Academy Report


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Academy Report

  1. 1. Academy ReportGuidelines for the Management of PatientsWith Periodontal Diseases based on certain genetic or behavioral factors. TheI n 2005, the American Academy of Periodontology undertook the development of guidelines for the same is true for periodontal diseases. These Guide- management of patients with periodontitis. The lines are meant to help identify patients who are atdevelopment process took into consideration the greatest risk early and, therefore, would benefit fromlatest research in the field of periodontics, comments specialty care. The Guidelines are in no way meantfrom Academy members, and input from other den- to replace a practitioner’s knowledge, skills, or abil-tal organizations. The final product – Guidelines for ities; a ‘‘one-size-fits-all’’ treatment plan for peri-the Management of Patients With Periodontal Dis- odontal diseases does not exist. The diagnosis andeases – is published in this issue of the Journal. treatment of periodontal diseases continue to pres- Today, there is greater public awareness about ent significant challenges to all practitioners regard-periodontal diseases and more treatment options for less of experience level.patients than ever before. However, as advance- We encourage periodontists to take these Guide-ments in periodontal therapy continue to develop at lines and incorporate them into their daily routinea record-breaking pace, periodontal diseases remain and share them with their referring colleagues. Thesethe most common cause of adult tooth loss. In addi- Guidelines provide a basis for strengthening existingtion, accumulating research is further defining the relationships and building new ones. Periodontistslinks between periodontal diseases and other sys- have a unique relationship with general dentists be-temic conditions such as diabetes, adverse preg- cause they are the only specialists who work with thenancy outcomes, and cardiovascular diseases. Patients restorative community throughout a patient’s life.are beginning to understand that good periodontal There are many times that we hear from our referringhealth is more important than ever before. colleagues that they have referred patients for spe- It is the Academy’s hope that these Guidelines will cialty care, but, for one reason or another, the patienthelp to improve the periodontal health of all patients never follows through. We urge you to take the timewith periodontitis. Evidence suggests that an in- to develop protocols with your referring colleaguescreasing number of patients would benefit from peri- for periodontal specialty care and to help optimizeodontal specialty care. Clearly, there has been some the health of your patients.confusion regarding periodontal treatment and con- This is an exciting time in periodontics. We en-tinued reevaluation of its effectiveness and when a courage you to share these Guidelines with all mem-periodontist should be consulted as a member of the bers of your dental team and work to incorporatepatient’s treatment team. These Guidelines can help them into the management of your periodontal pa-the entire dental team in the timely identification of tients. The Academy hopes that the adoption of thepatients with periodontal diseases and those most Guidelines into everyday practice will help to provideappropriate for specialty care. guidance and perspective to the dental community. Patients at risk for periodontal diseases can often Together, we can work to enhance and ensure thebe overlooked during a routine dental examination periodontal health of all.because they appear to be in a state of periodontalhealth, yet there can be underlying risk factors that Kenneth A. Krebs, DMD, President, Americancould increase the probability of periodontitis in the Academy of Periodontologyfuture. Many practitioners are aware that the conceptof risk in the treatment of chronic diseases is rapidly Donald S. Clem III, DDS, Chair, Task Force tobecoming an important component of patient care Develop the Guidelinesand will ultimately drive treatment decisions and ap-propriate referrals in the healthcare community. Forexample, we know that a patient in excellent cardio-vascular health today may be at high risk for de-veloping the disease at some point in the future doi: 10.1902/jop.2006.069001J Periodontol • September 2006 1607
  2. 2. Academy Report Guidelines for the Management of Patients With Periodontal Diseases who would benefit from comanagement and the P eriodontal diseases present significant chal- lenges for the public and dental profession. unique partnership between a periodontist and re- They are the major cause of tooth loss in ferring dentist. From time to time, the Academy will adults, and they can have a devastating impact on update these Guidelines. oral function and appearance. Emerging research An explanation of terms is included as part of the suggests possible links between inflammation Guidelines, and research supporting the content of caused by periodontal diseases and other adverse the Guidelines is available on the American Academy health conditions, such as heart attacks, strokes, of Periodontology’s Web site at http://www.perio. diabetes, and preterm and low-weight births. org. Some patients can be well managed within the general dental practice, whereas others would ben- efit from comanagement with a periodontist. Deter- LEVEL 3: PATIENTS WHO SHOULD BE TREATED mining if and when a patient should be referred to a BY A PERIODONTIST periodontist are sometimes difficult issues. Any patient with: Communication between the referring dentist and Severe chronic periodontitis periodontist is especially important in establishing Furcation involvement responsibilities for periodontal treatment and main- Vertical/angular bony defect(s) tenance. The education, experience, and interest of Aggressive periodontitis (formerly known as ju- individual practitioners vary, and, therefore, spe- venile, early-onset, or rapidly progressive peri- cialty referral may occur at different stages of a odontitis) patient’s disease state and risk level. The chronic Periodontal abscess and other acute periodontal nature of inflammatory periodontal diseases requires conditions that the clinician regularly reassess patients for ap- Significant root surface exposure and/or pro- propriate lifelong disease management. Because gressive gingival recession periodontal diseases can affect soft and hard tissues, Peri-implant disease practitioners are cautioned to address both soft tis- sue lesions and bone involvement. This is particu- Any patient with periodontal diseases, regardless of larly true for practices that administer ‘‘soft tissue severity, whom the referring dentist prefers not to treat. management’’ programs, as the limited approach of these programs may lead to inappropriate treatment of the patient’s periodontal diseases. LEVEL 2: PATIENTS WHO WOULD LIKELY Risk assessment is increasingly important in peri- BENEFIT FROM COMANAGEMENT BY THE odontal treatment planning and should be part of REFERRING DENTIST AND THE PERIODONTIST every comprehensive dental and periodontal evalu- Any patient with periodontitis who demonstrates at ation. This evolving paradigm in the treatment of reevaluation or any dental examination one or more chronic diseases, such as periodontal diseases, not of the following risk factors/indicators* known to only identifies the existence of disease and its se- contribute to the progression of periodontal verity, but also considers factors that may influence diseases: future progression of disease. Periodontal Risk Factors/Indicators The American Academy of Periodontology recog- nizes that the periodontist–dental team partnership is Early onset of periodontal diseases (prior to the unique in that it enables long-term comanagement of age of 35 years) periodontal patients. This concept of comanagement Unresolved inflammation at any site (e.g., bleed- may occur at different intervals of a patient’s treat- ing upon probing, pus, and/or redness) ment depending on risk factors that may contribute to the progression of periodontal diseases and its * It should be noted that a combination of two or more of these risk factors/ consequences. The following Guidelines are pro- indicators may make even slight to moderate periodontitis particularly vided to assist in the timely identification of patients difficult to manage (e.g., a patient under 35 years of age who smokes).1608 Academy Report Volume 77 • Number 9
  3. 3. Academy Report Pocket depths ‡ 5 mm Why did the Academy develop the Guidelines? Vertical bone defects The Academy’s objective is to encourage referring Radiographic evidence of progressive bone loss dentists and periodontists to work together to Progressive tooth mobility optimize the health of patients. Determining if and Progressive attachment loss when a patient should be referred to a periodontist Anatomic gingival deformities are sometimes difficult issues. These Guidelines Exposed root surfaces are intended to help the general practitioner in the A deteriorating risk profile rapid identification of those patients at greater risk for the consequences of periodontal inflammationMedical or Behavioral Risk Factors/Indicators and infection and, therefore, those patients most Smoking/tobacco use appropriate for specialty referral. Diabetes Despite recent advancements in periodontal therapy, Osteoporosis/osteopenia periodontal diseases continue to present significant Drug-induced gingival conditions (e.g., pheny- challenges for the public and dental profession. toins, calcium channel blockers, immunosup- Periodontal diseases remain a major cause of tooth pressants, and long-term systemic steroids) loss in adults. In addition, periodontal diseases are Compromised immune system, either acquired or associated with systemic conditions, such as cardio- drug induced vascular disease, diabetes, adverse pregnancy out- A deteriorating risk profile comes, and respiratory disease. Periodontists are experts in assessing and treating periodontal diseases. Accumulating evidence, including recent literature,LEVEL 1: PATIENTS WHO MAY BENEFIT FROM suggests that an increasing number of patientsCOMANAGEMENT BY THE REFERRING would benefit from periodontal specialty care. ThisDENTIST AND THE PERIODONTIST evidence also suggests that these patients are being referred later in the disease process than in the past.Any patient with periodontal inflammation/infectionand the following systemic conditions: Who needs/benefits from the Guidelines? Diabetes All dental teams and their patients need and will Pregnancy benefit from the Guidelines. Cardiovascular disease Chronic respiratory disease How were the Guidelines developed, and who devel- oped them? Did the Academy collaborate withAny patient who is a candidate for the following organized dentistry or any other groups or individ-therapies who might be exposed to risk from peri- uals on these Guidelines?odontal infection, including but not limited to thefollowing treatments: A Board of Trustees–appointed task force consist- ing of periodontal practitioners, academicians, and Cancer therapy researchers developed the Guidelines. Cardiovascular surgery The Academy distributed a draft version of the Joint-replacement surgery Guidelines to all members, the American Dental As- Organ transplantation sociation, Academy of General Dentistry, and Amer- ican Dental Hygienists’ Association for commentary. All organizations and more than 375 membersFREQUENTLY ASKED QUESTIONS (FAQs) provided commentary.The American Academy of Periodontology’s The task force revised the Guidelines based on theGuidelines for the Management of Patients With comments received.Periodontal Diseases What are the benefits of using the Guidelines?What are the Guidelines? The Guidelines will: The Guidelines provide information to assist in the timely identification of patients who would benefit Help the practitioner in triaging patients who from comanagement by the referring dentist and currently have or who are at risk for the develop- the periodontist. ment of periodontal diseases.J Periodontol • September 2006 Guidelines for the Management of Patients With Periodontal Diseases 1609
  4. 4. Academy Report Help the general practitioner more effectively ad- The Guidelines suggest that certain patients can only dress the association of periodontal diseases and be treated by a periodontist. Is this true? systemic diseases/conditions. No. Some patients can be well managed within the Assist the general dentist and hygienist in the general dental practice, whereas others would management of periodontal diseases. benefit from comanagement with a periodontist. Result in appropriate and timely treatment of The Academy understands that the education, periodontal diseases. experience, and interests of individual general- In addition, the Guidelines: practitioner dentists vary, and, therefore, specialty referral may occur at different stages of a patient’s Should enhance the restorative outcome of dental disease state and risk level. treatment by establishing and maintaining a Referral is not only associated with treatment but healthy periodontal foundation. also includes consultation. Are clear, concise, and should be easy to incorpo- rate into daily practice and will enhance the Do all patients who are referred to periodontists partnership between periodontists and referring require surgery? dentists. No. Comprehensive care by a periodontist includes Where do the Guidelines fit in the process of care? non-surgical and/or surgical therapies depending on the needs of the individual patient. The Guidelines will become an integral part of patient management. Dental implants, oral reconstructive and corrective The Guidelines do not replace the knowledge, procedures, and tissue engineering are not included skills, and abilities of the dental team. in the Guidelines. Why aren’t these procedures included? The Guidelines mention the concept of risk assess- ment. What is risk assessment, and why is it so These Guidelines are focused on the management important? of patients with periodontitis. They do not include all areas of periodontal specialty care or specific Risk assessment is the process of determining the treatment modalities. qualitative or quantitative estimation of the likeli- Dental implants, periodontal plastic surgery, oral hood of adverse events that may result from reconstructive surgery, and tissue-engineering pro- exposure to specified health hazards or from the cedures are currently performed by periodontists. absence of beneficial influences. Upon dental ex- The development of clinical guidelines for these amination, many practitioners incorrectly assume other areas of periodontics is being considered that a patient in a state of periodontal health is not by the Board of Trustees. at risk for developing periodontitis. Indeed, the patient may have risk factors/indicators (e.g., a Where is the research to support statements made in smoking habit, diabetes, and young age) that the Guidelines? could increase the probability of the occurrence of periodontitis in the future. Therefore, risk as- The Academy’s Web site includes many resources sessment helps predict a patient’s disease state at that support the Guidelines for the Management of some future point in time or the rate of progression Patients With Periodontal Diseases. These resources of current disease. are located at products/posppr2.html. Why are patients with furcation involvement consid- ered among those patients who ‘‘should be treated Is the Academy implying a medicolegal standard by a periodontist’’? with the dissemination of these Guidelines? Periodontists are specialists trained to assess and This document is intended to serve as a guide for treat the more advanced forms of periodontal the dental team in managing patients with peri- diseases and associated lesions. Furcation involve- odontal diseases. ments are among the most problematic periodon- The Academy believes that all dentists have the right tal lesions. Therefore, it is often appropriate that to practice according to their education, training, and earlier manifestations of these lesions be evaluated experience. Clearly, each dentist has an obligation to and managed by a periodontist. render treatment in the best interests of the patient.1610 Academy Report Volume 77 • Number 9
  5. 5. Academy Report It is hoped that this document will help dentists odontitis, and Acute Periodontal Conditions, please identify patients at greatest risk for periodontal refer to volume 4 of the Annals of Periodontology at diseases so that these patients receive appropriate and timely periodontal care. fication.htm. Peri-Implant Disease: Chronic inflammation and/EXPLANATION OF TERMS or bone loss around dental implants that may May: A choice to act or not; indicates freedom or influence implant status. liberty to follow a suggested alternative. Periodontal Inflammation: Most periodontal Should: A highly desirable direction but does not diseases including chronic and aggressive peri- mean mandatory. odontitis are inflammatory diseases. Chronic peri- Must: Used to express a command; indicates an odontitis has an infectious etiology from the imperative or duty. This term does not appear in endogenous plaque biofilm. This type of opportun- the document and is provided as a comparison to istic infection results in a chronic release of the terms ‘‘may’’ and ‘‘should.’’ inflammatory cytokines, prostaglandins, and de- Comanagement: A shared responsibility for patient structive enzymes from neutrophils and mononu- care between a periodontist and referring dentist. clear cells in the periodontium. The ensuing This patient management may consist of consul- chronic inflammation in the tissue is what leads to tation and/or treatment. the pathologic anatomic changes clinically detect- Reevaluation: Assessment of a patient’s peri- able as periodontal pockets and alveolar bone loss. odontal status and risk profile after therapy to be Furthermore, some microorganisms of the biofilm used as a basis for subsequent patient manage- and inflammatory mediators from the affected ment. tissue may adversely affect systemic chronic in- Deteriorating Risk Profile: Adverse changes in risk flammatory diseases and pregnancy outcomes. factors/indicators suggestive of disease onset or Significant Root Surface Exposure: Gingival re- progression. cession of sufficient magnitude that results in the Disease Definitions: For disease definitions such loss of tooth structure, sensitivity, esthetic con- as Severe Chronic Periodontitis, Aggressive Peri- cerns, or attachment loss.J Periodontol • September 2006 Guidelines for the Management of Patients With Periodontal Diseases 1611