Diagnosis of Periodontal Disease

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A little background first... I am a young dentist (graduated last year). I am now working for a dental corporation, and for the most part it has been a great experience... Much better than I anticipated.

Anyways... The company I work for is really pro-diagnosis of perio. If there is a 4 mm pocket you better be SRP... Which obviously isn't always the case. You have to take into account pocket depth, bone loss, recession, BOP, other local and systemic factors, etc. The corporation I work for is also pro-Arestin placement in every single pocket 5-6 mm, regardless of other findings. And some of the hygienists I work with feel that if you have to take a Cavitron out it's SRP. They also feel that if there is any subgingival calculus, it's SRP no matter what. It's also frustrating because they are talking to patients about bone loss when in fact a lot of times they don't have any (the crest of alveolar bone is within 1-2 mm of the CEJ).

We were taught that subgingival calculus is not a definite indication for SRP, especially in the absence of BOP, absence of pockets 4 mm and higher, and absence of bone loss. I was just curious what some other dentists do. What do you do to diagnose perio in patients, particularly those who might need localized SRP? How do you feel about Arestin? How often are you utilizing it in your practice and what are the indications?

Also... And maybe this is something I never fully grasped... But is motto true "once a perio patient, always a perio patient?" Are these patients always on perio maintenance, or if the disease is stabilized can they put back on regular prophies?

I'm interested to hear what others have to say. Thanks!

Originally Posted by Halcion

A little background first... I am a young dentist (graduated last year). I am now working for a dental corporation, and for the most part it has been a great experience... Much better than I anticipated.

Anyways... The company I work for is really pro-diagnosis of perio. If there is a 4 mm pocket you better be SRP... Which obviously isn't always the case. You have to take into account pocket depth, bone loss, recession, BOP, other local and systemic factors, etc. The corporation I work for is also pro-Arestin placement in every single pocket 5-6 mm, regardless of other findings. And some of the hygienists I work with feel that if you have to take a Cavitron out it's SRP. They also feel that if there is any subgingival calculus, it's SRP no matter what. It's also frustrating because they are talking to patients about bone loss when in fact a lot of times they don't have any (the crest of alveolar bone is within 1-2 mm of the CEJ).

We were taught that subgingival calculus is not a definite indication for SRP, especially in the absence of BOP, absence of pockets 4 mm and higher, and absence of bone loss. I was just curious what some other dentists do. What do you do to diagnose perio in patients, particularly those who might need localized SRP? How do you feel about Arestin? How often are you utilizing it in your practice and what are the indications?

Also... And maybe this is something I never fully grasped... But is motto true "once a perio patient, always a perio patient?" Are these patients always on perio maintenance, or if the disease is stabilized can they put back on regular prophies?

I'm interested to hear what others have to say. Thanks!

this to me just seems like ways they are pumping up their bottom line. i mean, at $20-40 per site for Arestin, of course they will want you to use it all the time. and your prerequisites for justifying SRP is just a bit overkill. hygienist everywhere use cavitron's for prophies all the time. as for the perio mantra "once a perio pt...", well i asked this one day and basically the logic was that you can do what you can to get rid of bad bugs, but they are always there in higher concentrations than someone that has never progressed to perio dx (G- anaerobes, etc). gotta make sure those pt's dont "fall of the wagon" per se.

Your practice is not practicing beyond the norm, but is on the threshold of what is considered normal/overtreatment IMHO

If the radiographic bone height is within 1-2 mm of the CEJ then the patient actually has lost bone, so that's not a lie. Remember that as a teenager, the bone height is usually right at the CEJ. Then, on any normal, healthy person, it starts to go down a little bit and then you see it between 0-1 mm from the CEJ. So if you're patients come in with bone levels over 1mm from the CEJ, they have "lost bone" but that doesn't really mean they have horrible periodontitis that is going to make their teeth fall out in 10 years. It's the technicality. You might wanna pull up a few of your hygienists radiographs one day and ask them if they see bone loss severe enough to warrant a deep cleaning.

All this aside, your office is pushing the Perio. It's not alone in doing so. The only thing you need to do is figure out where you want to sit on this fence and then clearly define it with observable criteria. For example, define that if a new patient comes in with 2 of the following criteria then they need Scaling and Root Planing:

- pockets of 4mm or greater on 3 or more teeth in one quadrant
- generalized BOP (not applicable for smokers)
- radiographically evident subgingival calculus
- gross, visually evident calculus

Then also make clear determinations about recall periods and when ScRP is needed again. So long as you have a set system that you follow like a flow chart for making your decisions and don't let your "gut" guide you, you are covering yourself.

Doctors use flow charts for making decisions all the time, and perio should be the same way so that you are consistent, even if that means you are consistently aggressive.

Originally Posted by Halcion

A little background first... I am a young dentist (graduated last year). I am now working for a dental corporation, and for the most part it has been a great experience... Much better than I anticipated.

Anyways... The company I work for is really pro-diagnosis of perio. If there is a 4 mm pocket you better be SRP... Which obviously isn't always the case. You have to take into account pocket depth, bone loss, recession, BOP, other local and systemic factors, etc. The corporation I work for is also pro-Arestin placement in every single pocket 5-6 mm, regardless of other findings. And some of the hygienists I work with feel that if you have to take a Cavitron out it's SRP. They also feel that if there is any subgingival calculus, it's SRP no matter what. It's also frustrating because they are talking to patients about bone loss when in fact a lot of times they don't have any (the crest of alveolar bone is within 1-2 mm of the CEJ).

We were taught that subgingival calculus is not a definite indication for SRP, especially in the absence of BOP, absence of pockets 4 mm and higher, and absence of bone loss. I was just curious what some other dentists do. What do you do to diagnose perio in patients, particularly those who might need localized SRP? How do you feel about Arestin? How often are you utilizing it in your practice and what are the indications?

Also... And maybe this is something I never fully grasped... But is motto true "once a perio patient, always a perio patient?" Are these patients always on perio maintenance, or if the disease is stabilized can they put back on regular prophies?

I'm interested to hear what others have to say. Thanks!

For a healthy pocket, the periodontal attachment should be at the CEJ. Attachment loss occurs when the perio probe goes beyond the CEJ level….this means that the root surface is exposed and this pt has a perio problem….scaling/root planning (SRP) is indicated for this patient. But if the attachment is at the CEJ and patient has a 4-5mm pocket, this probably is a pseudo pocket (swollen gingiva)….then regular cleaning, brushing, flossing should be good enough.

Instead of giving the patients the Arestin, why not just spend more time teaching the patients how to brush and floss properly? And stress the importance of brushing and flossing daily?

If the pocket depth returns to the normal level of 2-3mm after the initial therapy (SRP), then the patient can be put back on regular cleanings every 6 month. But if the pockets are still 5-6mm after the initial therapy, then the patient has two choices: a). SRP under local anesthesia every 3 months for the rest of his/her life or b). Pocket reduction surgery to bring the deep pocket back to the normal 2-3mm level. The surgery is obviously a better option. Remember, the toothbrush cannot reach the area deeper than 2-3mm.

My 2 cents