Screenings, Indices Their influence on the treatment plan (Berne concept)

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.

Periodontal probes UNC 15 WHO probe 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 CAL REC + PPD = CAL

6 surfaces around each tooth

Periodontal charting Pocket basis Free gingival margin Cementoenamel 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 WHO probe http://www.bsperio.org.uk/members/bpe2011.pdf Current guidelines for complex treatment of patients with periodontal disease

BPE Scoring codes: per sextant 0 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 Recommended therapy 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.

Self performed oral hygiene! Atraumatic cleaning of the sulcus Modified Bass technique

Cut the edge of the pyramid!

Motivation Plaque staining

Objective: epidemiological examinatin, monitoring, studiing on effectivity of tooth brushes or pastes Oral Hygiene Indices Oral Hygiene Index (Greene and Vermilion, 1960) 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

Plaque index (Silness & Loe 1964) recording both soft debris, mineralized deposits!

Gingival indices Gingival 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 treatment I.) Initial phase therapy (cause related treatments, hygienic phase) II.) Corrective phase III.) Sipportive periodontal care

Treatment phases of comprehensive periodontal therapy 1. BPE index 2. Treatment of MH and acut lesions (e.g. abscess, NUG/NUP) Systemic / Acute 3. Full perio chart: PPD, REC, CAL, FMPS, FMBS, furcation (I-III), mob (1-3) Initial 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) Corrective Supportive

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

1. Viral infection: HHV Acute lesions 2. ANUG/ANUP

3. Periodontal abscess Acute lesions

4. Pericoronitis Acute lesions 5. Acute traumatic occlusion

Decision tree in oral diagnostics Healthy Inflammed primary / secundary / tertiary prevention Primary prevention Gingivitis 4PPD 5mm, BOP + Secundary prevention OHI Professional cleaning Periodontitis PPD 5mm, BOP + Secunder tertiary prevention Mild Initial phase therapy Severe Comprehensive periodontal 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.

Case V. BPE: 4* 4 4* 4 4 4

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

The key element RABIT: Risk-Assessment Based Individualized Treatment

Periodontal supportive care Concept of recall: Succesfull complex periodontal treatment Adequate individual motivation and oral hygiene Regular professional mechanical cleaning in every 2-6 months depending on the clinical case, risk factors, individual oral hygiene and manuality Motivation and instruation every time!

Risk analysis (Lang & Tonetti 2003)

Periodontal supportive care Risk analysis (Lang & Tonetti 2003) Low risk patient Control in every 6 months High risk patient Control in every 2-3 months

Supportive periodontal care Recall - lifelong: why and when? 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

In the daily practice (Lang, Brägger, Salvi, Tonetti 2008) Polishing, fluoride application. Booking of the following appointment 10 min Monitoring, evaluation, diagnose 10-15 min Root surface debridement (if needed) Motivation, instructions Scaling and polishing 5-7 min 30-40 min