A Patient-Centered Approach to Periodontal Disease Detection


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A Patient-Centered Approach to Periodontal Disease Detection

  1. 1. A Patient-Centered Approach to Periodontal Disease Detection Bernard Loewenthal, DDS, BSSince periodontal diseases are now considered risk factors Meanwhile, periodontal diseases remain a concern infor a number of medical problems and continue to be an the dental community. They remain an important cause ofimportant cause of tooth loss in adults, the role of the hygien- halitosis and tooth loss in adults. This frequently results inist in the medical and dental communities has never been impaired chewing and speaking, an unpleasant smile, andmore important. This article discusses the rationale of peri- occlusal problems. Successful cosmetic dentistry cannot beodontal screening systems. Considerations for integrating an achieved without a healthy periodontium. No restoration,organized program for detecting and treating periodontal regardless of its aesthetics, can appear natural while sur-diseases in a practice are also discussed, including factors rounded by diseased gingiva. These problems, singly or inthat influence periodontal probing accuracy and the value combination, contribute to reduced self-esteem and totalof controlled-force electronic probes. A green/red, color- health. The early detection and treatment of periodontalcoded screening system is introduced and compared to diseases, with the aid of a clinician- and patient-friendlyPeriodontal Screening and Recording (PSR).* The compari- screening system, clearly remain opportunities to provideson includes information about the features of each sys- an important service to patients. As the population ages andtem’s probes, criteria for recording clinical findings, and the lifespans increase, we can expect even higher incidence ratesadvantages and disadvantages of each system. It is empha- of periodontal diseases.6-7 The early diagnosis and treatmentsized that a screening system is not a substitute for a com- of periodontal diseases, as with all diseases, would makeplete periodontal examination and charting, which should treatment less complex, less costly, and more predictable,be performed periodically. thereby greatly reducing its impact on the population.IntroductionThe dental hygienist has a vital role in prevention, detec-tion, and treatment of periodontal diseases. This role hasnever been more important than it is now, due to current 10research and findings, which indicate that periodontal dis-eases are a risk factor for heart disease, stroke, preterm low 7 5birthweight babies, and the regulation of blood glucose 3levels in diabetics.1-5 Because of these risk factors, screen-ing for periodontal diseases has begun to assume the sameimportance in the medical community as screening forhypertension and elevated blood cholesterol. 12 9Dr. Bernard Loewenthal is a board-certified periodontist, a 6former instructor at Tufts University School of Dental Medicine, 3and lecturer at The Institute for Advanced Dental Studies.He is the inventor of the PerioWise Probe and ScreeningSystem. Dr. Loewenthal can be contacted through his websitewww.periowise.com or at: 51 Stratham Heights Rd, Stratham, NH Figure 1. The color-coded probe is available in two03885-2547. Tel: 603-778-1234, Fax: 603-778-6422. calibrations. May/June 1999 39
  2. 2. Periodontal Disease Detection The purpose of this article is to present the rationale Periodontal Screening Record PATIENT _____________________ and technique of a relatively new, color-coded periodon- Mark the sextant(s) that have Gingivitis. tal screening system. This system is designed to be accu- Date _________ Date _________ rate and reliable, yet very simple. Its simplicity is a virtue I HEALTH I HEALTH I GINGIVITIS I GINGIVITIS in that it creates a common language with the patient, that I PERIODONTITIS R (1-5) (6-11) (12-16) L I PERIODONTITIS R (1-5) (6-11) (12-16) L of color. The color-coding enhances patient education, (Complete examination and recording recommended) (32-28) (27-22) (21-17) (Complete examination and recording recommended) (32-28) (27-22) (21-17) which in turn helps improve patient acceptance of treat- REMARKS REMARKS ment and compliance. Date _________ Date _________ I HEALTH I HEALTH Instituting a System I GINGIVITIS (1-5) (6-11) (12-16) I GINGIVITIS (1-5) (6-11) (12-16) I PERIODONTITIS R L I PERIODONTITIS R L Responsible patient care requires that all dental practices (Complete examination and (32-28) (27-22) (21-17) (Complete examination and (32-28) (27-22) (21-17) recording recommended) recording recommended) establish a periodontal screening system that facilitates early REMARKS REMARKS detection of periodontal diseases simply and effectively. If a concise and practical system is lacking, the result could Figure 2. The Screening Record (81⁄2" 11") can provide be delayed or inadequate periodontal care or even worse, periodontal screening history for 10 visits at a glance. the failure to diagnose periodontal diseases. The issue sur- rounding clinicians’ “failure to diagnose” was addressed insertion force, shape and size of the probe tip, angula- by The American Academy of Periodontology by releasing tion of the probe, variations in the inflammatory state of the the following statements on periodontal disease detection 8: gingiva, and errors of visual assessment. Ninety percent of the time, interexaminer variability has been shown to be To the profession: “All patients must be screened for the pres- ±1 mm.9 Probes penetrate deeper when higher insertion ence of periodontal diseases on a regular basis. When peri- forces are used.10 Smaller diameter probe tips penetrate odontal diseases are detected, a comprehensive charting more deeply than probes with larger diameter tips.11 It was record must be completed and effective treatment should found that a 0.6-mm tip is optimal, though most manu- be rendered promptly.” facturers provide tips of 0.5 mm or smaller. When compared To the consumer: “The American Academy of Periodontology to controlled-force electronic probes, conventional hand- recommends that all patients be screened for periodontal held probes tend to register deeper readings.12 The virtue diseases on a regular basis” and “Patients should be informed of controlled-force probes, some of which are electronic of the state of their periodontal health at every examination.” and record on a computer (eg, The Florida Probe, Gainesville, FL), is that they provide constant force, which Rationale minimizes one of the greatest variables in probing. However, The primary purpose of a periodontal screening system is there is reduced tactile sensitivity with controlled-force to identify those individuals who have a periodontal dis- probes that can be problematic in untreated periodontitis ease. A screening system should be accurate, effective, effi- patients. The presence of subgingival calculus can inter- cient, simple-to-use, and easy to understand. It should also fere significantly with probe insertion. Conventional probes provide sufficient documentation to enhance risk manage- allow the operator to navigate the tip of the probe past inter- ment, with minimal writing required, and an educational fering calculus. Some clinicians doubt that controlled-force component. It should enable the patients to immediately probes offer any advantage over handheld probes in rou- find out their periodontal status, as recommended by the tine clinical practice. Studies show little difference in repro- American Academy of Periodontology (AAP). It is the author’s ducibility of data between conventional and controlled-force observation that many dental practices do not routinely probes; therefore, there is little reason to use an electronic use a well-documented periodontal screening system, per- probe instead of a manual one in clinical practice.13 Modern haps because of complexity or confusion. technology provides us with the means to test gingival crevic- Dental professionals utilize a periodontal probe as the ular fluid for enzymes and antibodies indicative of peri- primary tool for making objective clinical measures of the odontal diseases. Microbiologic culturing and antibiotic periodontium. The measurements include attachment loss sensitivity tests provide information about specific bacter- or gain, bleeding indices, pocket depth, and plaque and ial pathogens and give insight as to which periodontal dis- gingival indices. The reproducibility and accuracy of prob- ease we are treating and which antibiotics may be effective. ing depth and clinical attachment level measurements are Temperature-sensitive probes (PerioTemp, Abiodent, influenced by several variables, including the choice of Cambridge, MA) furnish information about elevated sub- periodontal probe. The most important variables include gingival temperatures indicative of inflammation. Currently,40 The Journal of Practical Hygiene
  3. 3. Loewenthal PATIENT ________________________________ DATE _________________ Two very important aspects of a practice’s periodon- tal program are determining the endpoints of care and the tracking of patients. If disease is present, there should be a clear understanding of what endpoint of treatment is acceptable. If the patient presents no bleeding on probing with pocket depths of less than 3 mm, it should be deter- HEALTH GINGIVITIS PERIODONTITIS mined whether any periodontal treatment is necessary. A Green visible Green visible Green not visible with bleeding A PerioWise screening can show varying levels of health and disease. good understanding of what the endpoints of treatment YOUR STATUS: AREAS WITH GINGIVITIS RECOMMENDATIONS: are will facilitate the management of periodontal patients UPPER ___ Improve oral hygiene ___ Professional removal of ____ Health disease causing irritants and make treatment decisions easier to reach. Since peri- ____ Gingivitis Left Front Right I Brushing I Flossing (calculus and plaque removal) ____ Periodontitis I Irrigation I Other ___ Re-evaluation odontal diseases are subject to recurrence through rein- LOWER (over) fection, it is imperative that patients are continually maintained and monitored to detect reinfection.Figure 3. Patients can review their periodontal status onthe take-home Screening Report and read educationalinformation on the back side. A New Color-Coded Periodontal Screening Systemthe value of these tests for screening purposes on a large A relatively new, unique, simple, and clinician-friendly peri-scale basis may not be as great as the conventional meth- odontal screening system incorporating these concepts isods of visual inspection and periodontal probing.14 available to the dental profession (PerioWise, Premier Dental Bleeding on probing (BOP) is widely regarded as an Products Company, King of Prussia, PA). The system offersobjective sign of gingival inflammation, since it is either pre- speed, accuracy, simplicity, and reliability. It does not requiresent or absent.15 It is never normal, under any circum- remembering codes or numbers. Only one probe is neededstances, to have gingival bleeding. Periodontal probes are for a screening or a complete periodontal examination. Thisthe instruments of choice for eliciting bleeding.16 screening system also simplifies record keeping, thereby Periodontal pockets are clinically important because improving risk management. There is virtually no writingthey are the primary habitat for periodontal pathogens. necessary, other than placing check marks on two forms.The deeper pockets elicit more concern because the site Patients are given a take-home screening report that informsbecomes increasingly more difficult to clean.17 Conversely, them of their periodontal status, and includes recommen-the absence of deep pockets is an excellent predictor of dations for care as well as educational information aboutperiodontal stability.18 Consequently, bleeding on probing periodontal diseases.and pocket depth are excellent parameters to use in a peri- The required items in this system include:odontal screening system. • A color-coded periodontal probe • A periodontal “Screening Record” (to be kept in theDevelopment of an Organized Program patient chart)A periodontal screening system is the first step in what • A periodontal “Screening Report” (to be given to the patient)should be an organized program to detect and treat peri-odontal diseases. Before implementing a screening system, • A periodontal Patient Education Guide (to be used chairside)decisions must be made to integrate it smoothly into thephilosophy and flow of the practice. Who will do the Probe Specifications and Techniquesscreening, when will it be done, how much time will be Probe Specificationsneeded, and how will patients be informed of their peri- Designed to be clinician- and patient-friendly, the probeodontal status are elements that need to be established. has unique color-coding in which the first three millimeters Future hygiene appointments will have to be made (3 mm) are green. Clinical studies demonstrate that compareddepending upon the results of the screening examination to conventional metal probes, this color-coded polymericand practice philosophy. For example, if the screening probe allows enhanced visual detection, faster readings, sig-result for a patient is “periodontitis,” then another appoint- nificant safety around implants, and improved patient com-ment (if the complete examination and charting is not done fort.19,20 In addition, the probes are economical, since theyat the screening appointment) should be made for a com- are sterilizable by autoclave, Chemiclave, or dry heat, andplete periodontal examination and charting. If appropriate, can be utilized repeatedly while maintaining their accu-this appointment may include a genetic test for suscepti- racy to 0.1 mm.19 The green band is the key to both thebility to periodontitis. screening system and to patient education. May/June 1999 41
  4. 4. Periodontal Disease Detection This probe is available in two calibrations (Figure 1). The benefit of the 3-5-7-10-millimeter calibration is that it is very easy to interpolate the levels of 4 mm and 6 mm. The 3-6-9-12-millimeter calibration was created due to clini- cian demand. Although, the author feels that the 3-5-7-10- millimeter calibration is more precise in the crucial 3-mm to 7-mm range, both calibrations are easy to read. The probe is constructed of a space age polymer and FDA approved inks, both of which are approved for oral use. The tip diam- eter is 0.5 mm and has a double taper (not visible to the naked eye), which helps control flexibility. As a result of the con- troversy concerning the benefits of a ball tip, this feature was Figure 4. When the green band is visible with no bleeding, excluded. In an evaluation of the PDT Perio Probe (Pro- the diagnosis is periodontal “Health.” Dentec, Batesville, AR), which is a plastic probe used for PSR, it was found that the ball was a disadvantage because it “sometimes caused difficulty inserting.” 21 The PerioWise Probe is light and, according to many clinicians, has excellent tac- tile sensitivity. It is the author’s experience that clinicians may have to examine a few patients before they can become familiar with the lightness and the tactile sensitivity of the probe. Many hygienists have reported that patients readily accept the probe because it appears less threatening than a metal probe and it is more comfortable. The probe can be placed routinely with metal instruments for cleaning and sterilization, with no special treatment; however, any solu- tions containing phenol should be avoided, since phenol will Figure 5. When green band is visible and bleeding has remove the colors. Wear of the green band will occur from occurred, the diagnosis is “Gingivitis.” abrasion against rough surfaces, and eventually the probe will have to be replaced. As long as green is present at the 3-mm mark, the probe is completely accurate and usable. The probe received the ADA Seal of Acceptance in 1998. Technique When utilizing a color-coded probe, gently insert the probe tip in the gingival crevice and walk the probe 360° around each tooth or dental implant. Probing reveals the green or red bands may provoke bleeding. If the green band remains visible with no bleeding, then there is a condition of health, and probing can continue. Conversely, if the green band remains visible, but bleeding occurs, there is gingivitis. If Figure 6. When a red band is reached, the diagnosis is a red mark is reached, a probing depth of either 5 mm or “Periodontitis.” 6 mm has been reached, depending on the calibration of the probe utilized. In either case, reaching a red mark is the “trigger” for performing a complete periodontal exam- which is given to the patient. For convenience, the mouth ination and charting. The screening record and report should is divided into sextants for recording gingivitis on each be marked “periodontitis” and a periodontal examination form. This makes recording simple and facilitates patient should be completed as soon as time permits. understanding. Screening Forms The Screening Record There are two forms: The Screening Record, which The Screening Record (Figure 2) remains a permanent part remains in the patient chart, and The Screening Report, of the patient chart. This record provides a quick and easy42 The Journal of Practical Hygiene
  5. 5. Loewenthalreference to the patient’s periodontal screening history. exists there is nothing to record. The clinician should con-Recordings can be made on both sides of the form, thereby tinue to probe the next tooth — “green means go.”providing several years of periodontal screening history(10 visits) at a glance. This efficiency helps to improve risk Gingivitismanagement. The form should be marked with the patient’s Bleeding on probing is an objective sign of gingival inflam-periodontal status (Health, Gingivitis, or Periodontitis). The mation, since bleeding is either present or absent.15 Therefore,appropriate sextant(s) or tooth numbers should indicate if if the green band is visible when probing and bleedinggingivitis is present. A space is provided for remarks about occurs, there is a condition of gingivitis (Figure 5). Thethe patient’s condition. clinician should mark the appropriate sextant(s) on the Screening Record in the patient chart and on the ScreeningThe Screening Report Report and continue probing the next tooth.The Screening Report (Figure 3) is in prescription-pad sizeand formatted for ease of use. It is given to the patient and Periodontitisshould be marked with the patient’s periodontal status, When probing, if a red band is reached (Figure 6), probingalong with any recommendations for care. The sextant(s) should stop. This is indicative of periodontitis. “Red meansindicating gingivitis should be marked. The report should stop” just as “Green means go.” The Screening Record andbe reviewed with the patient and then given to him or her. the Screening Report should be marked “periodontitis.”Educational information about the ramifications, causes, Reaching a red mark on the probe indicates that there isand early treatment of periodontal diseases is provided on a probing depth of 5 mm or 6 mm (depending upon whichthe back of the report. This take-home screening report will calibration of the probe is being utilized). The cliniciangive the patient an opportunity to consider any problems should perform a comprehensive periodontal examinationor recommendations marked on the report by reviewing and charting as soon as time permits. If the green band isthe pictures of probing and the information it contains. no longer visible but the probe has not reached a red mark,The report will also enable the patient to share the infor- a reading of 4 mm or 5 mm has been attained. At this pointmation with a spouse or family member. clinical judgment and discretion should be used to either note the site on the screening record in “remarks” or toThe Periodontal Patient Education Guide perform a complete examination.A very helpful Patient Education Guide is available forchairside use.20 Instructions for performing a screening are A Comparison to PSRfound on the back of this guide. When disease is present, There are a few similarities and several significant differencesit is recommended that the patient be shown the difference between the PerioWise Screening System and Periodontalbetween a healthy and a diseased periodontium to enhance Screening and Recording (PSR). Both systems evaluate allpatient understanding and compliance. An effective method sites and are highly sensitive. PSR utilizes a ball-tipped probeis to show the patient clinical pictures, depicting gingival with a marking of 3.5 mm to 5.5 mm and utilizes five codes,health, gingivitis, and periodontitis, utilizing the Patient ranging from 0 to 4. The parameters used for determining aEducation Guide as a reference. Then, employing a hand code include probing depth, BOP, and the detection of cal-mirror or an intraoral camera, a color-coded probe can be culus or defective restorations. The code numbers increaseplaced for the patient to observe. The probe should first as the severity of periodontal diseases increase or when cal-be entered in a healthy site and then in a diseased site for culus or defective restorations are detected. According tocomparison. When the patient sees the green mark disap- some clinicians, the code numbers used in PSR have beenpear between the tooth and the gingiva, or observes bleed- confused with pocket depth measurements. Codes 0 throughing, there is an instant recognition of disease. The guide 2 include the detection of calculus and defective marginsalso provides information concerning the medical and den- that may not be indicative of disease. For example, Code 1tal consequence of periodontal diseases, in laymen’s terms. is defined as normal sulcus depth, with bleeding on prob- ing (ie, gingivitis). Code 2 also has normal sulcus depth andHealth no BOP; however, there are calculus or defective marginsIt is widely accepted that probing depths of three mil- present. Therefore, Code 2 represents the detection of etio-limeters (3 mm) or less, without signs of inflammation, logic agents for disease, but not disease itself.indicate periodontal health.14 Therefore, if the green band The PerioWise System uses a round-tipped probe andis visible and there is no bleeding during probing, there is only three levels of periodontal status; health, gingivitis, ora condition of health (Figure 4). When periodontal health periodontitis; there are no codes or numbers. The probing May/June 1999 43
  6. 6. Periodontal Disease Detection depth, as shown by the green and red color-coding found dental hygienist has a vital role in this detection. The uti- on the probe, and the presence or absence of BOP deter- lization of a color-coded periodontal screening system offers mine the state of periodontal health. Calculus or defective a fast, simple, and accurate method to screen patients for restorations are not used as measures of disease. With PSR, periodontal diseases. This system provides a convenient, each sextant is assigned a code number that represents the multiyear record of screenings, thereby enhancing risk man- highest code found in the sextant. The PerioWise system agement. The color-coded system enables patients to review requires that the notation of gingivitis, when found in a sex- their periodontal status immediately and enhances their tant, be indicated by a check mark. opportunity to understand and reflect on the ramifications The “triggers” for a complete examination are similar of delayed care. Use of this system will promote early and in both systems—5-mm to 6-mm probing depth. PSR effective treatment of periodontal diseases. requires a complete examination of a sextant when a Code 3 is indicated, and a complete examination of the entire den- Acknowledgment tition when Code 3 is indicated in two different sextants, The author wishes to thank Drs. Harley Ellinger, Robert or when a Code 4 is reached anywhere. The PerioWise sys- Spettel, and James Spivey for their valuable contributions. tem requires a complete examination of the entire denti- *Periodontal Screening and Recording (PSR) is a trademark and service mark of the American Dental Association. tion when “periodontitis” is detected anywhere. PSR findings are written on a sticker, which has sextant scores and the date, and is placed in the patient’s chart. PSR requires the References notation of recession, mucogingival problems, furcation 1. Meskin LH. Focal infection: Back with a bang! J Am Dent Assoc 1998; 129(1):8-16. involvement, and tooth mobility, with an asterisk marked 2 Beck J, Garcia R, Heiss G, et al. Periodontal disease and cardiovas- in the sextant where the problem exists. There is no room cular disease. J Periodontal 1996;67(10 suppl):1123-1137. 3 Joshipura KJ, Rimm EB, Douglass CW, Trichopoulos D. Poor oral health for additional notations. When reviewing the patient’s and coronary heart disease. J Dent Res 1996;75(9):1631-1636. screening history, the mark on the sticker signifies that 4. Offenbacher S, Katz V, Fertik G, et al. Periodontal infection as a possi- ble risk factor for preterm low birth weight. J Periodontol 1996;67 there is a problem in that sextant, but not what the prob- (10 suppl):1103-1113. lem is. The PerioWise system focuses on the changes caused 5. Taylor GW, Burt BA, Becker MP, et al. Severe periodontitis and risk for poor glycemic control in patients with non-insulin-dependent dia- by inflammatory periodontal diseases and leaves the detec- betes mellitus. J Periodontol 1996;67(10):1085-1093. tion of other indicators of disease for the periodic com- 6. Burt BA, Ismail AI, Eklund SA. Periodontal disease, tooth loss and oral hygiene among older Americans. Community Dent Oral Epidemiol prehensive examination. However, if another problem is 1985;13(2):93-96. detected (ie, recession mucogingival problems, furcation 7. Papapanou PN, Lindhe J, Sterrett JD, Eneroth L. Considerations on the contribution of aging to loss of periodontal tissue support. J Clin involvement, or tooth mobility) the clinician has the option Periodontol 1991;18(8):611-615. 8. American Academy of Periodontology: Position statement. AAP News of noting the finding in the remarks area of the screening Aug 1996:9. record. This system also emphasizes patient education and 9. Kingman A, Loe H, Anerud A, Boyson H. Errors in measuring para- meters associated with periodontal health and disease. J Periodontol provides a patient education guide and a take-home screen- 1991;62:477-486. ing report that indicates the patient’s level of heath or dis- 10. Mombelli A, Garf H. Depth of force patterns in periodontal probing. Attachment gain in relation to probing force. J Clin Periodontol ease and recommendations for care. PSR does not have a 1992;19:295-300. written method of informing the patients of their peri- 11. Keagle JG, Garnick JJ, Searle JR, et al. Gingival resistance to probing forces. Determination of optimal probe diameter. J Periodontol odontal status or recommendations for care. 1989;60:167-171. 12. Wang SF, Leknes KN, Zimmerman GJ, et al. Intra- and inter-examiner reproducibility in constant force probing. J Clin Periodontol 1995; Complete Periodontal Examination 22:918-992. 13. Armitage GC. Periodontal Diseases: Diagnosis. Annals of Periodontology A complete and comprehensive periodontal examination with 1996;1(1):73-83. accurate charting is important for all patients and should be 14. Armitage GC. Periodontal diseases: Diagnosis. Annals of Periodontol 1996;1(1):37-215. provided periodically. The previously described screening l5. Greenstein G. The role of bleeding on probing in the diagnosis of perio- system is not a substitute for a complete examination. Probing dontal disease. A literature review. J Periodontol 1984;55(12):684-688. 16. Mühlemann HR, Son S. Gingival sulcus bleeding—A leading symptom depths, attachment levels, mucogingival problems, gingival in initial gingivitis. Helv Odontol Acta 1971;15(2):107-113. recession, furcation involvement, tooth mobility, occlusal dis- 17. Armitage GC. Clinical evaluation of periodontal diseases. Periodontol 2000 1995;7:39-53. crepancies, defective restorations, and radiographic findings 18. Grbic JT, Lamster IB. Risk indicators for future clinical attachment loss should be evaluated during the complete examination. in adult periodontitis. Tooth and site variables. J Periodontol 1992;63(4):262-269. 19. Kazmierczak MD, Ciancio SG, Mather M, et al. Improved diagnostics: Conclusion Clinical evaluation of a color-coded, polymeric periodontal probe. Clin Prev Dent 1992;14(4):24-28. Due to the medical and dental consequences of periodontal 20. Periowise. The Dental Advisor Plus 1995;5(1):9. diseases, early detection is more important than ever. The 21. Clinical Research Associates Newsletter, PDT Perio Probe 1991;15(9):4.44 The Journal of Practical Hygiene