Perio Midterm Flashcards
How many stages and grades are assigned to each perio pt?
1 stage + 1 grade
What is the severity of perio diagnosis based on?
Most severe tooth
Your assessment of expected outcomes of suggested tx modalities
Prognosis
What are the different prognoses?
Favorable
Questionable
Unfavorable
Hopeless
Which prognosis?
Perio status of the tooth can be stabilized with comprehensive periodontal tx and maintenance.
Favorable
Which prognosis?
Future loss of the periodontal supporting tissues is unlikely if these conditions are met
Favorable
Which prognosis?
Perio status of the tooth is influenced by local and/or systemic factors that may or may not be able to be controlled.
Questionable
Which prognosis?
The periodontium can be stabilized with comprehensive treatment and periodontal maintenance if these factors are controlled; otherwise, future periodontal
breakdown may occur
Questionable
Which prognosis?
Periodo status of the tooth is influenced by local and/or systemic factors that cannot be controlled
Unfavorable
Which prognosis?
Periodontal breakdown is likely to occur even with comprehensive periodontal tx and maintenance
Unfavorable
Which prognosis?
Tooth must be extracted
Hopeless
What is the only evidence based prognosis scheme for molars with furcations?
Miller prognosis
What is the goal for Miller prognosis?
Score of < 5
What are the 4 categories of perio health?
Pristine perio health
Clinical perio health
Perio disease stability
Perio disease remission/control
Which category of perio health?
Absence of pocket depth > 3mm
(exception = most distal molar)
Pristine perio health
Which category of perio health?
Absence of attachment loss
Pristine perio health
Which category of perio health?
BOP < 10%
Pristine perio health
Clinical perio health
Which category of perio health?
Absence of clinical erythema, edema, pus
Pristine perio health
Clinical perio health
Which catgeory of perio health?
Can contain attachment loss due to recession
Clinical perio health
Which category of perio health?
No pocket depths of clinical importance (pseudopockets)
Clinical perio health
Which category of perio health?
Absence of minimal levels of clinical inflammation
Clinical perio health
Which category of perio health?
Normal osseous support
Clinical perio health
Which category of perio health?
Absence of inflammation and infection, but reduced periodontium
Perio disease stability
Which category of perio health?
Goal of perio patients
Perio disease stability
Which category of perio health?
Reducing predisposing factors and controlling modifying factors
Perio disease stability
Which category of perio health?
Cannot fully control modifying and predisposing factors
Perio disease remission/control
Which category of perio health?
Decreased inflammation and improvement in clinical parameters
Perio disease remission/control
Which category of perio health?
Stabilization of disease progression to low disease activity
Perio disease remission/control
Which category of perio health?
May be an acceptable alternative therapeutic goal in long-standing disease
Perio disease remission/control
Minimal recession without pre-existing active perio disease (ex: brushing too hard, ortho, etc)
Health
Denotes a healthy state in a patient with a previously diagnosed perio disease (attachment loss)
Stability
For patients with reduced periodontium
for any reason (recession, crown
lengthening procedure, or history of
periodontal therapy), as long as PDs
are ≤3 mm, the diagnosis is _____________
Gingivitis/inflammation on a reduced periodontium
For patients with a history of periodontitis, PDs ≥4 mm with BOP (at the same sites) indicate _______________
Recurrence of disease
Describe Step 1: initial case overview to assess disease
Full mouth PDs
Full mouth X-Rays
Missing teeth
Mild-moderate perio is usually Stage I or II
Severe-very severe perio is usually Stage III or IV
Describe Step 2: establish stage (for mild-moderate perio)
Confirm CAL
Rule out non-perio causes of CAL
Determine max CAL or radiographic bone loss (RBL)
Confirm RBL patterns
Describe Step 2: establish stage (for moderate-severe perio)
Determine max CAL or RBL
Confirm RBL patterns
Assess tooth loss due to perio
Evaluate case complexity factors
Describe Step 3: establish grade
Calculate RBL (% of root length x 100) divided by age
Assess risk factors
Measure response to SRP & plaque control
Assess expected rate of bone loss
Conduct detailed risk assessment
Account for medical/systemic inflammatory considerations
Root length, CAL, and CP for Stage I chronic perio
Root length = 15%
CAL = 1-2
CP = slight
Root length, CAL, and CP for Stage III or IV chronic perio
Root length = >30%
CAL = >5mm
CP = severe
PDs and gingival margin enteries are required for ____ sites and _____ teeth present at time of evaluation
all; all
If you have a PD of 3mm or less, what do you put in the GM?
Negative reciprocal, or blank
If you have a PD of 4mm or greater with CAL, what do you put in the GM?
-2 or blank
What do you enter when you see recession?
Positive numbers
What do you enter when you see pseudo-pockets?
Negative numbers
What do you enter when gingival margin is at the CEJ?
0
Go through the diagnosis sequence for chronic perio
Start with generalized or localized
Enter stage and grade
Enter chronic perio at end
(Ex: Generalized Stage I Grade B chronic perio)
Probing is considered what type of procedure?
Invasive
(premed, other consults may be necessary)
How often must a dental exam be updated (D0180)?
Anually
What code is used for a dental exam?
D0180
What must you use during a dental exam?
Disclosure stain for plaque index
What are the 3 major components of a perio exam?
Diagnosis, treatment plan, prognosis
What code is used for OHI?
D1330
Chronic perio is most prevalent in what age group?
Adults
(can occur in children too tho)
Patients diagnosed with chronic perio under 25 years old must be evaluated for a differential diagnosis of what?
Molar/incisor pattern perio
What should you assess in a patient with chronic perio?
Localized bone loss of 1st molar and incisors
Assess OH
The amount of destruction present in chronic perio is consistent with the presence of what?
Local factors (ex: primary and secondary etiologic factors)
What is a frequent finding in chronic perio?
Subgingival calc
What is chronic perio associated with?
Variable microbial pattern
Predisposing factors
Systemic diseases (diabetes, HIV)
Describe the rate of progression of chronic perio
Slow/moderate
(but can have periods of rapid destruction)
How can chronic perio be further classified?
Extent and severity
What can chronic perio be modified by (other than systemic diseases)?
Cig smoking
Emotional stress
Localized vs generalized chronic perio is based on what?
% of sites affected
30% or greater = generalized
30% or less = localized
Describe severity CAL and Armitage system of diagnosis (outdated but seen in chart notes)
Slight chronic perio = 1-2mm CAL
Moderate chronic perio = 3-4mm CAL
Severe chronic perio = 5+mm CAL
What is “CAL”?
Clinical/calculated attachment loss
What should you do for a patient with > than 3mm pockets without loss in CAL?
Enter appropriate negative number OR leave blank
What must be entered into the appropriate charting for ID?
Pseudopockets
T/F: Pts with subgingival calculus on enamel w/o CAL are not appropriate for SRP codes
True
What is the code for scaling with inflammation?
D4346
What is the code for scaling/root planing?
D4341, D4342
Which types of patients are likely to have pseudo pockets?
Young pts with edema and subgingival calc
Pts with associated pharmacologic effects
Exposure of root surface by apical shift in position of gingiva
Recession
Apical migration of JE; apical shift of gingiva
Root exposure
CEJ to the attachment
Actual recession
Visible on clinical exam; gingiva margin to CEJ
Apparent recession
Level of attached perio tissue; not directly visible, but determined by probing
Actual position
Level of gingival margin or crest of free gingiva that is seen by direct vision
Apparent position
What are the 2 causes of recession?
Pt self-care
Anatomical
What are the reasons for recession due to pt self-care?
Incorrect brushing
Abrasive toothpaste
Hard brush
What are the reasons for recession due to anatomy?
Eruption pattern
Position of tooth in alveolus
What gingival phenotype?
Probe visible
Thin (<1mm)
What gingival phenotype?
Probe not visible
Thick (>1mm)
What recession type?
No loss of interproximal attachment. CEJ is clinically not detectable at both mesial and distal aspects of tooth
Recession Type 1
What recession type?
Associated with loss of interproximal
attachment. The amount of inter-proximal attachment loss is less than or equal to the buccal attachment loss
Recession Type 2
Measured from the interproximal CEJ to the depth of the interproximal sulcus/pocket
Interproximal attachment loss
Measured from the buccal CEJ to the apical end of the buccal sulcus/pocket
Buccal attachment loss
What recession type?
Associated with loss of interproximal attachment. The amount of inter-proximal attachment loss is higher than the buccal attachment loss
Recession Type 3
What class? (Miller)
Recession not to MGJ; no interproximal bone or papilla loss; 100% coverage
Class 1
What class? (Miller)
Recession past MGJ; no interproximal bone or papilla loss; 100% coverage; possibility of root coverage
Class 2
What class? (Miller)
Recession past MGJ; interproximal bone or papilla loss; malposition; partial coverage
Class 3
What class? (Miller)
Recession past MGJ; severe interproximal bone or papilla loss; malposition; no coverage
Class 4
What scenarios does the gingival margin go to the CEJ (loss of attachment)?
Previous perio therapy
Recession
Attrition w/ age
Malposition teeth
What is the easiest way to identify gingival margin at the CEJ (loss of attachment)?
Embrasure space btwn 2 teeth is NOT filled with gingival tissue/papilla
What probe do you use to find furcations?
Nabers
Which furcation class?
Depression that does not catch probe
Class I
Which furcation class?
Furcation deep enough to catch probe, but not continuous w/ other furcations on same tooth
Class II
Which furcation class?
Bone loss through and through, but covered with gingival tissue
Class III
Which furcation class?
Bone loss through and through, directly exposed to oral environment, gingival margin is apical to entrance of furcation
Class IV
Marker of disease activity
Bleeding on probing
Should BOP be noted in chart?
YES - it is a marker of disease activity
Measures actual positives correctly identified (% of population that has a condition)
Sensitivity
Measures the actual negatives correctly identified (% of population that does NOT have a condition)
Specificity
BOP specificity/sensitivty
High specificity
Low sensitivity
Degree of looseness of a tooth when we move it
Mobility
What is mobility caused by?
Inflammation, bone loss, trauma
Which degree of mobility?
Within physiologic limits
0
Which degree of mobility?
< than 1mm BL/MD direction
1
Which degree of mobility?
1mm+ in BL/MD direction
2
Which degree of mobility?
Exceeding 1mm and depressible occluso-apical direction
3
Movement of teeth during function or parafunction
Functional mobility
Often detected earlier than bidigital tooth mobility and has been associated in the presence of inflammation, with increased bone
and attachment loss; pocket formation
Fremitus
How is fremitus seen/felt?
Place index finger on labial surface and pt grinds in lateral and protrusive movements
How do you measure the amount of attached gingiva?
Measure probing depth (ex: 2mm)
Measure height of keratinized gingiva (ex: 7mm)
Attached gingiva = keratinized gingiva - PD
Attached gingiva = 7-2 = 5mm
What do you enter in the GM in chart if there is recession?
+ number
What do you enter in the GM in chart if there is a PD of 3mm or less?
Reciprocal of PD or blank
What do you enter in the GM in chart if there is a pseudopocket?
Reciprocal of PD
What do you enter in the GM in chart if there is a PD of 3mm or greater and the pt has perio?
-2
What do you enter in the GM in chart if the free gingival margin is at the CEJ?
0
If you have a PD of 4mm or greater, what should you be thinking based on X-Rays and clinical impression?
“Where am I headed”
What should you do if you can’t probe?
Tell faculty
Triage X-Rays for exts
Plan SRP
Obtain baseline measurements quad by quad, appt by appt, AFTER removal of debris
Complete chart on last SRP if appropriate
Never do a full mouth debridement!!
What are the 5 disadvantages of the Armitage severity guidelines?
Time consuming
Inaccuracies from probing angles
Root length disregarded
Difficult to determine CEJ
Systemic diseases/local infections disregarded
What is the new classification based on?
Oncology
What are the 2 main factors of the new classification?
Stage
Grade
Severity and extent of disease at most affected area (CAL, RBL), tooth loss that has occurred bc of perio, complexity assessment of tx required
Stage
Stage is based on the most ________ ______ of perio
severe area
Estimate of future risks, rate of progression, response to therapy, systemic implications
Grade
The apical migration of the attachment apparatus, measured as the distance from the CEJ to the base of the periodontal pocket/sulcus
Clinical attachment loss (CAL)
The new disease classification system uses clinical attachment loss primarily at
___________ sites but may also include buccal/lingual sites
interdental
What factors define perio?
Interdental CAL at 2 or more non-adjacent teeth
OR
Buccal or lingual CAL is 3mm or greater with pockets greater than 3mm at 2 or more teeth
3 main factors to establish severity in staging
- Interdental CAL
- Radiographic bone loss (RBL)
- Tooth loss due to perio
Severity Stage I
Interdental CAL = 1-2mm
RBL = Coronal 1/3 (<15%)
Tooth loss = None
Severity Stage II
Interdental CAL = 3-4mm
RBL = Coronal third (15-33%)
Tooth loss = None
Severity Stage III
Interdental CAL = 5mm+
RBL = Middle 1/3 of root+
Tooth loss = 4 teeth or less
Severity Stage IV
Interdental CAL = 5mm+
RBL = Middle 1/3 of root+
Tooth loss = 5 teeth+
7 main factors to establish complexity in staging
- PD
- Type of bone loss
- Furcation
- Ridge defect
- Masticatory dysfunction
- Occlusal trauma
- Bite collapse, drifting, flaring
Complexity Stage I
PD = 4mm or less
Bone loss = horizontal
Complexity Stage II
PD = 5mm or less
Bone loss = horizontal
Complexity Stage III
PD = 6mm+
Bone loss = vertical, 3mm+
Furcation = class II or III
Ridge defect = moderate
Complexity Stage IV
PD = 6mm+
Bone loss = vertical, 3mm+
Furcation = class II or III
Ridge defect = severe
Masticatory dysfunction
Secondary occlusal trauma (mobility degree 2+)
Bite collapse, drifting, flaring
Remaining teeth = <20
For each stage, how do you describe extent as?
Localized (<30% teeth involved)
Generalized (>30% teeth involved)
Molar/incisor pattern
Which stage?
Pt shows perio of mild to moderate severity
Stage I and II
Which stage?
Pt has not lost any teeth due to disease
Stage I and II
Which stage?
More complex; require more advanced perio tx
Stage III and IV
Which stage?
Extent of tooth loss requires extensive rehab
Stage IV
Allows the clinician to incorporate individual patient factors into the diagnosis, which are crucial to comprehensive case management
Grade
Observed/inferred progression rate; risk for further deterioration due to environmental exposures (e.g., smoking) and co-morbidities (e.g., diabetes); risk that disease or treatment may adversely affect general healthy
Grade
What are the 3 fundamental principles that grading is based on?
- Not everyone is equally susceptible to perio
- Perio progression/severity is due to many influences on a response to microbial challenge
- Some cases require more intensive control of biofilm/inflammation than achieved during current principles of care
Grade A progression
Slow
Grade B progression
Moderate
Grade C progression
Rapid
Assume Grade ____ until clinical or medical history provide evidence of more rapid or slower progression, or risk factors increase the probability of more rapid progression
B
3 main factors to establish primary criteria in grading
- CAL or RBL
- % bone loss/age
- Case phenotype
Primary Criteria Grade A slow rate
CAL or RBL = No loss over 5 yrs
% bone loss/age = <0.25
Case phenotype = heavy biofilm; low destruction
Primary Criteria Grade B moderate rate
CAL or RBL = <2mm over 5 yrs
% bone loss/age = 0.25-1.0
Case phenotype = destruction commensurates w/ biofilm
Primary Criteria Grade C rapid rate
CAL or RBL = 2mm+ over 5 yrs
% bone loss/age = 1.0+
Case phenotype = destruction exceeds expectations given biofilm
2 main factors to establish grade modifiers in grading
- Smoking
- Diabetes
Grade Modifiers Grade A slow rate
Smoking = non-smoker
Diabetes = non-diabetic
Grade Modifiers Grade B moderate rate
Smoking = <10 cigs/day
Diabetes = HbA1c < 7%
Grade Modifiers Grade C rapid rate
Smoking = 10+ cigs/day
Diabetes = HbA1c is 7%+
Revision of Grade upwards is possible if the % bone loss / age ratio _________ substantially or the risk profile of the patient __________
increases; decreases
What are the 3 steps to staging and grading a patient?
- Initial case overview
- Stage
- Grade
Which step to staging/grading a patient?
Screen:
Full mouth PD
FMX
Missing teeth
Step 1 - initial case overview
Which step to staging/grading a patient?
Mild/moderate perio:
Confirm CAL; rule out non-perio causes
Determine max CAL or RBL
Confirm RBL patterns
Step 2 - staging
Which step to staging/grading a patient?
Moderate/severe perio:
Determine max CAL or RBL
Confirm RBL patterns
Assess tooth loss due to perio
Evaluate for complexity
Step 2 - staging
Which step to staging/grading a patient?
Calculate RBL/age
Assess risk factors (smoking, diabetes)
Measure response to SRP/plaque control
Assess expected rate of bone loss
Detailed risk assessment
Medical and systemic inflammatory considerations
Step 3 - grading
What are the 3 diagnostic aids for implant health?
Visual inspection
Probing
X-rays at 1 yr and after abutment connection
Absence of erythema, bleeding on probing, swelling, and suppuration.
Peri-implant health
The main characteristic is BOP on gentle probing; erythema, swelling, and/or suppuration may also be present
Peri-implant mucositis
Increased PD; absence of additional bone loss beyond initial bone remodeling
Peri-implant mucositis
What is the cause of peri-implant mucositis?
Plaque
Plaque-associated pathological condition,
characterized by inflammation in the peri-implant mucosa and subsequent progressive bone loss
Peri-implantitis
Clinical signs of inflammation, increased probing depths, and/or mucosal recession in addition to loss of supportive bone
Peri-implantitis
Absence of erythema (inflammation), BOP, swelling, and suppuration with no bone loss < 2.0 mm
Peri-implant health
Inflammation, presence of BOP, swelling, no BL < 2.0 mm, and strong evidence that plaque (biofilm) is the etiologic factor
Peri-implant mucositis
Inflammation, plaque-associated pathological condition in tissue, PD ≥ 4–8 mm, and subsequent progressive BL
Peri-implantitis
Records should include previous radiographs, PD at one-year postload.
In the absence of a previous exam, refer to the guidelines for peri-implantitis, PD ≥ 6 mm, BOP, and BL ≥ 3 mm with concurrent peri-implantitis diagnosis
Peri-implantitis in absence of previous exam
Conditions following the normal healing process of tooth loss that leads to diminished dimensions of the alveolar process/ridge, resulting in both hard- and soft-tissue deficiencies
Peri-implant soft/hard tissue deficiencies
All competencies must have an approved _____ entered in axium
plaque index
T/F: DO NOT polish calc
True
What is the code for dental prophylaxis?
D1110
What must be present in order to do SRP (D4341/D4342)?
Attachment loss
PDs 4mm+
When should you polish?
Only at re-eval appt
What is the code for perio re-eval?
D0171P
At the re-eval, PDs greater than what require referral to grad perio?
6mm
At the re-eval, what Stages/Grades require referral to grad perio?
Stage III/IV and/or Grade C
At the re-eval, how many sites with PDs of 5mm with BOP require referral to grad perio?
3+ sites
What is the code for perio maintenance?
D4910
What do you remove in a perio maintenance (D4910) appt?
Plaque, calc, stain
What is part of the perio maintenance code explanation (D4910)?
Limited SRP w/ anesthesia
Do NOT confused which 2 codes/appts?
Perio maintenance (D4910) and Prophy (D1110)
Insurance fraud!
What is the order of the tx plan?
Begin with OHI
Choose btwn prophy, SRP, scaling w/ inflammation
Re-eval 4-6 weeks after SRP
Recall or maintenance
What 2 clinical observations are an automatic Stage III?
Vertical bone loss 3mm+
Furcation involvement of Class II/III
What clinical observation is an automatic Stage IV?
<20 remaining teeth
Why should you not cross the midline during SRP?
Don’t want tongue to be completely numb
Want to give pt. one “good”/not sore side to chew on after tx
At the re-eval, what should you never tx plan for?
Another round of SRP and re-eval
