periodontal Splints, p.r.n.

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8. Occlusal Adjustment, p.r.n., for periodontal reasons

9. Re-evaluation: 4 to 6 weeks after last treatment



1. Full thickness, repositioned gingival flapa. (AKA Modified Widman Flap, open debridement)

2. Full thickness apically positioned mucogingival flap procedures and OsseousSurgery p.r.n.

3. Osseous Graft—usually single site

4. Reconstructive Gingival/Osseous Surgical Procedures - GTR

5. Gingivectomy or gingivoplasty or D-Wedge procedure

6. Implants (After all active perio therapy is complete!)

7. Post-operative care— BID CHX rinsing, determined by attending periodontist

D. Maintenance:1. Periodontal Maintenance (D4910) : Post Tx, Trial or Compromised

2. 3 - 4 months depending on patients level of plaque control / overall risk profilea. Every 2 months for first year in aggressive cases

3. Use of local drug delivery in isolated recurrent sites p.r.n. Arestin, PerioChip

4. If significant active disease is detected consider a new comp exam and re-enter active Tx

CASE TYPE IV

Clinical Features:

- Generalized gingivitis with severe periodontitis

- Pocket depths are 6mm+

- Attachment levels > 5 mm

- Severe bone loss (> 40%), both horizontal and vertical

- Unsatisfactory gingival and osseous topography


- Mobile teeth in the 1, 2, and 3 range

- Furcation involvements (Grades I, II, and III possible)


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A. Systemic and acute phases (PRN)



2. Periodontal Scaling, Root planing, Polish, 1 to 4 sessions done in Surgical Services

i. Antiseptics such as 0.5% Povidone Iodine as an irrigant during ultrasonic

debridement can be useful for aggressive cases and debridement should be

accomplished within a 48 hour time frame if at all possible

ii. Systemic antibiotic coverage for aggressive cases –start just prior to debridement

Other Possible treatment procedures in this phase:

3. Oral Surgery (Exodontia)

4. Caries Control for NON-routine, large or investigative lesions – pulp test first!

5. Endodontics and/or vitality testing


7. Periodontal Splints, p.r.n.

8. Occlusal Adjustment, p.r.n., for periodontal reasons

9. Re-evaluation 4 –6 weeks after last visit



1. Full thickness, repositioned gingival flapa. (AKA Modified Widman Flap, open debridement)

2. Full thickness apically positioned mucogingival flap procedures and Osseous Surgery p.r.n.

3. Osseous Graft—usually single site

4. Reconstructive Gingival/Osseous Surgical Procedures – GTR

5. Gingivectomy or gingivoplasty or D-Wedge procedure

6. Implants

7. Root Resection Procedures8. Gingivectomy, Gingivoplasty, or D-Wedge Procedures; may be accomplished in

conjunction with other Periodontal Procedures

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9. Post-operative care including temporary Chlorhexidine rinsing—determined by attendingperiodontist

D. Maintenance:

1. Periodontal Maintenance (D4910) : Post Tx, Trial or Compromised

2. Every 2 months for first year post-op then consider every 3 months


4. Tailored home care hygiene regimen, interdental cleaners, irrigation, topical OTC rinses

a. Consider Periostat BID for 3 months (discretion of clinician)

5. Could be done in Surgical Services for high risk patients (discretion of clinician)

CASE TYPE V

Clinical Features:

- Any form of periodontitis that has not responded to adequate treatment and maintenance

o AKA Downhill or extreme downhill cases

- Continued attachment loss despite therapy and compliant maintenance


- Most often associated with tobacco /smoking habit




A. Systemic and Acute phase p.r.n.



i. possible microbiological sampling

2. Periodontal Scaling, Root planing, Polish, 1 to 2 sessions to be done in Surgical Services

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3. Antiseptics such as 0.5% Povidone Iodine as an irrigant during ultrasonic debridement

accomplished within a 48 hour time frame if at all possible

4. Systemic antibiotic coverage

Other Possible treatment procedures in this phase:

As listed above if not already dealt with


Usually not repeated, but could be at discretion of periodontistConsider exodontia and Implant therapy

D. Maintenance:

1. Periodontal Maintenance (D4910) : Compromised

2. Every 2 months


4. Tailored home care hygiene regimen, interdental cleaners, irrigation, topical OTC rinses

a. Periostat BID Q three months intermittently

5. Done in Surgical Services whenever possible

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Adjunctive Periodontal Therapies and General Comments

Topical Antiseptic Rinses

Chlorhexidine Gluconate 0.12% - Most useful as a BID mouth rinse during disease

control phase to help eliminate or reduce pathogenic flora and during the immediate

post-surgical phase to prevent reinfection. Not recommended for long term use.

Listerine Antiseptic – Most useful as a BID mouth rinse during maintenance phase to

reduce plaque and gingivitis. LA may also have some benefit as a sub-gingival irrigant

in the highly motiviated periodontitis patient during maintenance phase as a part of

home care and as an in-office subgingival irrigant for patients who require SBE

prophylaxis

Systemic Antibiotics – Not generally recommended in chronic periodontitis cases with

the possible exception of the poorly controlled diabetic patient. Use of the systemic

antibiotic should be considered the standard of care in forms of aggressive or refractory

cases.

Locally placed, Controlled Release Antimicrobials

Contraindicated in aggressive or refractory periodontitis cases.

Most useful for isolated recurrent sites in the chronic periodontitis patient during

maintenance phase. Can be considered a viable treatment for isolated sites in patients

who are poor surgical candidates. Placement of these agents must be preceded by

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thorough scaling and root planing. Arestin, Atridox and PerioChip are currently used in

the MUSoD Clinic.

Host modulating agents

Periostat – 20 mg doxycycline BID for 90 days. Enzyme inhibitor with

limited/unremarkable antibacterial properties. May be useful in recurrent or refractory

periodontitis cases. Long term cost-benefit analysis of this therapy is not clear and

should be used sparingly. Cost for a 3 month regimen is ~$540.

Surgical vs. Non surgical therapy

In general, even single rooted teeth with probing depths of > 6 mm require surgical

access for proper debridement. This is particularly true in a dental school setting where

the non-surgical therapy is provided by a novice.

Multi-rooted teeth or teeth with significant root grooves or concavities often require

surgical access even in moderate probing depths (4-6 mm).

In the untreated periodontitis patient, prophylaxis should not be carried out prior to

scaling and root planing. In the treated perio patient all maintenance is D4910.

Mobile teeth should be stabilized prior to surgery for an adequate result.

Good plaque control is an important criterion for surgical treatment.

Implant therapy

Implants are a viable option for many patients and can be placed by periodontists as

well as oral surgeons. Careful treatment planning is a must in these cases.

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Maintenance therapy criteria for assessing stability

Site and Patient-level criteria that students and faculty should consider in assessing the

stability of periodontal patients at the MUSoD clinics should include the following:

a. Inflammation as measured by bleeding on probing (BOP) i. Full mouth BOP > 15%, suggests instability ii. Sites that consistently show BOP overtime may be unstable iii. Sites that consistently show no BOP are likely stable

b. Probing depth measurements (PD) i. Sites with PD increase of > 2 mm from baseline or previous visit, unstable ii. # of significant periodontal pocket depths (10 or more sites > 4mm PD, unstable) iii. 6 mm or greater PD at any site consider unstable iv. Progressive gingival recession from baseline or previous charting

c. Radiographic considerations i. Loss of crestal bone height based on vertical bite wings, unstable ii. Consistent presence of crestal lamina dura suggests stability

d. Patient-level considerations i. Poor hygiene in the presence of attachment loss PI > 30%, unstable ii. Smoking > _ Pack /day, unstable iii. Diabetic with HBA1c > 9, unstable iv. High stress events, divorce, loss of loved one, unemployment, unstable

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Periodontal Diagnosis Case Classification and Potential Treatment Guide