Controversies in Periodontal Practice - CDD.ppt

Controversies in
Periodontal
Practice

Controversies in Periodontal Practice - ISP 6th National P.G Workshop, Trivandrum 2 July 14th & 15th 2007
Why do we have controversies?
Lack of complete knowledge &
understanding.
Over dependence on historical,
anecdotal data.
Lack of well controlled, high standard
clinical trials.
Lack of critical meta analyses.
Innate fusel to change our ideas with
the progress of time.

Controversies in Periodontal
Practice
1. Classification System
2. Diagnosis
3. Prognosis
4. Surgical vs. non surgical
treatment
5. Systemic antibiotic
medication
6. Multiple visit SRP vs.
FMDT
7. Gingival curettage
8. Removal of pocket
epithelium in Periodontal
flaps
9. Resective osseous surgery
10. Tooth mobility & splinting
11. Perio Endo controversies
12. Removable partial Dentures
& Periodontal health
13. Mucogingival problems &
their management
14. Periodontal therapy vs.
Implants

Classification
Systems For
Periodontal
Diseases

Classification Systems -
Controversies
 Which classification system best suits us?
Are the systems available to as
reproducible?
Is the AAP 1999 classification sacrosanct?
Do all these systems based mainly on
clinicians experience?

Classification Systems –The
Facts
Since the last 135 years over 50
recognized classification systems for
periodontal diseases have been proposed.
The development & evolution of
classification systems have been largely
influenced by paradigms dominant during
that historical period.

The Facts Contd…
Clinical features between 1870-
1920,classical pathology between 1920-
1970 & infectious etiology between 1970-
till now have dominated classification
strategies.
The 1989 classification put too much
emphasis on age & rate of progression.

The Facts Contd…
The 1999 classification is too exhaustive &
more of an enumeration .
Most clinicians resent any change.

Classification Systems –
Problems
Till 1960 very little was known about the
etiology of periodontal diseases.
Systemic factors were given too much
importance in the older classifications.
A lot of emphasis was placed on
“Degenerative Lesions’’ till 1977.
Microbial etiology although established still
doesn't offer conclusive identification.

The Problems
Contd…
Too many variables affecting the
pathogenesis.
Extreme heterogenicity.
Most of the time diagnosis is made upon
data obtained in a single visit.
Newer diagnostic methods still far from
relevant & helpful.

Classification Systems –
Unanswered Questions
 How can the rate of progression be estimated in
a single visit?
 How can the role of systemic factors accounted
or ignored?
 How do all the risk factors be correlated with the
amount of destruction?

Unanswered Questions
Contd…
 With conventional diagnostic techniques in
everyday practice how can the microbial &
immunologic status established?

Classification Systems-The
Position
 With the improved knowledge classification
systems have tried to be more comprehensive.
 With the present chair side diagnostic methods
available it is impossible to accurately determine
the rate of destruction ,role of specific
microorganisms & immunologic background.
 A certain degree of overlap, confusion is
inevitable in border line cases.

The Position Contd…
 The 1999 classification while rectifying many
lacunae's of 1989 system, nevertheless is not
without drawbacks.
 Classification systems do not seem to have
much bearing on the prognosis & treatment
outcomes.

The Diagnosis – Controversies
How good are the conventional diagnostic
methods?
Are the indices employed useful in clinical
practice?
Can the etiological factors established
consistently?
Can the cause – effect established
regularly?

Controversies
Contd...
Are we over relying on historical/past
events?
How sensitive and specific are our
diagnostics methods?
How do you evaluate treated cases?
How reliable/relevant are the newer
diagnostic techniques?

The Diagnosis – Facts
The current conventional diagnostic
methods despite several drawbacks are
still relevant.
Indices while exceedingly useful in
epidemiological surveys are of limited use
in day to day practice as they either
underestimate or over estimate the
disease & subject to high inter & intra
operator variations.

Facts Contd…
With the current diagnostic methods
etiological factors can not always be
established accurately.
In many situations such as trauma from
occlusion, environmental risk factors the
cause – effect can not be established
accurately.
The current diagnostic methods does rely
too much on historical/past events.

Facts Contd…
Negative predictive value seems more
stronger than positive predictive value.
It is extremely difficult to relate P.D. C.A.L
recession & make a diagnosis in treated
cases.
Newer diagnostic methods while have
shown considerable promise are far from
being employed in daily practice.

The Diagnosis –
Position
At present we do not have a predictable
methods to evaluate disease activity.
Disease susceptibility is again difficult to
determine.
Borderline cases continue to pose
problem.

Position Contd…
The present diagnostic methods rely on
past events.
Treated cases often present problems in
diagnosis.

Prognosis – Controversies
With the current understanding of the
disease process, can periodontal
prognosis be determined accurately?
Do we have an evidence bases model to
determine the prognosis?
Are the risk assessment methods
followed, offer a true evaluation?

Controversies Contd…
Should prognosis be determined in the
initial examination?
Are the terms good, fair, guarded, poor,
etc etc largely subjective?

Prognosis – The Facts
The complexity of periodontal pathology
and the incomplete understanding of the
same precludes the clinician in
determining the prognosis accurately.
Few systematic reviews & meta analysis
lead us to believe that prognosis prediction
is accurate only when the extremities are
considered viz very good, or hopeless.

The Facts Contd….
At present we do not have an evidence
based model to assist in the determination
of prognosis.
Prognosis of the entire dentition is not
equivalent to the sum total of the
prognosis of individual teeth.

The Facts Contd…
Response to anti infective or cause related
therapy is often dramatic, on the other
hand, despite diligent treatment, some
sees continue to loose attachment. Hence
prognosis cannot be determined with a
single examination.
With the existing knowledge available to
us, terms such as fair, poor, guarded etc,
or subjective & based on anecdotal
experience.

The Facts Contd…
Experimental evidence is not available to
confirm the long held belief that prognosis
is better in an older patient.
There is little evidence that older people
respond either more favorably or less
favorably.
Most of the studies confirm that smoking
makes the prognosis less favorable.

The Facts Contd…
Increasing light has been thrown on
genetic predisposition.
Current evidence does not provide a basis
for assigning prognostic categories on the
basis of race.
Not enough is known whether there is any
difference in the prognosis between males
and females.

The Facts Contd…
Except Diabetes Mellitus and HIV/AIDS,
there is not enough evidence to relate
systemic conditions with periodontal
prognosis.
No conclusive evidence to show that
prognosis is poor in stressed individuals.

The Facts Contd…
Bleeding on probing while confirms
disease presence is not an indicator of
disease progression.
However bleeding at the base of sulcus
during maintenance visits could be
indicative of disease progression.

The Facts Contd…
Suppuration does not indicate poor
prognosis
Presence of non progressive mobility does
not indicate poor prognosis.

Prognosis – Position
Conflicting data reported in various studies
precludes the clinician in making an
accurate determination of prognosis
except in well-defined cases.
Prognosis determination should not be
rigid & should be reviewed following
successive stages of treatment.

Surgery vs. Non Surgery -
Controversies
Are the results of non surgical procedures
& surgical approach comparable?
Are the results obtained following surgery
maintainable?
Which is more important – “Patient factors”
or “Defect Morphology” in deciding for
surgery?

Does surgery actually prolong the life of
the dentition?
Finally considering all the factors is
surgery worth it?

Surgery vs. Non Surgery -
Problems
Eternal controversy, conflicting views.
Too many patient variables, different
outcomes.
Systematic review extremely difficult.
Often other considerations such as
monetary, insurance, consumer act etc
dictate decisions.

The goals of Periodontal Therapy
Creation of an oral environment that is
conducive to maintain the patients
dentition in a healthy, comfortable,
functional, esthetic state.
Whenever feasible to regenerate and
preserve periodontal attachment.

What does non surgical
therapy accomplish?
Healing seems to complete in 3 – 6
months.
Number of bleeding sites markedly
reduced.
Reduction in P.D & Gain in CAL varies
mainly dependent on initial presentation.
Mild Gingival Recession.
Overall Observations:

What does non surgical
therapy accomplish? Contd…
Loss of CAL in shallow pockets.
Negligible change in alveolar bone height.
Negligible defect fill.
Negligible changes in Mucogingival
Complex.
Non molar teeth responded better than
molar teeth.
Overall Observations:

Effects of surgical periodontal
therapy as compared to non surgical
More probing depth reduction.
Greater loss of CAL in shallow pockets.
More gain of CAL in deeper pockets.
More gingival recession initially but no
difference later.
Loss of crestal bone.
Variable gingival morphology.
Variable esthetic outcome.

Surgery vs. Non Surgery long term
outcome (Ramfjord Studies)
Both modalities required SPT.
Greater necessity of SPT non surgical
patients.
No difference in no. of teeth requiring re-
treatment.
No difference in no. of teeth requiring
extractions.

Surgery vs. Non Surgery –
The Position
Patient factors play the biggest role in
treatment selection.
Probing depths of less than 5mm
particularly in non molar teeth are better
treated non surgically, but this is only a
guideline.

Deeper pockets benefit better by surgery.
Fibrous enlarged gingiva may require
surgery.
Osseous defects including furcations
benefit by surgery.
Whenever regeneration is predictable
surgery is the choice.

Systemic
Antimicrobials in
Periodontal
therapy

Systemic Antimicrobials -
Controversies
Which are the periodontal conditions
requiring systemic antimicrobials?
Who are the patients requiring such
therapy?
When such therapy is recommended?
What is the regimen to be followed?

Can periodontal surgery be avoided if
antimicrobials are used?
What are the adverse effects of such
therapy?
Ultimately is it in the overall
interest/benefits of the patients?

Systemic antimicrobials –
Problems
Periodontal infections are different from
other microbial infections.
Too many variables.
Complex microbial population.

Problems Contd…
Neither identity of the causative organism
not microbial susceptibility are readily
available in day to day practice.
Literature replete with conflicting reports.

Rationale for use of Systemic
antimicrobials in Periodontics
Many micro organisms are tissue invasive.
Mechanical therapy does not eliminate
pathogens completely particularly from
inaccessible areas.

Rationale for use of Systemic
antimicrobials in Periodontics Contd…
Aggressive type of periodontal conditions
required strong counter attack.
Refractory cases require multifaceted
approach.

The Facts
Non of the systemic reviews have zeroed
on to the exact protocol.
Except in the treatment of NUG,
antimicrobials have no additional benefit in
gingivitis cases.
Chronic periodontitis seems to be
managed best by SRP alone, but
aggressive and refractory lesions benefit
by antimicrobials.

The Facts Contd…
Use of antimicrobials as a mono therapy is
no solution.
At present selection of an antibiotic is
empirical.
Recolonisation if microorganisms varies.

The Facts Contd…
There is no over whelming evidence that
antimicrobials reduce the need for surgery.
Not sufficient data available regarding
development of resistant strains.

The Facts Contd…
Meticulous mechanical debridement must
precede antimicrobial therapy.
Antimicrobial therapy when used
judiciously where indicated are essentially
non toxic & acceptable to most of the
patients.

The Position
Systemic antimicrobials are indicated in
patients who show progressive attachment
loss despite diligent mechanical therapy.
Aggressive Periodontal conditions
with/without systemic conditions benefit
from this therapy.

Acute Periodontal conditions with systemic
manifestations are indications.
Antimicrobial therapy must succeed
mechanical therapy.
Use as a mono therapy contra indicated.
The choice of particular drug is empirical.

Post surgical
Antimicrobial
medication

Post surgical antimicrobial
medication - Controversies
Should antimicrobials be prescribed
regularly in every case after Periodontal
surgery?
Do antimicrobials affect surgical outcome?
If antimicrobials are prescribed, then which
one/combination?
Do regenerative procedures benefit by
antimicrobial medication?

medication – The Facts
Provided proper aseptic & infection control
procedures have been followed it is not
mandatory to prescribe antimicrobials in
an otherwise normal patient, after a
properly performed Periodontal surgery.
Antimicrobials while prevent P.O infection
do not influence surgical outcome.

The Facts Contd…
Since the only reason to prescribe
antimicrobials is to prevent P.O infection, a
simple regiment may be followed.
However many clinicians combine
Periodontal therapy also at this stage.
In one study antimicrobials did influence
the outcome following regenerative
Periodontal therapy.

medication – The Position
Most of the literature data available have
shown that P.O antimicrobial medication
has come to stay regardless whether
indicated or not.

Scaling & Root Planing –
Multiple visits vs. Full Mouth
Disinfection therapy

Multiple visit SRP vs.
FMDT - Controversies
Given long standing, established efficacy
of S.R.P accomplished in multiple visits is
full mouth disinfection significantly
superior?

Multiple visit SRP vs. FMDT –
The Facts
Perceived advantages are questionable.
The protocol followed in different studies is
not uniform.
The microbial assays followed in these
studies need to be standardised &
reproducible.
The significance of FMDT on long term
results is yet not known.

The Facts Contd…
FMDT resulted in more pain & discomfort
necessitated increased intake of
analgesics.
No histological/SEM studies have been
done to evaluate the efficacy of
instrumentation.

Multiple visit SRP vs. FMDT –
The Position
With the present state of knowledge FMDT
may be offered only as an alternative to a
patient who is unable to attend multiple
visits.

Removal of pocket
epithelium in Periodontal
flaps

Removal of pocket
epithelium - Controversies
Is complete removal of pocket epithelium
achieved consistently?
Is it absolutely necessary to remove the
pocket epithelium?
Is the internal bevel incision a must in
Periodontal flaps?

Removal of pocket
epithelium – The Facts
Studies have shown that pocket epithelium
does not get completely removed by
internal bevel incision.
Residual pocket epithelium degenerates.
Favorable results may be obtained
regardless of whether pocket epithelium is
removed.
Internal bevel incision just for the sake of
removing pocket epithelium may not be
necessary.

Removal of pocket
epithelium – The Position
Provided all the irritants from the root
surface is removed the objective of
complete removal of pocket epithelium is a
questionable surgical objective.

Gingival Curettage -
Controversies
Should gingival curettage as a separate
procedure be considered obsolete?
Does it have any advantage over SRP?
Does ENAP remain in vogue?
Does the long term results of Curettage
hold any vindication of it?

Gingival Curettage – The
Facts
Short & long term clinical trials have
confirmed that gingival curettage provides
no additional benefits compared to SRP
alone.
The pocket epithelium is neither removed
completely nor the procedure provides
increased root surface access.

The Facts Contd…
No new attachment is gained following
Curettage.
Employment of LASER showed no
increased advantage either by way of
reduced bacterial count or better results.

Gingival Curettage – The
Position
It is a procedure of historical interest.

Resective Osseous Surgery -
Controversies
Is it justifiable to remove supporting bone?
Is positive bone architecture important?
In the light current knowledge of
Periodontal pathogenesis, is pocket
eradication mandatory?

Resective Osseous Surgery –
The Facts
The reducing probing depths, CAL, margin
locations & gingival contour obtained in
the immediate post healing phase are not
sustainable over time.
If plaque control is attained & other patient
risk factors are controlled, positive bone
architecture is not mandatory to maintain
health.

The Facts Contd…
Pocket eradication is not very vital
provided standard SPT is available.
Resective osseous surgery has limited use
in advance cases, intra-bony defects.
However the results after ROS are more
predicable.

Resective Osseous Surgery –
Position
While the short term results after ROS are
good the procedure has limited indication
since the emphasis currently is
regeneration & conservation of tissues.

Tooth Mobility & Splinting -
Controversies
Does tooth mobility indicate poor
prognosis?
Are mobile teeth more prone for
Periodontal break down?
Is the therapeutic outcome different
between mobile & non mobile teeth?
Can clinicians attempt regenerative
procedures in mobile teeth?
Should all mobile teeth be splinted?

Tooth Mobility & Splinting –
The Facts
Conflicting reports are found in the
literature about the significance of tooth
mobility.
In one 10 year old longitudinal study
mobility at base line was associated with
increased bone loss over time.
Better healing responses were seen
following Periodontal therapy in firm rather
than mobile teeth.

The Facts Contd…
Less favorable response was seen in
mobile teeth following regenerative
procedures.
However well controlled studies have
shown that non progressive mobility is not
detrimental to periodontal health.
If other factors are under control mobility
has no influence on the treatment
outcome.

The Facts Contd…
Other than permanent Periodontal splint,
splinting mainly favours instrumentation &
boost patient confidence.
Temporary splinting for more than 6 weeks
is of no benefit.

Tooth Mobility & Splinting –
Position
Teeth with non progressive tooth mobility
do not necessarily indicate poor prognosis.
It is better to have firm teeth while
planning regenerative procedures.
Provisional splinting which boost the
patient morale and facilitates
instrumentation however should not be
kept for more than 6 weeks.

The Periodontal –
Endodontic
Relationships

The Perio Endo Relationship -
Controversies
Does Periodontal disease cause pulp
necrosis?
Does Periodontal therapy cause pulp
changes?
Do severely Periodontally involved teeth
with normal vitality response, still require
RCT as a prophylactic measure?
What is the effect of pulp less teeth on
Periodontal tissues?

Do Endodontically treated teeth respond
differently to Periodontal therapeutic
procedures?
Can Periodontal regenerative techniques
be attempted on Endodontically treated
teeth?

The Perio Endo Relationship –
The Facts
Many of the reports published in the early
60’s and 70’s describing pulpal changes in
Periodontally involved teeth were
inaccurate & suffered from histological
artifacts.
Well framed recent studies have not found
any evidence of Periodontitis causing pulp
necrosis.

The Facts Contd…
Even teeth with severe Periodontitis
reaching the apical third of the root were
found to have normal pulps.
Only when the blood supply to the pulp at
the apical foramen was affected. The pulp
showed changes.

The Facts Contd…
Pulpal insults through exposed lateral
canals/patent dentinal tubules have
relatively insignificant effects on the ability
of the pulp to survive.
This is more so for teeth not serving as
abutments.

The Facts Contd…
There is no evidence that teeth with
moderate to severe Periodontitis
necessarily require RCT as a prophylactic
measure.
Periodontal therapy has not found to have
any effect on pulp.

Periodontally affected tooth vis a
vis Endodontic status – Position
Unless Periodontal disease extends all the
way to the tooth apex, the weight of
evidence in the literature suggests that the
dental pulp is capable of surviving
significant insults & that the effect of
Periodontal disease as well as Periodontal
treatment on the dental pulp is negligible.

Position Contd…
The relationship of Periodontal disease &
pulp has been exaggerated in historical
literature.

Endodontically involved teeth &
Periodontal health & healing – The
Facts
Various studies have reported wide
ranging findings on the effect of pulp
disease on Periodontal health & healing.
A tooth with a necrotic pulp or that has
RCT may pose a risk factor for Periodontal
disease.
Significantly increased P.D & CAL were
found in pulp less teeth than normal ones.

The Facts Contd…
The rate of bone destruction in teeth with
Periapical lesion appeared to be
statistically more albeit clinically marginal.
In one study, use of DFDBA in
endodontically treated teeth showed less
bone fill than normal teeth.

The Facts Contd…
However well controlled studies, where
Endodontic treatment was judged
adequate, these teeth responded in the
same way as others.
Well controlled studies have shown that
prognosis is good even for molars treated
by RCT.

Endodontically involved teeth
& Periodontal health - Position
The Periodontal prognosis is not affected if
a satisfactory, adequate Endodontic
treatment is done.
Although there might be some statistical
difference clinically Endodontically treated
teeth respond similarly to Periodontal
therapy as compared to vital teeth.

Removable Partial Dentures
& Periodontal Health

RPD & Periodontal Health -
Controversies
Are removable partial dentures detrimental
to the periodontal tissues?
How to replace lost teeth in a patient
where implants are not possible?
What is the effect of removable partial
denture on Periodontally compromised
dentition?

Does insertion of a partial denture
constitute a risk factor for periodontal
health?

RPD & Periodontal Health –
The Facts
Most of the studies have shown that RPDs
promote plaque formation, cause gingival
recession and deterioration of periodontal
health.
However, a very few controlled trials have
compared the effect of RPD in different
groups of patients over long time.

The Facts Cont……
Some of the studies while showing
increased plaque accumulation did not
reveal worsening of periodontal status.
In one study mobility status were improved
following insertion of RPDs.
No systematic review is available since
there were huge differences in the
periodontal status & the design of RPDs
among different groups of patients.

The Facts Contd……
Teeth particularly in contact with RPDs
such as lingual or palatal plates exhibited
more changes.
Patients who practiced optimal oral
hygiene did not show any deterioration in
their periodontal health after insertion of
RPDs.

RPD & Periodontal Health –
Position
RPDs per se do not constitute a risk factor
for periodontal disease.
Patients with poor oral hygiene are not
candidates for RPDs.
Well designed RPDs in patients who
practice optimal oral hygiene may in fact
preserve periodontal tissues.
The design of RPDs has a major role in
preventing periodontal complications.

Mucogingival problems &
their management

Mucogingival problems & their
management - Controversies
Is a minimum zone of attached gingiva
mandatory?
If found narrow should the width of the
keratinised gingiva augmented inevitably?
When orthodontic treatment is planned
should the augmentation be done prior to
or later?
Is vestibuloplasty necessary for solely
Periodontal reasons?

What are the indications for frenectomy?
Should frenectomy done before or after
Orthodontic treatment in case of mid line
diastema?
How predictable and sustainable are the
root coverage procedures?

Mucogingival problems & their
management – The Facts
Most of the well controlled studies have
found that if sound oral hygiene measures
are practiced, an individual can maintain
with minimum width of attached gingiva.
Augmentation of keratinised gingiva is
recommended.

The Facts Contd…
Only when there is specific indication such
as persistent inflammation, repeated tooth
brush injury, progressive recession, teeth
selected as an abutment & at implant
sites.

The Facts Contd…
It is better gingival augmentation is done
prior to Orthodontic treatment as contrary
to the earlier believed thought Orthodontic
treatment does not bring about increased
dimension of keratinised gingiva.

The Facts Contd…
Frenectomy is indicated usually in the
maxilla if it is causing problems.
Mandibular frenum seldom needs
intervention. Lingual frenum often required
correction.
Frenectomy should be done after the
orthodontic treatment.

The Facts Contd…
At present only the CAF, SCTG & GTR
have been found to be predictable.
Sustainability of the results obtained
depends upon the host of other factors.

Periodontal
Therapy or Implant
Placement

Periodontal Therapy or Implant
Placement – Controversies
How does the clinician decide whether to
retain the tooth or replace them with
implants?
Should all teeth with questionable
prognosis be extracted and implants
placed?

Periodontal Therapy or
Implant Placement – The Facts
With the present knowledge it is difficult to
predict the outcome of the Periodontal
therapy and the longevity of the teeth
following the Periodontal therapy in a
compromised tooth.
Other factors such as smoking, diabetes,
esthetics, number & distribution of
remaining teeth & the economy play a
major role in decision making.

The Facts Contd…
The success rate and the survival of both
Periodontally well treated tooth and a
properly placed implant are excellent.
Teeth with advanced mobility, extensive
restorations, grade III & IV furcations,
fractures, bone loss up to the apex
requiring complex Endodontic therapy
where the outcome is uncertain may
probably be replaced with implants.

The Facts Contd…
There has been no reports regarding the
outcome of implants placed in cases of
aggressive Periodontitis.

Implant Placement – Position
When there is a reasonable doubt about
the long term prognosis of Periodontal
therapy and implant is certainly a viable
alternative provided all the other factors
are conducive.
Both the modalities of treatment of
properly executed resulted in a survival
rate between 80 – 92%.

Implant Placement – Position
The percentage of dental implants placed
in patients with aggressive forms of
Periodontal diseases is unknown.

Bibliography
 Bordersten A.et al 1981-1984- Effects of non surgical
periodontal therapy Journal of Clinical
Periodontology: 8 & 11:57-76.
 Cobb -1996 – Non Surgical Pocket Therapy,
Mechanical Annals of Periodontology :13:205–210.
 Heitz – Mayfield (2005) – How effective is surgical
therapy compared with non-surgical debridement?
Periodontology 2000:37:72-87
 Ramfjord S.P (1987) - Results of 4 modalities of
Periodontal treatment compared over 5 years.
Journal of Clinical Periodontology:14:445 – 452

Bibliography
 Slots J & Jorgensen (2002) – Effective, safe,
practical & affordable Periodontal antimicrobial
therapy – Where are we going and are we there yet?
Periodontology 2000: 28:298 – 312
 Walker C et al (2004) – Chemotherapeutics :
antibiotics & other antimicrobials : Periodontology
2000:36:146 – 165
 Greenstein G (2002) – Full mouth therapy versus
individual quadrant root planing : a Critical
Commentary : J. Period:73:797 – 812
 Green well et al

Bibliography
 Gianfranco – Periodontology 2000
 American Academy of Periodontology statement
regarding Gingival Curettage : J. P – Oct
2002:73:1229 – 1230
 Grianfranco Carnevale & Wayne B Kaldahl (2000) –
Resective Osseous Surgery – Perio 2000:22:59 -87
 Armitage Gary (2002) classifying Periodontal
diseases, a long standing dilemma – Perio
2002:30:9-23
 Thomas M. V (2004) – Formulating a Periodontal
diagnosis & Prognosis in “Periodontics, Medicine,
Surgery & Implants” – Rose & others (eds)
Mosby:172 – 199

Bibliography
 Harrington G. W. et al (2002) The Periodontal –
Endodontic Controversy – Perio 2000:30:123 – 130
 Genco RJ (1999) – Consensus report – Muco gingival
therapy – Annals of Periodontology:2:702 – 706
 O’Neal R. B (2002) – restoration or implant
placement : a growing treatment planning Quandarz
Perio 2000:30:111 – 122.

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