A New Guide to Nonsurgical Management of Periodontal Disease

The recent advances and surprising popularity of today’s new dental treatments are making this one of the most exciting times in which to practice dentistry. As baby boomers age and gen-X’ers mature, increasing numbers of the adult population who have not visited the dentist or received regular dental care will be coming to the dental office for treatment, both to improve their appearance and maintain their health. A significant number of these new patients, along with existing patients in the practice, will now require periodontal treatment.

In a 1998 study, it was found that over 80% of adults have some form of periodontal disease.1 Over 50% had gingivitis involving an average of three to four teeth. Subgingival calculus was found in 67% of the population. Adult periodontitis with pocket depth greater than or equal to 4 mm was present in 30% of the population, involving an average of three to four teeth. The fact that severe pockets greater than or equal to 6 mm were found in less than 5% of the population shows that periodontal treatment has made an impact on the current adult population. In 1999, it was found that 53% of the adult population between 30 and 90 years of age showed signs of previous periodontal disease, with 20% of the teeth showing attachment loss of at least 3 mm.2 The prevalence of probing depth greater than 3 mm was 63.9%, with 19.6% of examined teeth affected. It was then estimated that at least 35% of the adult population has periodontitis.

While it is obvious that there is now an increasing need for periodontal care, we must be ready to provide it with proven skill and expertise. A consistent system for evaluation, diagnosis, and treatment must be used if we are to expect a consistently predictable result. The management of periodontal disease is now recognized and considered as “periodontal medicine.” At the 1996 World Workshop in Periodontitis, Offenbacher introduced this term to describe a discipline that focuses on validating the association between oral infection and systemic disease.3 Periodontitis is now recognized as a potential risk factor for cardiovascular disease, and is believed to have an impact on the elevation of blood sugar levels in diabetes.4 Periodontal medicine includes the treatment of periodontal disease by a system of surgical and nonsurgical dental and medical means. This includes use of new drug products such as systemic enzyme suppression that modifies host-destructive pathways, improving host response with low dosage doxycycline (Periostat, Collagenex Pharmaceuticals), application of site-specific anti-infectives, including encapsulated minocycline (Arestin, OraPharma), in addition to scaling, root planing, full-mouth ultrasonics, and prophylaxis.5

With the knowledge we have of the multiple components of the periodontal disease process, we can now manage periodontal disease predictably, optimizing both the oral and systemic health of our patients. With a system to manage periodontal disease that includes an abbreviated probing system to document the patient’s condition and to aid in diagnosis and planning appropriate treatment, it is now easier and more efficient to treat these patients.

This article describes the Stat-Ck System, which we developed to allow the dentist/hygienist to predictably manage the periodontal patient with 4 to 6 mm of pocketing.

The Importance of Probing

Figure 1. A colored probe makes the probing markings easily seen by the patient. Figure 2. The standard silver/black marking probe is very difficult for the patient to see or understand.

As with all successful treatment, a comprehensive periodontal exam must be performed first. It should include a pocket depth probing with six measurements of each tooth: the distobuccal, midbuccal, mesiobuccal, mesiolingual, mid-lingual, and distolingual line angles. Traditionally, these probings are transcribed on a chart that records all measurements. To record pocket depth, most dentists/hygienists use a traditional periodontal probe that has been marked in millimeters. These probing techniques must be synchronized to eliminate the inaccuracies that often arise. The probe should stop at the dentogingival seal. Use of a full-color probe, such as the Hu-Friedy Colorvue, makes it easier to read the probing depths, and for the patient to see the probe and depth of their pockets (Figure 1). The Colorvue is easily read and has band markings in 3, 6, 8, and 11 mm. A novel design allows the tip to be unscrewed and replaced without replacing the entire probe handle. The patient is able to see the probe markings, which are often difficult to see using the standard metal probe with black markings (Figure 2).

Probing has always presented difficulties because the accuracy can be affected by the degree of tissue health, probing force, angle of the probe on entry, probe thickness, patient sensitivity, and visibility and presence of calculus. Despite these difficulties, probing still remains the most reliable method available for evaluating periodontal status.6

There is a system for using this information as a screening technique. In 1992, the ADA and the American Academy of Periodontology introduced periodontal screening and recording (PSR). It was designed to be a simplified probing technique for the screening of periodontal disease.7 It notified the patient that there was a problem and that more comprehensive examination data were necessary before treatment could be performed, or when performed at a recall visit, that further treatment would be necessary.

The Stat-Ck System

Complete recording of periodontal probing readings is time consuming, and the numeric recording system is sometimes confusing to the patient. However, recordings can be abbreviated and a scoring system used that the patient can easily understand. Both have been incorporated into the Stat-Ck System, which presents a treatment system based on these recordings. The deepest pocket depth for each quadrant is selected, assigned a letter grade of A through F, and recorded on an individual Stat-Ck Periodontal Record sheet created for this. Recommended treatment is listed for each grade category, which is based on the understanding of the cause of periodontal disease and our current ability to use combined therapies.

Since the oral exam of all dental patients should include periodontal probing, the Stat-Ck Periodontal Record allows the dentist to assess, inform, and recommend appropriate periodontal care for the patient’s condition. The baseline data collected allows the dentist to detect periodontal disease at an early state. The Stat-Ck System is designed to aid in diagnosis and treatment of the patient with pocket depths of 4 to 6 mm, who previously may have gone unassessed and/or untreated. It also allows the dentist to implement treatment to successfully manage periodontal disease nonsurgically, provided that the patient will complete the necessary recommended treatment and continue with periodontal follow-up care.

One goal of the periodontal exam should be to establish effective patient communication about periodontal disease and its prevention and treatment. The Stat-Ck System creates a visual awareness of periodontal disease for the patient. It also creates a similar awareness for the entire staff, including the front desk personnel and the dental assistants. It educates the patient and allows the staff to understand the guidelines for early diagnosis, prevention, and treatment of periodontal disease. When completed, the dentist has obtained the necessary information on which to base a diagnosis and treatment plan.

While this sounds easy, getting patients to accept the necessary care, start treatment, and stay on a regular follow-up schedule for supportive care is not always a simple thing to accomplish. However, with the Stat-Ck grading system, an increased awareness of disease/health is created, and support of the patient by the entire office staff will make this task easier to achieve. While the dentist/hygienist in the 21st century should be the “CEO” of supervised periodontal care,8 patients must become active as the recipients of the necessary care, and do their small part at home to help treatment succeed. If they know that following this system can help them avoid the surgical knife, they will always be more compliant.

Documentation of a patient’s condition is critical if we are to achieve success with our treatment. In a survey of 2,500 dentists, McFall and colleagues9 found that the diagnostic information describing their patients’ periodontal conditions was inadequate. Very few probings were taken, and a periodontal diagnosis was made in only 16% of the patients, with bleeding noted in only 13% of the records. In speaking to many general dentists and hygienists around the country, a common problem we have found is that the patients’ conditions are not known to them before their office visits. Because of this, there is often not enough chair time allowed for the necessary new patient periodontal exam, and sometimes for the evaluation and treatment of the recall patient.

With the Stat-Ck Record System, an examination can be completed in as little as 2 to 3 minutes. The recording system has been simplified. A complete six-point periodontal probing of all the teeth is performed and recorded by quadrant. However, only the deepest probing is recorded for that quadrant, represented by a grade of A through F. In place of the traditional numerical probing record, giving your patient a letter grade allows them to relate their condition to pass/health and fail/disease. These grades reflect the deepest pocket in each quadrant (see Figure 9), representing the following conditions: A = Asymptomatic/Healthy (4 mm or less); B = Bleeding (4 mm or less); C = Calculus (4 mm or less); D = Depth, when probing (5 to 6 mm); and F =  Failing (greater than 6 mm).

The Stat-Ck Record System is a time saver and can give the dentist/hygienist significant information about the patient’s condition. With its grading system, patients will easily understand their condition and be more likely to accept the treatment necessary to correct their condition. It is not intended to replace a complete periodontal exam. Using it to evaluate the periodontal status of your patients will also satisfy the medical-legal requirements for evaluation and documentation.

Patients readily understand the concept of being graded, much like they were in school. They understand that an “A” is passing, while “F” is a failing condition. With the Stat-Ck system, patients are made aware that their condition can improve. This is additional motivation for them to begin treatment.

For all patients, treatment protocol recommendations include sharpening hand instruments prior to treatment. This is best done with the new PerioStar 3000 (Kerr-Hawe Neos), which machine sharpens the instrument to a razor sharp edge, preserving the cutting edge far better than manual sharpening.10 It also makes the root planing of the tooth much less traumatic. Optical magnification, as with the Orascoptic system of loupes, should be used when performing the exam and when providing treatment. Magnification permits much better vision while working, therefore improving our ability to treat because we can see so much more. What we cannot see cannot be treated. Ultrasonic subgingival debridement of the full mouth should be done at each visit, which can further improve the outcome of treatment. And the treatment should be painless, made easier with the use of topical and local anesthetics and nitrous oxide analgesia, where needed.

Figure 3. Type A Stat-Ck is a grade "A" patient.

The Stat-Ck Grade “A” patient (Figure 3) is asymptomatic. There is 4 mm or less of pocket depth probing, and no bleeding on probing (BOP) or subgingival debris present. Treatment guidelines for this patient would be a routine prophy.

Figure 4. Type B Stat-Ck is a grade "B" patient.

The Grade “B” patient (Figure 4) has BOP at any site in the quadrant. There is 4 mm or less of pocket depth at any site, and there is no subgingival debris present. Treatment guidelines for this patient are scaling, full-mouth ultrasonics, prophy, and host modulation, suggested to be used when bleeding persists.

Figure 5. Type C Stat-Ck is a grade "C" patient.

The Grade “C” patient (Figure 5) has calculus (subgingival debris) and BOP present at any site in the quadrant. There is 4 mm or less of pocket depth at any site. Treatment guidelines for this patient are scaling, root planing, full-mouth ultrasonics, prophy, and host modulation, suggested to be used when bleeding persists.

Figure 6. Type D Stat-Ck is a grade "D" patient.

The Grade “D” patient (Figure 6) has pocket depths of 5 to 6 mm, with calculus and/or BOP present at any site in the quadrant. Treatment guidelines include scaling, root planing, full- mouth ultrasonics, prophy, host modulation (for at least 3 months), and application of site-specific anti-infectives where the pockets are 5 to 6 mm.

Figure 7. Type F Stat-Ck is a grade "F" patient.

The Grade “F” patient (Figure 7) has pocket depths greater than 6 mm, with calculus and BOP present at any site in the quadrant. Treatment guidelines include scaling, root planing, full- mouth ultrasonics, prophy, host modulation, and application of site-specific anti-infectives where the pockets are 5 mm or greater. These patients should be considered for referral to the periodontist.

The Stat-Ck System was designed to offer guidelines for successful periodontal management of patients with early-stage disease. Since 80% of the patients who have the disease are in the early stages,1 these are the cases the general dentist should select to treat. However, it is important to have a good working relationship with a periodontist, to whom the “F” patients can be referred for treatment.

Guidelines for referral to a periodontist include a case advanced beyond your comfort level, a behavior management problem, a case with nonresponsive problem sites, or simply a patient you can’t or don’t want to handle in your office. Certainly, if the “F” patient refuses referral and/or refuses to consider surgery, the Stat-Ck guidelines can be utilized with the proviso to the patient that it may not control or successfully manage their condition. The responsibility for this condition then lies with the patient.

The Grade “A” and “B” patients should focus their attention on home care. This type of prevention is still the key to successful nonsurgical periodontal treatment.11 Aggressive inteproximal cleaning must always be done, and is best started with a power brush, such as the Sonicare (Philips Oral Healthcare, Inc). Plaque levels can now be significantly reduced using the Sonicare. Stabilized chlorine dioxide rinses and paste (such as Oxyfresh), which can be dispensed directly to the patient from the dental office, reduce the adverse effect of the plaque by reducing hydrogen sulfide levels, which can cause bad breath and be responsible for the progression of periodontal disease. Even the absolute best dentistry will fail in the absence of proper home care, which must be as state-of-the-art as your treatment in the presence of active periodontal disease. Proper instructions and handout reminders should accompany the patient home.

Figure 8. The Complete Stat-Ck Record sheet for scoring quadrant grades.


Figure 9. Stat-Ck Record for initial visit.

The Stat-Ck Record sheet allows for recording the quadrant grades (Figure 8). For the initial visit, it has space in a box that can be checked for each quadrant where a site-specific anti-infective such as Arestin is placed. There is also a line for marking the date if a prescription has been written for host modulation (Periostat). This is illustrated in Figure 9. It also lists the diagnostic Grade Book categories “A” through “F,” with criteria for these categories and the treatment guidelines.

Figure 10. Stat-Ck recall visit record.

There are also nine additional boxes below this for Follow-Up Stat-Ck Periodontal Records. An example of this box is illustrated in Figure 10. Presuming that these records are done on a 3-month interval, a total of 30 months can be recorded on one sheet. The patient can be given this at their visit as a “report card” status of their condition, which they can compare with prior recordings. It reassures the patient of their improvement, or puts them on notice of the need for additional care.

We have used this system successfully in 1,000 patients to manage their periodontal conditions nonsurgically. Currently, many offices that have adopted a system for their nonsurgical management program for periodontal disease are participating in a data collection study to further verify the efficacy of the Stat-Ck System.

Conclusion

The Stat-Ck System is an exciting and effective way to predictably manage the periodontal patient with 4- to 6- mm pockets. Coaching of the office staff by an outside, experienced third party that is directly familiar with nonsurgical periodontal care as discussed is suggested to help make it easier to adapt this new technology to the practice and obtain top performance results. Such help makes it easier to assist the patient in making the right decision to accept the recommended and necessary care, and will mentor the practice through the desired change. Traditionally, after a new system is introduced it is often tempting to go back to the old way of doing things when the schedule is busy. Coaching will maintain the consistency and commitment necessary to make the system succeed.

The Stat-Ck System will help the practice continue its growth and be more successful in providing care that the patient both needs and wants. Its use will make the patient happier, with fewer complaints, and as our main goal, much healthier.


References

1. Oliver RC, Brown LJ, Loe H. Periodontal diseases in the US population. J Periodontol. 1998;69:269-278.

2. Albandar JM, Brunelle JA, Kingman A. Destructive periodontal disease in adults 30 years of age and older in the US, from 1988 through 1994.  J Periodontol. 1999;70:13-29.

3. Offenbacher S. Periodontal diseases: pathogenesis. Ann Periodontol. 1996; 1:821-878.

4. Beck JD, Garcia RG, Russ G, et.al. Periodontal disease and cardiovascular disease. J Periodontol. 1996;67:1123-1137.

5. Gottehrer N, Donley T. A current protocol for nonsurgical periodontal therapy. Dent Today. 2001;20:76-81.

6. Knocht A, Zohn H, Deasy M, et al. Screening for periodontal disease: radiographs versus PSP. J Am Dent Assoc. 1999;127:749.

7. ADA, AAP. Periodontal Screening and Recording Training Program Kit. Chicago, 1992.

8. Gottehrer N, Blitzer R. The 21st century dentist: the CEO of supervised periodontal care. Dent Today. 2000;19:105-109.

9. McFall WT Jr, Bader JD, Rozier RG, et al. Presence of periodontal data in patient records of dental practitioners. J Periodontol. 1988;59:445-449.

10. Bowker A, Cutts J, Kendall A, et al. A Comparison of Mechanical and Manual Sharpening Techniques on Universal Curets (private study). Loma Linda Univ. Dental Hygiene,2001.

11. Gottehrer N, Light D. Prevention: the key to successful nonsurgical periodontal treatment. Dent Today. 2002;21:85.



Dr. Gottehrer has maintained a private practice in aesthetics, periodontics, and implant dentistry in Havertown and Abington, Pa, since 1975. He is a board certified diplomate of the American Academy of Periodontology and is former assistant clinical professor of oral medicine at the New York University College of Dentistry. He can be reached at (610) 449-9500 or This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Disclosure: Dr. Gottehrer is chief medical officer of Dynamic Dental Systems, Inc, which developed the Stat-Ck System.

Mr. Shirdan began in dentistry managing the practice of a local solo Philadelphia general practice for 5 years. During this period he began to consult with other local dentists applying the skills he developed outside the dental field. In 1989, he founded Systems Practice Management, Inc, a dental practice management and consulting firm. He has been a consulting advisor for customers of one of the largest dental supply companies. Mr. Shirdan’s primary focus has been working with hundreds of practices to create systems for treatment planning, staff training, goal attainment, internal and external marketing, computer system integration, and graphic design. His seminars and management services are focused, practical, and generate results for the committed dental professional. His clients have experienced overwhelming financial growth while effectively experiencing harmony with the entire dental team. He can be reached at (610) 494-8571.



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