Labelled diagram of periodontal anatomy showing the relationship between the tooth and surrounding tissues. Visible labels include 'Sulcular epithelium', 'Connective tissue', 'Cementum', 'PDL' (Periodontal Ligament), 'Alveolar bone', 'CEMENTOBLASTS' with an arrow indicating activity on cementum, 'PDL fibroblasts', and 'OSTEOBLASTS'. Blue spheres likely represent bacteria in the sulcus. **Lindh'e's Clinical Periodontology and Implant Dentistry** by Tord Berglund, , William V. Giannoble, , Mariano Sanz, , and Niklaus P. Lang **PUBLISHER** John Wiley & Sons, Incorporated **DATE** 2021-11-08 **Journal of Clinical Periodontology** **EFP** **HOME** | **ABOUT** | **CONTRIBUTE** | **BROWSE** **Volume 47, Issue S22** **Clinical Practice Guideline** Special Issue: Treatment of Stage I-III Periodontitis. The EFP S3 Level Clinical **Pages: 1-391** **July 2020** **Issue Edited by:** David Herrera Gonzalez, Mariano Sanz, Maurizio Tonetti **BDJ Minimum Intervention Dentistry Themed Issue** **VERIFIABLE CPD PAPER** **CLINICAL** **Evidence-based, personalised and minimally invasive** **treatment for periodontitis patients – the new EFP** **S3-level clinical treatment guidelines** Moritz Kertschull*1,2,3 and Iain Chapple1,2 **PERIODONTICS** **The Complete Summary** Edited by **Fernando Suárez, DDS, MS** STUDY GUIDE <font style="color: #aaa; font-size: 10pt;">QUINTESSENCE PUBLISHING</font> **Periodontology** **at a Glance** **Valeria Cervello, Araceli Tognai and Roberta F. Genco** 2    #### Lindhe's Clinical Periodontology and Implant Dentistry - Authors: Tord Berglundh, William V. Giannobile, Mariano Sanz, and Niklaus P. Lang - Publisher: John Wiley & Sons, Incorporated - Date: 2021-11-08 #### Journal of Clinical Periodontology (EFP) - Volume 47, Issue S22 - Clinical Practice Guideline - Special Issue: Treatment of Stage I-III Periodontitis - The EFP S3 Level Clinical - Pages: 1-391 - July 2020 - Issue Edited by: David Herrera Gonzalez, Mariano Sanz, Maurizio Tonetti #### BDJ Minimum Intervention Dentistry Themed Issue - Verifiable CPD Paper – Clinical - Evidence-based, personalised and minimally invasive treatment for periodontitis patients – the new EFP S3-level clinical treatment guidelines - Authors: Moritz Kertschull*1,2,3 and Iain Chapple1,2 #### Periodontology: The Complete Summary - Edited by Fernando Suárez, DDS, MS - Study Guide - Publisher: Quintessence Publishing #### Periodontology at a Glance - Authors: Valeria Cervello, Araceli Tognai and Roberta F. Genco Book cover photo for 'Lindh'e's Clinical Periodontology and Implant Dentistry' showing the front cover design. Book cover photo for 'Periodontics: The Complete Summary' featuring a study guide section and anatomical illustration of teeth. Book cover photo for 'Periodontology at a Glance' featuring an illuminated dental arch model. # Principles of Periodontal Diagnosis and Treatment Planning ```mermaid graph TD A[HISTORY] --> B(Record systemic factors, risk factors) A --> C[EXAMINATION] D(Screening, radiographs, other special tests) --- C C --> E(Record local factors) C --> F[DIAGNOSIS] F --> G(Based on current classification) F --> H[TREATMENT PLAN OPTIONS] H --> I[TREAT_IN_PRACTICE] H --> J[REFER TO SPECIALIST] H --> K[Initial periodontal therapy<br>Corrective periodontal therapy<br>Supportive periodontal therapy] K --> L[RECALL] ```  ```mermaid graph TD A[HISTORY] --> B(Record systemic factors, risk factors) A --> C[EXAMINATION] D(Screening, radiographs, other special tests) --- C C --> E(Record local factors) C --> F[DIAGNOSIS] F --> G(Based on current classification) F --> H[TREATMENT PLAN OPTIONS] H --> I[TREAT_IN_PRACTICE] H --> J[REFER TO SPECIALIST] H --> K[Initial periodontal therapy<br>Corrective periodontal therapy<br>Supportive periodontal therapy] K --> L[RECALL] ``` Flowchart: A labeled diagram illustrating the principles of periodontal diagnosis and treatment planning. The flow begins at the top with 'HISTORY' leading to recording systemic factors/risk factors, then proceeds down through 'EXAMINATION' (which branches from screening/radiographs/other special tests) to record local factors. This leads to 'DIAGNOSIS' based on current classification. From diagnosis, arrows branch to 'TREATMENT PLAN OPTIONS', which splits into three paths: 'TREAT IN PRACTICE', 'REFER TO SPECIALIST', and a central path listing initial/corrective/supportive periodontal therapy. All paths converge or lead toward a final 'RECALL' box. # Aims of Periodontal Therapy * Design a treatment plan to achieve the best possible biologic, functional, and esthetic outcomes, while preserving original structural characteristics whenever possible. * Develop a comprehensive treatment plan with: > Short-term goals: Immediate resolution of acute symptoms. > Long-term goals: Maintenance of a healthy and functional periodontal environment. * Treat and correct pathological processes related to periodotional tissues. * Eliminate gingival inflammation and address conditions derived from it. * Identify and manage risk factors.  - Design a treatment plan to achieve the best possible biologic, functional, and esthetic outcomes, while preserving original structural characteristics whenever possible. - Develop a comprehensive treatment plan with: - Short-term goals: Immediate resolution of acute symptoms. - Long-term goals: Maintenance of a healthy and functional periodontal environment. - Treat and correct pathological processes related to periodontal tissues. - Eliminate gingival inflammation and address conditions derived from it. - Identify and manage risk factors. A composite image depicting a human mouth with teeth and gums. Inside the oral cavity, several miniature figures dressed as construction workers are shown performing tasks on scaffolding structures built around the teeth and gingiva. This visual metaphor illustrates the concept of 'repairing' or treating periodontal tissues, aligning with the slide's theme of therapy aims. **GOALS:** • Preserve, improve and maintain natural dentition, implants and surrounding tissues. • Obtain healthy periodontium/peri-implant tissues: absence of inflammation and progressive attachment/bone loss. PROCEDURES TO ESTABLISH AND MAINTAIN HEALTH ** 5 **GOALS:** - Preserve, improve and maintain natural dentition, implants and surrounding tissues. - Obtain healthy periodontium/peri-implant tissues: absence of inflammation and progressive attachment/bone loss. **PROCEDURES TO ESTABLISH AND MAINTAIN HEALTH** Clinical Endpoints of Therapy • 1) Attainment of sustained high levels of achievement in personal plaque control, reflected as sustained full-mouth bleeding on probing scores around 10% of teeth. (The absence of bleeding on probing over repeated examinations is the best indicator of periodontal stability currently available.) • 2) Absence of an increase in attachment loss and/or bone loss. • 3) No periodontal pockets more than 4 mm with bleeding on probing or no deep periodontal pockets greater than or equal to 6 mm [≥6 mm] • 4) Tooth hypermobility should be such that it does not impair the patient's plaque control efforts and allows the patient to function to an acceptable level in comfort. • 5) Appropriate control of risk factors (smoking and diabetes) - 1) Attainment of sustained high levels of achievement in personal plaque control, reflected as sustained full-mouth bleeding on probing scores around 10% of teeth. (The absence of bleeding on probing over repeated examinations is the best indicator of periodontal stability currently available.) - 2) Absence of an increase in attachment loss and/or bone loss. - 3) No periodontal pockets more than 4 mm with bleeding on probing or no deep periodontal pockets greater than or equal to 6 mm [≥6 mm] - 4) Tooth hypermobility should be such that it does not impair the patient's plaque control efforts and allows the patient to function to an acceptable level in comfort. - 5) Appropriate control of risk factors (smoking and diabetes) **Periodontal management form (e-form)** **1. RELEVANT MEDICAL & DENTAL HISTORY** **RELEVANT MEDICAL HISTORY** DIABETES: ☐ Y ☐ N ☐ CONTROLLED: ☐ Y ☐ N ☐ OTHER MEDICAL CONDITIONS & MEDICATIONS HbA1c level: __________% SMOKING: ☐ Y ☐ N ☐ YEARS __________ NUMBER A DAY: __________ Quit date: __________ Interest to quit: ☐ Y ☐ N ☐ QUARTER __________ **RELEVANT DENTAL HISTORY** Signs of Gingival bleeding ☐ Bad Breath/Taste ☐ Teeth Migration ☐ Gingival Infection ☐ Tooth loss: Caries ☐ Perio ☐ Type of Brush: Manual ☐ Power/ Electric ☐ Type of Interdental Cleaning: Floss ☐ Brushes ☐ Other __________ Type of Tooth paste: Fluoridated ☐ Non Fluoridated ☐ Other __________ Type of Mouthrins: __________ --- **CLINICAL PARAMETERS PREVALENCE** Bacterial Biofilm Score % __________ BOP % __________ Periodontal Probing Depth 1-3 mm % __________ Periodontal Probing Depth 4-6 mm % __________ Periodontal Probing Depth 7 or more mm % __________ --- **CPTN / PSR** 0 = Healthy 3 = 4 - 5 mm 1 = BOP (no recession) 4 = 6 mm or deeper 2 = Calculus in presence * = Recession/furcation --- **GINGIVAL RECEPTION DEFECTS** | Gingival Site | REC Depth | GT | KTW | CEJ (A / B) | Step (+/-) | | :--- | :--- | :--- | :--- | :--- | :--- | | No recession | | | | | | | RT1 | | | | | | | RT2 | | | | | | | RT3 | | | | | | --- **2. CLINICAL EXTRAORAL & INTRAORAL EXAMINATION** **TMJ & PARAFUNCTION** Bruxism: ☐ Y ☐ N | Occlusal Wear: ☐ Y ☐ N | ≥20 Teeth: ☐ Y ☐ N Clicking: ☐ Y ☐ N | Pain/Locking: ☐ Y ☐ N | Referral: ☐ Y ☐ N Occlusal Interferences & Furcations: [Scale 8-0] **PROSTHESES** When was Prosthesis made: __________ | Lips: __________ Type: __________ | Lining Mucosa: __________ Material: __________ | Tongue: __________ Patient Satisfied: ☐ Y ☐ N | Palate: __________ Condition: __________ | Floor of the Mouth: __________ **SOFT TISSUE FINDINGS** Lips: __________ Lining Mucosa: __________ Tongue: __________ Palate: __________ Floor of the Mouth: __________ Condition: __________ Other: __________ --- **GINGIVAL TISSUES** Colour: __________ Contour: __________ Texture: __________ Phenotype: ☐ Thin Scallop ☐ Flat Thick ☐ Thick Scallop Biofilm Amount: __________ Biofilm Distribution: [Chart 8-0] Dental Hypersensitivity: __________ [Scale 8-0] --- **CALCULUS DISTRIBUTION** Supragingival Calculus C: __________ Gingiv E: __________ Enlargement: __________ Subgingival Calculus C: __________ [Chart 8-0] --- **OTHER BIOFILM RETENTIVE FACTORS** Overhangs: __________ Overcontoured Restorations: __________ Pontics: __________ Caries: __________ Root Anomalies: __________ Other: __________ --- *DO PERIODONTAL CHARTING ON TITANIUM AND THEN COMPLETE CLINICAL PARAMETERS CPTN /PSR AND RECESSION   **Periodontal management form (e-form)** **1. RELEVANT MEDICAL & DENTAL HISTORY** **RELEVANT MEDICAL HISTORY** DIABETES: ☐ Y ☐ N ☐ CONTROLLED: ☐ Y ☐ N ☐ OTHER MEDICAL CONDITIONS & MEDICATIONS HbA1c level: __________% SMOKING: ☐ Y ☐ N ☐ YEARS __________ NUMBER A DAY: __________ Quit date: __________ Interest to quit: ☐ Y ☐ N ☐ QUARTER __________ **RELEVANT DENTAL HISTORY** Signs of Gingival bleeding ☐ Bad Breath/Taste ☐ Teeth Migration ☐ Gingival Infection ☐ Tooth loss: Caries ☐ Perio ☐ Type of Brush: Manual ☐ Power/ Electric ☐ Type of Interdental Cleaning: Floss ☐ Brushes ☐ Other __________ Type of Tooth paste: Fluoridated ☐ Non Fluoridated ☐ Other __________ Type of Mouthrins: __________ --- **CLINICAL PARAMETERS PREVALENCE** Bacterial Biofilm Score % __________ BOP % __________ Periodontal Probing Depth 1-3 mm % __________ Periodontal Probing Depth 4-6 mm % __________ Periodontal Probing Depth 7 or more mm % __________ --- **CPTN / PSR** 0 = Healthy 3 = 4 - 5 mm 1 = BOP (no recession) 4 = 6 mm or deeper 2 = Calculus in presence \* = Recession/furcation --- **GINGIVAL RECESSION DEFECTS** | Gingival Site | REC Depth | GT | KTW | CEJ (A / B) | Step (+/-) | | :--- | :--- | :--- | :--- | :--- | :--- | | No recession | | | | | | | RT1 | | | | | | | RT2 | | | | | | | RT3 | | | | | | --- **2. CLINICAL EXTRAORAL & INTRAORAL EXAMINATION** **TMJ & PARAFUNCTION** Bruxism: ☐ Y ☐ N | Occlusal Wear: ☐ Y ☐ N | ≥20 Teeth: ☐ Y ☐ N Clicking: ☐ Y ☐ N | Pain/Locking: ☐ Y ☐ N | Referral: ☐ Y ☐ N Occlusal Interferences & Furcations: [Scale 8-0] **PROSTHESES** When was Prosthesis made: __________ | Lips: __________ Type: __________ | Lining Mucosa: __________ Material: __________ | Tongue: __________ Patient Satisfied: ☐ Y ☐ N | Palate: __________ Condition: __________ | Floor of the Mouth: __________ **SOFT TISSUE FINDINGS** Lips: __________ Lining Mucosa: __________ Tongue: __________ Palate: __________ Floor of the Mouth: __________ Condition: __________ Other: __________ --- **GINGIVAL TISSUES** Colour: __________ Contour: __________ Texture: __________ Phenotype: ☐ Thin Scallop ☐ Flat Thick ☐ Thick Scallop Biofilm Amount: __________ Biofilm Distribution: [Chart 8-0] Dental Hypersensitivity: __________ [Scale 8-0] --- **CALCULUS DISTRIBUTION** Supragingival Calculus C: __________ Gingiv E: __________ Enlargement: __________ Subgingival Calculus C: __________ [Chart 8-0] --- **OTHER BIOFILM RETENTIVE FACTORS** Overhangs: __________ Overcontoured Restorations: __________ Pontics: __________ Caries: __________ Root Anomalies: __________ Other: __________ --- \*DO PERIODONTAL CHARTING ON TITANIUM AND THEN COMPLETE CLINICAL PARAMETERS CPTN /PSR AND RECESSION Figure of the 'Periodontal management form (e-form)' showing the left column. It includes sections for 'Patient Details', 'Relevant Medical & Dental History' with checkboxes for Diabetes, Smoking, Brush types, and Toothpaste types, and 'Clinical Parameters Prevalence'. Figure of the 'Periodontal management form (e-form)' showing the right column. It includes sections for 'Clinical Extraoral & Intraoral Examination' covering TMJ/Parafunction, Prostheses, Soft Tissue Findings, Gingival Tissues, Calculus Distribution, Other Biofilm Retentive Factors, and a table for 'Gingival Recession Defects'. Periodontal Examination, Diagnosis, Prognosis & Treatment plan ### 3. RADIOGRAPHIC FINDINGS <table> <tr> <th>NORMAL BONE LEVEL</th> <th>HORIZONTAL BONE LOSS</th> <th>ANGULAR BONE LOSS</th> </tr> <tr> <td>8 7 6 5 4 3 2 1 | 1 2 3 4 5 6 7 8<br>8 7 6 5 4 3 2 1 | 1 2 3 4 5 6 7 8</td> <td>8 7 6 5 4 3 2 1 | 1 2 3 4 5 6 7 8<br>8 7 6 5 4 3 2 1 | 1 2 3 4 5 6 7 8</td> <td>8 7 6 5 4 3 2 1 | 1 2 3 4 5 6 7 8<br>8 7 6 5 4 3 2 1 | 1 2 3 4 5 6 7 8</td> </tr> <tr> <th>MILD BONE LOSS</th> <th>MODERATE BONE LOSS</th> <th>SEVERE / ADVANCED BONE LOSS</th> </tr> <tr> <td>8 7 6 5 4 3 2 1 | 1 2 3 4 5 6 7 8<br>8 7 6 5 4 3 2 1 | 1 2 3 4 5 6 7 8</td> <td>8 7 6 5 4 3 2 1 | 1 2 3 4 5 6 7 8<br>8 7 6 5 4 3 2 1 | 1 2 3 4 5 6 7 8</td> <td>8 7 6 5 4 3 2 1 | 1 2 3 4 5 6 7 8<br>8 7 6 5 4 3 2 1 | 1 2 3 4 5 6 7 8</td> </tr> </table> LOCALISED BONE LOSS ☐ (30% AND LESS TEETH) GENERALISED BONE LOSS ☐ (MORE THAN 30% TEETH) DENTAL CARIES: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ENDODONTIC: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ OVERHANGS: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ OPEN CONTACTS: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ DEFICIENT RESTORATIONS: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ OTHER FINDINGS: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ### 4. PERIODONTAL DIAGNOSIS & PROGNOSIS ☐ **CLINICAL GINGIVAL HEALTH** (BOP < 10% PROBING ≤ 3mm) ☐ **CLINICAL GINGIVAL HEALTH ON A REDUCED PERIODONTIUM** (BOP < 10% ON NON-PERIODONTITIS PATIENT RECESSION PROBING ≤ 3mm) ☐ **GINGIVITIS:** (BOP MORE 10% NO POCKETS) ☐ **DENTAL BIOFILM ASSOCIATED GINGIVITIS** (LOCALISED ☐ 30% AND LESS BOP / GENERALISED ☐ MORE THAN 30% BOP) ☐ **OTHER FORMS OF GINGIVITIS:** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ☐ **PERIODONTITIS:** <table> <tr> <th></th> <th>INTERDENTAL CAL</th> <th>RADIOGRAPHIC BONE LOSS</th> <th>TOOTH LOSS</th> <th>COMPLEXITY</th> </tr> <tr> <td>☐ <b>STAGE I</b></td> <td>1-2 mm ☐</td> <td>< 15% HORIZONTAL BONE LOSS</td> <td>☐ NO TOOTH LOSS</td> <td>☐ MAX PROBING DEPTH ≤ 4mm</td> </tr> <tr> <td>☐ <b>STAGE II</b></td> <td>3-4 mm ☐</td> <td>15-33% HORIZONTAL BONE LOSS</td> <td>☐ NO TOOTH LOSS</td> <td>☐ MAX PROBING DEPTH ≤ 5mm</td> </tr> <tr> <td>☐ <b>STAGE III</b></td> <td>≥ 5 mm ☐</td> <td>MIDDLE ROOT THIRD AND MORE ☐ ANGULAR</td> <td>☐ ≤ 4 TEETH</td> <td>☐ MAX PROBING DEPTH ≥ 6mm ☐ FURCATION GRADE II or III ☐ MODERATE RIDGE DEFECT ☐</td> </tr> <tr> <td>☐ <b>STAGE IV</b></td> <td>≥ 5 mm ☐</td> <td>MIDDLE ROOT THIRD AND BEYOND ☐ ANGULAR</td> <td>☐ ≥ 5 TEETH</td> <td>☐ MAX PROBING DEPTH ≥ 6 mm ☐ FURCATION GRADE II or III ☐ SEVERE RIDGE DEFECTS ☐</td> </tr> </table> LESS THAN 20 TEETH REMAINING ☐ MASTICATORY DYSFUNCTION ☐ 2ry OCCLUSAL TRAUMA ☐ BITE COLLAPSE ☐ **DISTRIBUTION:** LOCALISED ☐ (30% AND LESS TEETH) GENERALISED ☐ (MORE THAN 30% TEETH) INCISIVE MOLAR ☐ <table> <tr> <th></th> <th>EVIDENCE OF BONE LOSS</th> <th>% BONE LOSS / AGE</th> <th>CASE PHENOTYPE</th> <th>SMOKING</th> <th>DIABETES</th> </tr> <tr> <td>☐ <b>GRADE A</b></td> <td>NO LOSS 5 YEARS ☐</td> <td>< 0.25 ☐</td> <td>HEAVY FILM DEPOSITS LOW DESTRUCTION ☐</td> <td>☐ NON SMOKING</td> <td>☐ NORMO GLYCEMIC</td> </tr> <tr> <td>☐ <b>GRADE B</b></td> <td>< 2 mm 5 YEARS ☐</td> <td>0.25 TO 1.0 ☐</td> <td>FILM DEPOSITS CORRESPOND TO DESTRUCTION ☐</td> <td>☐ < 10 CIGARETTES DAY</td> <td>☐ HbA1c < 7.0 %</td> </tr> <tr> <td>☐ <b>GRADE C</b></td> <td>≥ 2 mm 5 YEARS ☐</td> <td>≥ 1.0 ☐</td> <td>LOW FILM DEPOSITS HIGH DESTRUCTION ☐</td> <td>☐ ≥ 10 CIGARETTES DAY</td> <td>☐ HbA1c ≥ 7.0 %</td> </tr> </table> OTHER MODIFYING FACTORS: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ☐ **CURRENTLY STABLE PERIODONTITIS:** (REDUCED PERIODONTIUM BOP < 10% POCKETS 4 mm OR LESS) ☐ **CURRENTLY REMISSION PERIODONTITIS:** (GINGIVAL INFLAMMATION ON A REDUCED PERIODONTIUM BOP ≥ 10% ON A TREATED PERIODONTITIS CASE POCKETS 4 mm OR LESS) ☐ **CURRENTLY UNSTABLE PERIODONTITIS:** (BOP > 10% AND POCKETS 4-5 mm OR MORE) ☐ **OTHER FORMS OF PERIODONTITIS:** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ☐ **PERI-IMPLANT HEALTH** ☐ **PERI-IMPLANT MUCOSITIS** ☐ **PERI-IMPLANTITIS** ☐ **PERI-IMPLANT ANOMALIES** **OVERALL PERIODONTAL PROGNOSIS:** GOOD ☐ FAIR ☐ POOR ☐ QUESTIONABLE ☐ HOPELESS ☐ **REFERRAL REQUIRED** describe unit and needs \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ --- ### 5. PERIODONTAL TREATMENT PLAN <table> <tr> <th>EMERGENCIES PHASE OF PERIODONTAL TREATMENT</th> <th>DATE</th> <th>UPDATED MEDICAL</th> <th>ATS</th> <th>ITEM COMPLETED - TUTOR SIGNATURE</th> </tr> <tr><td></td><td></td><td></td><td></td><td></td></tr> <tr><td></td><td></td><td></td><td></td><td></td></tr> <tr><th>RISK MANAGEMENT PHASE OF PERIODONTAL TREATMENT</th><td></td><td></td><td></td><td></td></tr> <tr><td></td><td></td><td></td><td></td><td></td></tr> <tr><td></td><td></td><td></td><td></td><td></td></tr> <tr><th>FUNDAMENTAL PHASE OF PERIODONTAL TREATMENT</th><td></td><td></td><td></td><td></td></tr> <tr><td></td><td></td><td></td><td></td><td></td></tr> <tr><td></td><td></td><td></td><td></td><td></td></tr> <tr><td></td><td></td><td></td><td></td><td></td></tr> <tr><td></td><td></td><td></td><td></td><td></td></tr> <tr><td></td><td></td><td></td><td></td><td></td></tr> <tr><td></td><td></td><td></td><td></td><td></td></tr> <tr><td></td><td></td><td></td><td></td><td></td></tr> <tr><td></td><td></td><td></td><td></td><td></td></tr> <tr><td></td><td></td><td></td><td></td><td></td></tr> <tr><th>RE-EVALUATION PHASE OF PERIODONTAL TREATMENT</th><td></td><td></td><td></td><td></td></tr> <tr><td></td><td></td><td></td><td></td><td></td></tr> <tr><td></td><td></td><td></td><td></td><td></td></tr> <tr><th>CORRECTIVE PHASE OF PERIODONTAL TREATMENT</th><td></td><td></td><td></td><td></td></tr> <tr><td></td><td></td><td></td><td></td><td></td></tr> <tr><td></td><td></td><td></td><td></td><td></td></tr> <tr><td></td><td></td><td></td><td></td><td></td></tr> <tr><td></td><td></td><td></td><td></td><td></td></tr> <tr><td></td><td></td><td></td><td></td><td></td></tr> <tr><td></td><td></td><td></td><td></td><td></td></tr> <tr><th>MAINTENANCE PHASE:</th><td></td><td></td><td></td><td></td></tr> <tr><td></td><td></td><td></td><td></td><td></td></tr> <tr><td></td><td></td><td></td><td></td><td></td></tr> </table> **PROPOSED MAINTENANCE INTERVAL:** 3 Months ☐ 6 months ☐ 12 months ☐ Other: \_\_\_\_\_\_\_\_\_\_         ### 3. RADIOGRAPHIC FINDINGS | NORMAL BONE LEVEL | HORIZONTAL BONE LOSS | ANGULAR BONE LOSS | | :--- | :--- | :--- | | 8 7 6 5 4 3 2 1 \| 1 2 3 4 5 6 7 8<br>8 7 6 5 4 3 2 1 \| 1 2 3 4 5 6 7 8 | 8 7 6 5 4 3 2 1 \| 1 2 3 4 5 6 7 8<br>8 7 6 5 4 3 2 1 \| 1 2 3 4 5 6 7 8 | 8 7 6 5 4 3 2 1 \| 1 2 3 4 5 6 7 8<br>8 7 6 5 4 3 2 1 \| 1 2 3 4 5 6 7 8 | | MILD BONE LOSS | MODERATE BONE LOSS | SEVERE / ADVANCED BONE LOSS | | 8 7 6 5 4 3 2 1 \| 1 2 3 4 5 6 7 8<br>8 7 6 5 4 3 2 1 \| 1 2 3 4 5 6 7 8 | 8 7 6 5 4 3 2 1 \| 1 2 3 4 5 6 7 8<br>8 7 6 5 4 3 2 1 \| 1 2 3 4 5 6 7 8 | 8 7 6 5 4 3 2 1 \| 1 2 3 4 5 6 7 8<br>8 7 6 5 4 3 2 1 \| 1 2 3 4 5 6 7 8 | LOCALISED BONE LOSS ☐ (30% AND LESS TEETH) GENERALISED BONE LOSS ☐ (MORE THAN 30% TEETH) DENTAL CARIES: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ENDODONTIC: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ OVERHANGS: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ OPEN CONTACTS: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ DEFICIENT RESTORATIONS: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ OTHER FINDINGS: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ### 4. PERIODONTAL DIAGNOSIS & PROGNOSIS ☐ **CLINICAL GINGIVAL HEALTH** (BOP < 10% PROBING ≤ 3mm) ☐ **CLINICAL GINGIVAL HEALTH ON A REDUCED PERIODONTIUM** (BOP < 10% ON NON-PERIODONTITIS PATIENT RECESSION PROBING ≤ 3mm) ☐ **GINGIVITIS:** (BOP MORE 10% NO POCKETS) ☐ **DENTAL BIOFILM ASSOCIATED GINGIVITIS** (LOCALISED ☐ 30% AND LESS BOP / GENERALISED ☐ MORE THAN 30% BOP) ☐ **OTHER FORMS OF GINGIVITIS:** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ☐ **PERIODONTITIS:** | | INTERDENTAL CAL | RADIOGRAPHIC BONE LOSS | TOOTH LOSS | COMPLEXITY | | :--- | :--- | :--- | :--- | :--- | | ☐ **STAGE I** | 1-2 mm ☐ | < 15% HORIZONTAL BONE LOSS | ☐ NO TOOTH LOSS | ☐ MAX PROBING DEPTH ≤ 4mm | | ☐ **STAGE II** | 3-4 mm ☐ | 15-33% HORIZONTAL BONE LOSS | ☐ NO TOOTH LOSS | ☐ MAX PROBING DEPTH ≤ 5mm | | ☐ **STAGE III** | ≥ 5 mm ☐ | MIDDLE ROOT THIRD AND MORE ☐ ANGULAR | ☐ ≤ 4 TEETH | ☐ MAX PROBING DEPTH ≥ 6mm ☐ FURCATION GRADE II or III ☐ MODERATE RIDGE DEFECT ☐ | | ☐ **STAGE IV** | ≥ 5 mm ☐ | MIDDLE ROOT THIRD AND BEYOND ☐ ANGULAR | ☐ ≥ 5 TEETH | ☐ MAX PROBING DEPTH ≥ 6 mm ☐ FURCATION GRADE II or III ☐ SEVERE RIDGE DEFECTS ☐ | LESS THAN 20 TEETH REMAINING ☐ MASTICATORY DYSFUNCTION ☐ 2ry OCCLUSAL TRAUMA ☐ BITE COLLAPSE ☐ **DISTRIBUTION:** LOCALISED ☐ (30% AND LESS TEETH) GENERALISED ☐ (MORE THAN 30% TEETH) INCISIVE MOLAR ☐ | | EVIDENCE OF BONE LOSS | % BONE LOSS / AGE | CASE PHENOTYPE | SMOKING | DIABETES | | :--- | :--- | :--- | :--- | :--- | :--- | | ☐ **GRADE A** | NO LOSS 5 YEARS ☐ | < 0.25 ☐ | HEAVY FILM DEPOSITS LOW DESTRUCTION ☐ | ☐ NON SMOKING | ☐ NORMO GLYCEMIC | | ☐ **GRADE B** | < 2 mm 5 YEARS ☐ | 0.25 TO 1.0 ☐ | FILM DEPOSITS CORRESPOND TO DESTRUCTION ☐ | ☐ < 10 CIGARETTES DAY | ☐ HbA1c < 7.0 % | | ☐ **GRADE C** | ≥ 2 mm 5 YEARS ☐ | ≥ 1.0 ☐ | LOW FILM DEPOSITS HIGH DESTRUCTION ☐ | ☐ ≥ 10 CIGARETTES DAY | ☐ HbA1c ≥ 7.0 % | OTHER MODIFYING FACTORS: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ☐ **CURRENTLY STABLE PERIODONTITIS:** (REDUCED PERIODONTIUM BOP < 10% POCKETS 4 mm OR LESS) ☐ **CURRENTLY REMISSION PERIODONTITIS:** (GINGIVAL INFLAMMATION ON A REDUCED PERIODONTIUM BOP ≥ 10% ON A TREATED PERIODONTITIS CASE POCKETS 4 mm OR LESS) ☐ **CURRENTLY UNSTABLE PERIODONTITIS:** (BOP > 10% AND POCKETS 4-5 mm OR MORE) ☐ **OTHER FORMS OF PERIODONTITIS:** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ☐ **PERI-IMPLANT HEALTH** ☐ **PERI-IMPLANT MUCOSITIS** ☐ **PERI-IMPLANTITIS** ☐ **PERI-IMPLANT ANOMALIES** **OVERALL PERIODONTAL PROGNOSIS:** GOOD ☐ FAIR ☐ POOR ☐ QUESTIONABLE ☐ HOPELESS ☐ **REFERRAL REQUIRED** describe unit and needs \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ --- ### 5. PERIODONTAL TREATMENT PLAN | EMERGENCIES PHASE OF PERIODONTAL TREATMENT | DATE | UPDATED MEDICAL | ATS | ITEM COMPLETED - TUTOR SIGNATURE | | :--- | :--- | :--- | :--- | :--- | | | | | | | | | | | | | | **RISK MANAGEMENT PHASE OF PERIODONTAL TREATMENT** | | | | | | | | | | | | | | | | | | **FUNDAMENTAL PHASE OF PERIODONTAL TREATMENT** | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | **RE-EVALUATION PHASE OF PERIODONTAL TREATMENT** | | | | | | | | | | | | | | | | | | **CORRECTIVE PHASE OF PERIODONTAL TREATMENT** | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | **MAINTENANCE PHASE:** | | | | | | | | | | | | | | | | | **PROPOSED MAINTENANCE INTERVAL:** 3 Months ☐ 6 months ☐ 12 months ☐ Other: \_\_\_\_\_\_\_\_\_\_\_ Table titled '3. RADIOGRAPHIC FINDINGS' containing a grid of tooth numbering charts (1-8) labeled by bone loss severity: NORMAL BONE LEVEL, HORIZONTAL BONE LOSS, ANGULAR BONE LOSS, MILD BONE LOSS, MODERATE BONE LOSS, and SEVERE / ADVANCED BONE LOSS. Below the grid are checkboxes for LOCALISED BONE LOSS and GENERALISED BONE LOSS. Blank line item table section listing categories: DENTAL CARIES, ENDODONTIC, OVERHANGS, OPEN CONTACTS, DEFICIENT RESTORATIONS, OTHER FINDINGS, with space for handwritten notes next to each. Table titled '4. PERIODONTAL DIAGNOSIS & PROGNOSIS'. Contains checkboxes for Clinical Gingival Health, Gingivitis, Dental Biofilm Associated Gingivitis, and Other Forms of Gingivitis. Includes fields for distribution types (Localised/Generalised). Complex table detailing Periodontitis Stages (I through IV). Columns include Interdental Cal (Probing Depth), Radiographic Bone Loss, Tooth Loss, and Complexity. Rows define criteria for Stage I (1-2mm, <15% loss), Stage II (3-4mm, 15-33% loss), Stage III (≥5mm, angular/middle root third, ≤4 teeth), and Stage IV (≥5mm, angular/middle root third beyond, ≥5 teeth). Also includes checkboxes for Distribution (Localized/Generalised/Incisive Molar) and complexity factors like Furcation Grade and Ridge Defects. Table defining Prognosis Grades A, B, and C based on Evidence of Bone Loss, % Bone Loss/Age, Case Phenotype, Smoking status, and Diabetes status. Grade A: No loss 5 years, <0.25 bone loss, heavy film deposits low destruction. Grade B: <2mm 5 years, 0.25-1.0 bone loss, film deposits correspond to destruction. Grade C: ≥2mm 5 years, ≥1.0 bone loss, low film deposits high destruction. Table listing Perio-Implant Health conditions: Currently Stable Periodontitis, Currently Remission Periodontitis, Currently Unstable Periodontitis, Other Forms of Periodontitis, Perio-implant Health, Perio-implant Mucositis, Perio-implantitis, and Perio-implant Anomalies. Each has a checkbox and description lines. Row for Overall Periodontal Prognosis with checkboxes for GOOD, FAIR, POOR, QUESTIONABLE, HOPELESS. Followed by a blank line for 'REFERRAL REQUIRED describe unit and needs'. Treatment Plan Chart titled '5. PERIODONTAL TREATMENT PLAN'. Structured into four main phases: EMERGENCIES PHASE OF PERIODONTAL TREATMENT, RISK MANAGEMENT PHASE OF PERIODONTAL TREATMENT, FUNDAMENTAL PHASE OF PERIODONTAL TREATMENT, RE-EVALUATION PHASE OF PERIODONTAL TREATMENT, CORRECTIVE PHASE OF PERIODONTAL TREATMENT, and MAINTENANCE PHASE. Each phase has a header and multiple lined rows for data entry. The rightmost columns track Date, Updated Medical, ATS, Item Completed, and Tutor Signature. Bottom row specifies Proposed Maintenance Interval options (3 Months, 6 months, 12 months, Other). **Basic Periodontal Examination (BPE)** - An example BPE score grid might look like this: | 4 | 3 | 3* | |---|---|----| | - | 2 | 4* | Both the number and the * should be recorded if a furcation is detected. E.g. the score for a sextant could be 3* (indicating a probing depth 3.5-5.5mm plus a furcation involvement in the sextant).   **Basic Periodontal Examination (BPE)** - An example BPE score grid might look like this: | 4 | 3 | 3\* | |---|---|----| | - | 2 | 4\* | Both the number and the \* should be recorded if a furcation is detected. E.g. the score for a sextant could be 3\* (indicating a probing depth 3.5-5.5mm plus a furcation involvement in the sextant). Labeled diagram showing the Basic Periodontal Examination (BPE) score grid. The image displays a dental arch divided into upper and lower sextants with corresponding numerical scores: 4, 3, 3* in the top row and -, 2, 4* in the bottom row. Table representing an example BPE score grid with values 4, 3, 3*, -, 2, 4* arranged in two rows and three columns. Accompanying text explains that both the number and asterisk should be recorded if a furcation is detected, providing context for interpreting scores like 3* or 4*. # How to record the BPE: ## [CSS image object with text "BSP British Society of Periodontology Basic Periodontal Examination (BPE)"] ### How to record the BPE 1. The dentition is divided into 6 sextants and the **highest** score for each sextant is recorded: * **Upper right** (17 to 14) * **Lower right** (47 to 44) * **Upper anterior** (13 to 23) * **Lower anterior** (43 to 33) * **Upper left** (24 to 27) * **Lower left** (34 to 37) 2. All teeth in each sextant are examined (with the exception of 3rd molars unless 1st and/or 2nd molars are missing). 3. For a sextant to qualify for recording, it must contain at least 2 teeth. 4. A World Health Organisation (**WHO**) **BPE** probe is used. This has a `ball end` 0.5mm in diameter and a black band from 3.5mm to 5.5mm. Light probing force should be used (20-25 grams). 5. The probe should be `walked around` the teeth in each sextant. All sites should be examined to ensure that the highest score in the sextant is recorded before moving on to the next sextant. If a code 4 is identified in a sextant, continue to examine all sites in the sextant. This will help to gain a fuller understanding of the periodontal condition and will make sure that furcation involvements are not missed. 10 ### How to record the BPE 1. The dentition is divided into 6 sextants and the **highest** score for each sextant is recorded: - **Upper right** (17 to 14) - **Lower right** (47 to 44) - **Upper anterior** (13 to 23) - **Lower anterior** (43 to 33) - **Upper left** (24 to 27) - **Lower left** (34 to 37) 2. All teeth in each sextant are examined (with the exception of 3rd molars unless 1st and/or 2nd molars are missing). 3. For a sextant to qualify for recording, it must contain at least 2 teeth. 4. A World Health Organisation (**WHO**) **BPE** probe is used. This has a `ball end` 0.5mm in diameter and a black band from 3.5mm to 5.5mm. Light probing force should be used (20-25 grams). 5. The probe should be `walked around` the teeth in each sextant. All sites should be examined to ensure that the highest score in the sextant is recorded before moving on to the next sextant. If a code 4 is identified in a sextant, continue to examine all sites in the sextant. This will help to gain a fuller understanding of the periodontal condition and will make sure that furcation involvements are not missed. The logo for the British Society of Periodontology (BSP). It features a green square containing a white smile icon next to the text 'BSP' in grey. Below this is the full name 'British Society of Periodontology' and the title 'Basic Periodontal Examination (BPE)' in green. # Scoring ## Scoring Codes | Code | Description | | :--- | :--- | | **0** | **Pockets <3.5mm**<br>No calculus/overhangs, no bleeding on probing (black band entirely visible) | | **1** | **Pockets <3.5mm**<br>No calculus/overhangs, bleeding on probing (black band entirely visible) | | **2** | **Pockets <3.5mm**<br>Supra or subgingival calculus/overhangs (black band entirely visible) | | **3** | **Probing depth 3.5-5.5mm**<br>(Black band partially visible, indicating pocket of 4-5mm) | | **4** | **Probing depth >5.5mm**<br>(Black band disappears, indicating a pocket of 6mm or more) | | **\*** | **Furcation involvement** | 11  #### Scoring Codes | Code | Description | | :--- | :--- | | **0** | **Pockets <3.5mm**<br>No calculus/overhangs, no bleeding on probing (black band entirely visible) | | **1** | **Pockets <3.5mm**<br>No calculus/overhangs, bleeding on probing (black band entirely visible) | | **2** | **Pockets <3.5mm**<br>Supra or subgingival calculus/overhangs (black band entirely visible) | | **3** | **Probing depth 3.5-5.5mm**<br>(Black band partially visible, indicating pocket of 4-5mm) | | **4** | **Probing depth >5.5mm**<br>(Black band disappears, indicating a pocket of 6mm or more) | | **\*** | **Furcation involvement** | A medical diagram illustrating dental scoring codes based on probing depth and pocket conditions. The figure is divided into six vertical panels labeled with green squares containing numbers or symbols (0, 1, 2, 3, 4, *). Each panel contains a cross-section of a tooth showing the gum line and periodontal tissue. Below each illustration is text describing the condition: Code 0 shows healthy gums (<3.5mm); Code 1 shows bleeding on probing; Code 2 shows calculus/overhangs; Code 3 indicates a probing depth of 3.5-5.5mm; Code 4 indicates a probing depth >5.5mm where the black band disappears; and the asterisk (*) indicates furcation involvement. # How to use BPE The **BPE** is a measurement of the depth of the pocket around a tooth. The BPE is also used to assess the health of the gum and bone around the tooth. ## How to use BPE * All new patients should have the **BPE** recorded * For patients with codes 0, 1 or 2, the **BPE** should be recorded at every routine examination * For patients with **BPE** codes of 3 or 4, more detailed periodontal charting is required * **Code 3:** Initial therapy including self-care advice (oral hygiene instruction and risk factor control) then, post-initial therapy, record a 6-point pocket chart in that sextant only * **Code 4:** If there is a Code 4 in any sextant then record a 6-point pocket chart throughout the entire dentition * **BPE** cannot be used to monitor the response to periodontal therapy because it does not provide information about how sites within a sextant change after treatment. To assess the response to treatment, a 6-point pocket chart should be recorded pre and post- treatment * For patients who have undergone initial therapy for periodontitis, and who are now in the maintenance phase of care, then full probing depths throughout the entire dentition should be recorded at least annually ### In addition it is recommended that: * **BPE** should not be used around implants (4 or 6-point pocket charting should be used) * Radiographs should be available for all Code 3 and Code 4 sextants. The type of radiograph used is a matter of clinical judgement but crestal bone levels should be visible. Many clinicians would regard periapical views as essential for Code 4 sextants to allow assessment of bone loss as a percentage of root length and visualisation of the periapical tissues * When a 6-point pocket chart is indicated it is only necessary to record sites of 4mm and above (although 6 sites per tooth should be measured) * Bleeding on probing should always be recorded in conjunction with a 6-point pocket chart #### How to use BPE The **BPE** is a measurement of the depth of the pocket around a tooth. The BPE is also used to assess the health of the gum and bone around the tooth. - All new patients should have the **BPE** recorded - For patients with codes 0, 1 or 2, the **BPE** should be recorded at every routine examination - For patients with **BPE** codes of 3 or 4, more detailed periodontal charting is required - **Code 3:** Initial therapy including self-care advice (oral hygiene instruction and risk factor control) then, post-initial therapy, record a 6-point pocket chart in that sextant only - **Code 4:** If there is a Code 4 in any sextant then record a 6-point pocket chart throughout the entire dentition - **BPE** cannot be used to monitor the response to periodontal therapy because it does not provide information about how sites within a sextant change after treatment. To assess the response to treatment, a 6-point pocket chart should be recorded pre and post- treatment - For patients who have undergone initial therapy for periodontitis, and who are now in the maintenance phase of care, then full probing depths throughout the entire dentition should be recorded at least annually #### Additional Recommendations - **BPE** should not be used around implants (4 or 6-point pocket charting should be used) - Radiographs should be available for all Code 3 and Code 4 sextants. The type of radiograph used is a matter of clinical judgement but crestal bone levels should be visible. Many clinicians would regard periapical views as essential for Code 4 sextants to allow assessment of bone loss as a percentage of root length and visualisation of the periapical tissues - When a 6-point pocket chart is indicated it is only necessary to record sites of 4mm and above (although 6 sites per tooth should be measured) - Bleeding on probing should always be recorded in conjunction with a 6-point pocket chart 13 --- 0 No need for periodontal treatment 1 Oral hygiene instruction (OHI) 2 As for Code 1, plus removal of plaque retentive factors, including all supra and subgingival calculus 3 As for Code 2 and RSD if required 4 OHI, RSD. Assess the need for more complex treatment; referral to a specialist may be indicated * Treat according to BPE Code (0–4). Assess the need for more complex treatment; referral to a specialist may be indicated  0 No need for periodontal treatment 1 Oral hygiene instruction (OHI) 2 As for Code 1, plus removal of plaque retentive factors, including all supra and subgingival calculus 3 As for Code 2 and RSD if required 4 OHI, RSD. Assess the need for more complex treatment; referral to a specialist may be indicated \* Treat according to BPE Code (0–4). Assess the need for more complex treatment; referral to a specialist may be indicated A clinical chart titled 'Guidance on Interpretation of BPE Scores' displaying six vertical panels illustrating different periodontal conditions. Each panel contains a photograph of teeth with a periodontal probe inserted to demonstrate the depth of the pocket or presence of calculus. The panels are labeled 0 through 4 and an asterisk (*), corresponding to specific treatment guidelines: Code 0 ('No need for periodontal treatment'), Code 1 ('Oral hygiene instruction (OHI)'), Code 2 ('As for Code 1, plus removal of plaque retentive factors...'), Code 3 ('As for Code 2 and RSD if required'), Code 4 ('OHI, RSD. Assess the need for more complex treatment...'), and Code * ('Treat according to BPE Code (0–4)...'). <!-- Flowchart: Flowchart for implementing the 2017 Classification of Periodontal Diseases to Reach a Diagnosis in Clinical Practice --> <table border="1" cellspacing="0"> <tr><th colspan="4">History, examination and screening for periodontal disease</th><th rowspan="10" bgcolor="#000000"><br>Scan me</th></tr> <tr><th colspan="4">including BPE and assessment of historic periodontitis (interdental recession)</th></tr> <tr> <td colspan="3" rowspan="6" bgcolor="#d4edda"> <b>Code 0 / 1 / 2</b><br> with no obvious evidence of interdental recession </td> <td rowspan="13" bgcolor="#f8d7da"> <b>Staging and grading, current disease status and risk factor assessment<br>(PTO)</b> </td> </tr> <tr> <td rowspan="4" bgcolor="#d4edda"><10% bleeding on probing</td> <td rowspan="4" bgcolor="#d4edda">10-30% bleeding on probing</td> <td rowspan="4" bgcolor="#d4edda">>30% bleeding on probing</td> </tr> <tr> <td>Clinical Gingival Health</td> <td>Localised Gingivitis</td> <td>Generalised Gingivitis</td> </tr> <tr><td colspan="3">Diagnosis should also include a comment on plaque retentive factors where a BPE code 2 is present</td></tr> <tr><td rowspan="2">No pockets ≥4mm and no radiographic evidence of bone loss due to periodontitis</td><td rowspan="2">Pockets ≥4mm remain and/or radiographic evidence of bone loss due to periodontitis</td></tr> </td> </tr> <tr><td rowspan="4" bgcolor="#d4edda"> <b>Code 3</b><br> with no obvious evidence of interdental recession </td> <td rowspan="7" bgcolor="#f8d7da"> <b><30% of teeth</b><br>Localised Periodontitis</td> </tr> <tr> <td>Appropriate radiographic assessment</td> </tr> <tr> <td>Initial periodontal therapy and review in 3 months with localised 6-point pocket chart in involved sextant(s)</td> </tr> <tr><td rowspan="2">No pockets ≥4mm and no radiographic evidence of bone loss due to periodontitis</td><td rowspan="2">Pockets ≥4mm remain and/or radiographic evidence of bone loss due to periodontitis</td></tr> <tr><td colspan="4">continue with code <b>0/1/2</b> pathway</td> </tr> <tr><td rowspan="10" bgcolor="#d4edda"> <b>Code 4</b><br> and/or obvious evidence of interdental recession </td> <td rowspan="10" rowspan="2"> <b>Molar-incisor pattern</b><br> Periodontitis Molar-Incisor Pattern </td> <td rowspan="10" rowspan="2"> <b>continue with code<br>4 pathway</b> </td> </tr> </tr> <tr> <td>Appropriate radiographic assessment</td> </tr> <tr><td rowspan="7">Full periodontal assessment (including detailed 6-point pocket chart)</td> <td rowspan="4"> <b>≥30% of teeth</b><br> Generalised Periodontitis </td> </tr> <tr><td rowspan="4"> <b><30% of teeth</b><br>Localised Periodontitis</td> <td rowspan="4"> <b>≥30% of teeth</b><br> Generalised Periodontitis </td> </tr> <tr><td rowspan="2"> <b>Molar-incisor pattern</b><br> Periodontitis Molar-Incisor Pattern </td> <td rowspan="2"> <b><30% of teeth</b><br>Localised Periodontitis</td> </tr> <tr><td rowspan="2"> <b>≥30% of teeth</b><br>Generalised Periodontitis</td> </tr> </table> <div style="text-align: right; font-size: small;">14</div>  | History, examination and screening for periodontal disease | | | | Scan me | | :--- | :--- | :--- | :--- | :--- | | including BPE and assessment of historic periodontitis (interdental recession) | | | | | | **Code 0 / 1 / 2** with no obvious evidence of interdental recession | | | **Staging and grading, current disease status and risk factor assessment (PTO)** | | | | <10% bleeding on probing | 10-30% bleeding on probing | >30% bleeding on probing | | | | Clinical Gingival Health | Localised Gingivitis | Generalised Gingivitis | | | Diagnosis should also include a comment on plaque retentive factors where a BPE code 2 is present | | | | | | No pockets ≥4mm and no radiographic evidence of bone loss due to periodontitis | Pockets ≥4mm remain and/or radiographic evidence of bone loss due to periodontitis | | | | | **Code 3** with no obvious evidence of interdental recession | | **<30% of teeth** Localised Periodontitis | | | | Appropriate radiographic assessment | | | | | | Initial periodontal therapy and review in 3 months with localised 6-point pocket chart in involved sextant(s) | | | | | | No pockets ≥4mm and no radiographic evidence of bone loss due to periodontitis | Pockets ≥4mm remain and/or radiographic evidence of bone loss due to periodontitis | | | | | continue with code **0/1/2** pathway | | | | | | **Code 4** and/or obvious evidence of interdental recession | | **Molar-incisor pattern** Periodontitis Molar-Incisor Pattern | **continue with code 4 pathway** | | | Appropriate radiographic assessment | | | | | | Full periodontal assessment (including detailed 6-point pocket chart) | **≥30% of teeth** Generalised Periodontitis | **<30% of teeth** Localised Periodontitis | **≥30% of teeth** Generalised Periodontitis | | | | **Molar-incisor pattern** Periodontitis Molar-Incisor Pattern | **<30% of teeth** Localised Periodontitis | **≥30% of teeth** Generalised Periodontitis | | Flowchart: Flowchart for implementing the 2017 Classification of Periodontal Diseases to Reach a Diagnosis in Clinical Practice. The diagram begins with 'History, examination and screening for periodontal disease including BPE and assessment of historic periodontitis (interdental recession)'. It branches into three main pathways based on Code: Code 0/1/2 (green), Code 3 (yellow/beige), and Code 4 (pink/red). Each pathway details steps such as bleeding on probing percentages, radiographic assessments, therapy reviews, and final diagnoses like Gingivitis or various forms of Periodontitis. A QR code is present in the top right corner. **Emergency care phase** **Fundamental phase (Step 1 and 2 EFP Guideline)** **Re-assessment/re-evaluation phase** **Corrective phase (Step 3 EFP Guidleline)** **Supportive care phase of periodontal therapy** *Text within the flowchart/image:* **Preliminary/systemic phase** **Reevaluation** **Initial therapy (phase 1)** **Reevaluation (4 to 8 weeks)** **Maintenance therapy (phase 4)** **Surgical therapy (phase 2)** **Reevaluation** **Restorative therapy (phase 3)** **Fig 8-2 Sequence of periodontal phases of treatment.** **15**  **Emergency care phase** **Fundamental phase (Step 1 and 2 EFP Guideline)** **Re-assessment/re-evaluation phase** **Corrective phase (Step 3 EFP Guideline)** **Supportive care phase of periodontal therapy** **Preliminary/systemic phase** **Reevaluation** **Initial therapy (phase 1)** **Reevaluation (4 to 8 weeks)** **Maintenance therapy (phase 4)** **Surgical therapy (phase 2)** **Reevaluation** **Restorative therapy (phase 3)** **Fig 8-2 Sequence of periodontal phases of treatment.** Flowchart illustrating the sequence of periodontal phases of treatment. The diagram starts with a blue box labeled 'Preliminary/systemic phase', followed by an arrow pointing to 'Reevaluation'. Next is 'Initial therapy (phase 1)', leading to another 'Reevaluation (4 to 8 weeks)'. From there, the flow splits into two paths: one leading to 'Surgical therapy (phase 2)' and the other to 'Restorative therapy (phase 3)'. Both paths converge towards a large orange triangle labeled 'Maintenance therapy (phase 4)', which also receives input from 'Reevaluation' between the restorative and surgical therapies. - #Clinical Practice Guideline # Journal of Clinical Periodontology **WILEY** EFP European Federation of Periodontology **Treatment of stage I–III periodontitis—The EFP S3 level clinical practice guideline** Mariano Sanz^1^ | David Herrera^1^ | Moritz Kebschull^2,3,4^ \| Iain Chapple2,3^1^ | Søren Jepsen^5^ \| Tord Beglundh6\| | Anton Sculean7\| \|[ Maurizio S. Tonetti^8,9^ |-1 On behalf of the EFP Workshop Participants and Methodological Consultants - The 2017 World Workshop on Periodontitis Classification introduced a system linking stages and grades of the disease to tailored prevention and treatment strategies, addressing severity, complexity, and individual risk factors. - Developed by the European Federation of Periodontology (EFP) using evidence from 15 systematic reviews and the GRADE system, the S3-Level Clinical Practice Guidelines outline a stepwise approach for managing Stage I–III periodontitis. - Recommendations focus on behavioral changes, biofilm control, surgical interventions, and supportive care to ensure long-term periodontal health. . - These guidelines provide an evidence-based framework for effective treatment, supporting lifelong oral health and informing clinical practice and policy. 16  **Treatment of stage I–III periodontitis—The EFP S3 level clinical practice guideline** Mariano Sanz, David Herrera, Moritz Kebschull, Iain Chapple, Søren Jepsen, Tord Beglundh, Anton Sculean, Maurizio S. Tonetti, on behalf of the EFP Workshop Participants and Methodological Consultants - The 2017 World Workshop on Periodontitis Classification introduced a system linking stages and grades of the disease to tailored prevention and treatment strategies, addressing severity, complexity, and individual risk factors. - Developed by the European Federation of Periodontology (EFP) using evidence from 15 systematic reviews and the GRADE system, the S3-Level Clinical Practice Guidelines outline a stepwise approach for managing Stage I–III periodontitis. - Recommendations focus on behavioral changes, biofilm control, surgical interventions, and supportive care to ensure long-term periodontal health. - These guidelines provide an evidence-based framework for effective treatment, supporting lifelong oral health and informing clinical practice and policy. A thumbnail image of the cover page for the clinical practice guideline titled 'Treatment of stage I–III periodontitis—The EFP S3 level clinical practice guideline' published in the Journal of Clinical Periodontology by Wiley. It includes author names and affiliations. BDJ Minimum Intervention Dentistry Themed Issue **VERIFIABLE CPD PAPER** **CLINICAL** Evidence-based, personalised and minimally invasive treatment for periodontitis patients – the new EFP S3-level clinical treatment guidelines Moritz Kebschull${}^{1,2,3}$ and Iain Chapple${}^{1,2}$ **Step 0** **PREREQUISITE TO THERAPY** - Educate, classification, diagnosis, risk assess, care plan **Step 1** **RISK** - Risk factor control, OHI, adjuncts for GI, PMPR, supra-gingival scaling **Step 2** **INTERVENE** - Sub-gingival biofilm & calculus removal $\pm$ adjuncts **Step 3** **CHECK** - Non-responder sites: Re-RSD/surgery **Step 4** **EXIT** - plan longer-term care (above) **Supportive care/rehabilitation** **E** 17  **Evidence-based, personalised and minimally invasive treatment for periodontitis patients – the new EFP S3-level clinical treatment guidelines** Moritz Kebschull and Iain Chapple **Step 0** – **PREREQUISITE TO THERAPY**: Educate, classification, diagnosis, risk assess, care plan **Step 1** – **RISK**: Risk factor control, OHI, adjuncts for GI, PMPR, supra-gingival scaling **Step 2** – **INTERVENE**: Sub-gingival biofilm & calculus removal ± adjuncts **Step 3** – **CHECK**: Non-responder sites: Re-RSD/surgery **Step 4** – **EXIT**: Plan longer-term care (above) **Supportive care/rehabilitation** A labeled flowchart diagram illustrating the EFP S3-level clinical treatment guidelines for periodontitis. The chart is structured as a stepped process moving from bottom to top, with each step represented by a colored rectangular bar and an associated triangular marker containing a letter. Step 0 (green) is 'PREREQUISITE TO THERAPY'. Step 1 (blue) is 'RISK'. Step 2 (purple) is 'INTERVENE'. Step 3 (pink) is 'CHECK'. Step 4 (orange) is 'EXIT'. At the top, an orange triangle marked 'E' points to 'Supportive care/rehabilitation', which is positioned above Step 4. Preliminary/Emergency Phase: Emergency Dental Treatments - Pain and acute infections should be managed promptly, including: - Endodontic treatment for infected or abscessed teeth. - Treatment of periodontal abscesses. - Management of necrotizing periodontal diseases (painful and acute). - Extraction of hopeless teeth (can be postponed if necessary). 18  **Preliminary/Emergency Phase: Emergency Dental Treatments** - Pain and acute infections should be managed promptly, including: - Endodontic treatment for infected or abscessed teeth. - Treatment of periodontal abscesses. - Management of necrotizing periodontal diseases (painful and acute). - Extraction of hopeless teeth (can be postponed if necessary). Illustration of a dentist examining a patient's mouth with a dental mirror and light. The image serves as a visual anchor for the 'Emergency Dental Treatments' section. Treatment of stage I-III periodontitis—The EFP S3 level clinical practice guideline Mariano Sanz | David Herrera | Moritz Kebschull | Iain Chapple | Søren Jepsen | Tord Beglundh | Anton Sculean | Maurizio S. Tonetti | On behalf of the EFP Workshop Participants and Methodological Consultants #1st Step The first step in therapy is aimed at guiding behaviour change by motivating the patient to undertake successful removal of supragingival dental biofilm and risk factor control and may include the following interventions: * Supragingival dental biofilm control * Interventions to improve the effectiveness of oral hygiene [motivation, instructions (oral hygiene instructions, OHI)] * Adjunctive therapies for gingival inflammation * Professional mechanical plaque removal (PMPR), which includes the professional interventions aimed at removing supragingival plaque and calculus, as well as possible plaque-retentive factors that impair oral hygiene practices. * **Risk factor control**, which includes all the health behavioural change interventions eliminating/mitigating the recognized risk factors for periodontitis onset and progression (**smoking cessation**), improved metabolic control of diabetes, and perhaps physical exercise, dietary counselling and weight loss). 19 **1st Step** The first step in therapy is aimed at guiding behaviour change by motivating the patient to undertake successful removal of supragingival dental biofilm and risk factor control and may include the following interventions: - Supragingival dental biofilm control - Interventions to improve the effectiveness of oral hygiene [motivation, instructions (oral hygiene instructions, OHI)] - Adjunctive therapies for gingival inflammation - Professional mechanical plaque removal (PMPR), which includes the professional interventions aimed at removing supragingival plaque and calculus, as well as possible plaque-retentive factors that impair oral hygiene practices. - **Risk factor control**, which includes all the health behavioural change interventions eliminating/mitigating the recognized risk factors for periodontitis onset and progression (**smoking cessation**), improved metabolic control of diabetes, and perhaps physical exercise, dietary counselling and weight loss. **Re-evaluation/Re-assessment** This first step of therapy should be implemented in all periodontitis patients, irrespective of the stage of their disease, and should be re-evaluated frequently in order to: * **Continue to build motivation and adherence**, or explore other alternatives to overcome the barriers * **Develop skills in dental biofilm removal** and modify as required * **Allow for the appropriate response of the subsequent steps** of therapy **Re-evaluation/Re-assessment** This first step of therapy should be implemented in all periodontitis patients, irrespective of the stage of their disease, and should be re-evaluated frequently in order to: - **Continue to build motivation and adherence**, or explore other alternatives to overcome the barriers - **Develop skills in dental biofilm removal** and modify as required - **Allow for the appropriate response of the subsequent steps** of therapy **2nd Step:** The second step of therapy (cause-related therapy) is aimed at controlling (reducing/eliminating) the subgingival biofilm and calculus (subgingival instrumentation). In addition to this, the following interventions may be included: * Use of adjunctive physical or chemical agents * Use of adjunctive host-modulating agents (local or systemic) * Use of adjunctive subgingival locally delivered antimicrobials * Use of adjunctive systemic antimicrobials * This second step of therapy should be used for all periodontitis patients, irrespective of their disease stage, only in teeth with loss of periodontal support and/or periodontal pocket formation. * In specific clinical situations, such as in the presence of deep probing depths, first and second steps of therapy could be delivered simultaneously (such as for preventing periodontal abscess development). **2nd Step:** The second step of therapy (cause-related therapy) is aimed at controlling (reducing/eliminating) the subgingival biofilm and calculus (subgingival instrumentation). In addition to this, the following interventions may be included: - Use of adjunctive physical or chemical agents - Use of adjunctive host-modulating agents (local or systemic) - Use of adjunctive subgingival locally delivered antimicrobials - Use of adjunctive systemic antimicrobials - This second step of therapy should be used for all periodontitis patients, irrespective of their disease stage, only in teeth with loss of periodontal support and/or periodontal pocket formation. - In specific clinical situations, such as in the presence of deep probing depths, first and second steps of therapy could be delivered simultaneously (such as for preventing periodontal abscess development). # **Re-evaluation/Re-assessment** The individual response to the second step of therapy should be assessed once the periodontal tissues have healed (**periodontal re-evaluation**). ➢ **If the endpoints of therapy:** * No periodontal pockets greater than 4 mm with bleeding on probing or * No deep periodontal pockets greater than or equal to 6 mm [≥6 mm] have not been achieved, the third step of therapy should be considered. ➢ **If the treatment has been successful in achieving the endpoints of therapy**, patients should be placed in a **supportive periodontal care (SPC)** programme.  **Re-evaluation/Re-assessment** The individual response to the second step of therapy should be assessed once the periodontal tissues have healed (**periodontal re-evaluation**). - **If the endpoints of therapy:** - No periodontal pockets greater than 4 mm with bleeding on probing or - No deep periodontal pockets greater than or equal to 6 mm [≥6 mm] have not been achieved, the third step of therapy should be considered. - **If the treatment has been successful in achieving the endpoints of therapy**, patients should be placed in a **supportive periodontal care (SPC)** programme. Clinical photograph demonstrating periodontal re-evaluation. The image shows a close-up view of a tooth being examined with a periodontal probe inserted into the gingival sulcus to measure pocket depth and assess bleeding on probing. # 3rd Step: * The third step of therapy is aimed at treating those areas of the dentition non-responding adequately to the second step of therapy (presence of pockets greater than or equal to 4 mm [≥4 mm] with bleeding on probing or presence of deep periodontal pockets greater than or equal to 6 mm [≥6 mm]), with the purpose of gaining further access to subgingival instrumentation, or aiming at regenerating or resecting those lesions that add complexity in the management of periodontitis (intra-bony and furcation lesions). It may include the following interventions: * Repeated subgingival instrumentation with or without adjunctive therapies * Access flap periodontal surgery * Resective periodontal surgery * Regenerative periodontal surgery Additional surgical procedures, such as mucogingival, preprosthetic, preimplant, or implant surgeries, may be performed depending on patient needs. When there is indication for surgical interventions, these should be subject to an additional patient consent and specific evaluation of risk factors or medical contra-indications should be considered. This corrective phase may also entail the orthodontic repositioning of drifted teeth. **3rd Step:** The third step of therapy is aimed at treating those areas of the dentition non-responding adequately to the second step of therapy (presence of pockets greater than or equal to 4 mm [≥4 mm] with bleeding on probing or presence of deep periodontal pockets greater than or equal to 6 mm [≥6 mm]), with the purpose of gaining further access to subgingival instrumentation, or aiming at regenerating or resecting those lesions that add complexity in the management of periodontitis (intra-bony and furcation lesions). It may include the following interventions: - Repeated subgingival instrumentation with or without adjunctive therapies - Access flap periodontal surgery - Resective periodontal surgery - Regenerative periodontal surgery Additional surgical procedures, such as mucogingival, preprosthetic, preimplant, or implant surgeries, may be performed depending on patient needs. When there is indication for surgical interventions, these should be subject to an additional patient consent and specific evaluation of risk factors or medical contra-indications should be considered. This corrective phase may also entail the orthodontic repositioning of drifted teeth. # Re-evaluation/Re-assessment | Circle 1 (Left) | Circle 2 (Left) | Arrow | Result (Center) | Icon (Right) | | :--- | :--- | :--- | :--- | :--- | | **No**<br>PPD>4mm<br>with BOP | **No Deep**<br>pockets<br>≥6mm | ➜ | **SPC** | Checklist Icon | 24  **Re-evaluation/Re-assessment** | No PPD > 4 mm with BOP | No Deep pockets ≥ 6 mm | → | SPC | A flowchart diagram illustrating the criteria for 'Re-evaluation/Re-assessment' leading to a state labeled 'SPC'. It features two input circles on the left: one stating 'No PPD>4mm with BOP' and the other 'No Deep pockets ≥6mm'. A plus sign indicates these conditions are combined, followed by an arrow pointing to a central circle containing the acronym 'SPC', which represents the resulting status. **Supportive Periodontal Care (Maintenance Phase)** **Objective:** * Maintain periodontal stability in treated periodontitis patients. * Integrates preventive and therapeutic interventions from earlier therapy steps. **Personalized Care:** * Tailored based on gingival and periodontal status of the patient. * Regular recall visits scheduled according to individual patient needs. **Monitoring and Re-Treatment:** * Re-treatment may be necessary if recurrent disease is detected. * Requires proper diagnosis and treatment planning when needed. * In some cases, extraction of hopeless teeth may be required. **Patient Compliance:** * Adherence to oral hygiene regimens is crucial. * Encouragement of healthy lifestyle habits to prevent disease recurrence. 25 **Supportive Periodontal Care (Maintenance Phase)** **Objective:** - Maintain periodontal stability in treated periodontitis patients. - Integrates preventive and therapeutic interventions from earlier therapy steps. **Personalized Care:** - Tailored based on gingival and periodontal status of the patient. - Regular recall visits scheduled according to individual patient needs. **Monitoring and Re-Treatment:** - Re-treatment may be necessary if recurrent disease is detected. - Requires proper diagnosis and treatment planning when needed. - In some cases, extraction of hopeless teeth may be required. **Patient Compliance:** - Adherence to oral hygiene regimens is crucial. - Encouragement of healthy lifestyle habits to prevent disease recurrence. **Supportive Periodontal Care** **(Maintenance Phase)** * **Update medical and smoking history** * **Oral hygiene assessment and reinforcement of oral hygiene if necessary** * **Full periodontal charting** * **Sensibility testing of suspected teeth** * **Instrumentation of sites with residual pocket >4mm** * **Fluoride application on the exposed roots to prevent dental caries** * **Regular assessment of prosthetic restorations and radiographic evaluation may also be indicated.** 26 **Supportive Periodontal Care (Maintenance Phase)** - Update medical and smoking history - Oral hygiene assessment and reinforcement of oral hygiene if necessary - Full periodontal charting - Sensibility testing of suspected teeth - Instrumentation of sites with residual pocket > 4 mm - Fluoride application on the exposed roots to prevent dental caries - Regular assessment of prosthetic restorations and radiographic evaluation may also be indicated. img>Dental lecture slide with purple background</img> # SPC In Daily Practice: **The recall hour** should be planned to meet patient’s individual needs. **It consist** of four sections: **1. EXAMINATION**, RE-EVALUATION & DIAGNOSIS (ERD):** This section consists of 10-**15**mins. **2. MOTIVATION, REINSTRUCTION** & INSTRUMENTATION: This section **consist** of 30-40mins of motivation, reinstruction of oral hygiene, instrumentation concentrated on sites diagnosed with persistent inflammation **3. TREATMENT OF REINFECTED SITES** may include small surgical corrections. **4. POLISHING OF ENTIRE DENTITION, APPLICATION OF FLUORIDES** & DETERMINATION OF **FUTURE SPT APPOINTMENT**: 5-10mins should be reserved for this section. **SPC In Daily Practice:** The recall hour should be planned to meet patient’s individual needs. It consists of four sections: 1. **EXAMINATION, RE-EVALUATION & DIAGNOSIS (ERD):** This section consists of 10–15 mins. 2. **MOTIVATION, REINSTRUCTION & INSTRUMENTATION:** This section consists of 30–40 mins of motivation, reinstruction of oral hygiene, instrumentation concentrated on sites diagnosed with persistent inflammation. 3. **TREATMENT OF REINFECTED SITES** may include small surgical corrections. 4. **POLISHING OF ENTIRE DENTITION, APPLICATION OF FLUORIDES & DETERMINATION OF FUTURE SPT APPOINTMENT:** 5–10 mins should be reserved for this section. ```mermaid graph TD subgraph Phases_of_treatment [Phases of treatment] A[Preliminary/systemic phase] --> B[Initial therapy/disease control phase] B --> C[Surgical therapy] C --> D[Restorative therapy] D --> E[Maintenance/SPT] end A --- A1["• Treatment of emergencies<br>• Extraction of hopeless teeth"] B --- B1["• Plaque control<br>• Patient education/motivation<br>• Removal of plaque and calculus, scaling and root planing, and polishing<br>• Correction of restorative and prosthetic contributing factors<br>• Caries control and restoration (provisional or definitive)<br>• Antimicrobial therapy (local or systemic)<br>• Occlusal therapy<br>• Provisional splinting and prosthesis<br>• Endodontic treatment<br>• Consultation with specialists, establish treatment plan (tentative or final)"] B1 --- B2["<b>Reevaluation of phase 1 at 4 to 8 weeks</b><br>• Probing depth, attachment levels, and gingival inflammation<br>• Plaque and calculus, caries"] C --- C1["• Periodontal surgical therapy, including implant placement"] C1 --- C2["Reevaluation of phase 2"] D --- D1["• Definitive restorations<br>• Fixed and removable prostheses<br>• Evaluation of response to restorative procedures"] E --- E1["• Full evaluation (plaque, calculus, oral hygiene/motivation)<br>• Bitewing radiographs, full-mouth series, or panoramic radiographs as needed<br>• Occlusal guard"] classDef phase fill:#ffcc66,stroke:#333,stroke-width:1px; classDef details fill:#dae8fc,stroke:#333,stroke-width:1px,text-align:left; classDef reeval fill:#3c91b6,stroke:#333,stroke-width:1px,color:#fff; class A,B,C,D,E phase; class A1,B1,C1,D1,E1 details; class B2,C2 reeval; ``` **Fig 8-3** Phases of periodontal therapy.  **Phases of treatment** - Preliminary/systemic phase → Initial therapy/disease control phase → Surgical therapy → Restorative therapy → Maintenance/SPT **Preliminary/systemic phase:** - Treatment of emergencies - Extraction of hopeless teeth **Initial therapy/disease control phase:** - Plaque control - Patient education/motivation - Removal of plaque and calculus, scaling and root planing, and polishing - Correction of restorative and prosthetic contributing factors - Caries control and restoration (provisional or definitive) - Antimicrobial therapy (local or systemic) - Occlusal therapy - Provisional splinting and prosthesis - Endodontic treatment - Consultation with specialists, establish treatment plan (tentative or final) **Reevaluation of phase 1 at 4 to 8 weeks:** - Probing depth, attachment levels, and gingival inflammation - Plaque and calculus, caries **Surgical therapy:** - Periodontal surgical therapy, including implant placement **Reevaluation of phase 2** **Restorative therapy:** - Definitive restorations - Fixed and removable prostheses - Evaluation of response to restorative procedures **Maintenance/SPT:** - Full evaluation (plaque, calculus, oral hygiene/motivation) - Bitewing radiographs, full-mouth series, or panoramic radiographs as needed - Occlusal guard **Fig 8-3** Phases of periodontal therapy. A flowchart diagram illustrating the 'Phases of treatment' for periodontal therapy. The figure is structured into four main phases (Phase 1 through Phase 4) arranged vertically on the left side in yellow boxes: Preliminary/systemic phase, Initial therapy/disease control phase, Surgical therapy, Restorative therapy, and Maintenance/SPT. To the right of each phase, light blue boxes detail the specific procedures included (e.g., plaque control, scaling and root planing, surgical therapy). Darker blue boxes indicate reevaluation steps at intervals within the process. Arrows connect the phases sequentially. | Oral Health and Risk Assessment, Diagnosis & Care Plan | | | | | :--- | :--- | :--- | :--- | | **Diagnosis** | **Periodontal Health** | **Gingivitis** | **Periodontitis** | | | | | Extract teeth with hopeless prognosis or unsavable teeth – eg grade III mobile | | **STEP 1** | Building foundations for optimal treatment outcomes | | | | | I: | | | | | Explain disease, risk factors & treatment alternatives, risks & benefits including no treatment | | | II: | Encourage and support behaviour change for OH improvement | | | Explain importance of Oral Hygiene (OH), encourage and support behaviour change for OH improvement | | | | III: | Reduction of risk factors including removal of plaque retentive features, smoking cessation and diabetes control interventions | | | | IV: | Provide individually tailored OH advice including interdental cleaning, +/- adjunctive efficacious toothpaste & mouthwash, +/- Professional Mechanical Plaque Removal (PMPR) including supra and subgingival scaling of the clinical crown | | | | V: | Select recall period following published guidance and considering risk factors such as smoking and diabetes | | | | VI: | Oral Health Educator (I, II), Hygienist, Therapist (I – IV), Dentist, Practitioner accredited for Level 2 and 3 care (I – V) | | | **BSP** | British Society of Periodontology and Implant Dentistry | | | | | | | | | | | | Re-evaluate | | | | Non-engaging patient – return to <b>STEP 1</b> & repeat | | | | | Engaging patient – move to <b>STEP 2</b> | | | | | Consider referral | | | | | | <b>STEP 2</b> (see over) | | **© The British Society of Periodontology and Implant Dentistry 2021** | www.bsperio.org.uk | *29* | |  **Oral Health and Risk Assessment, Diagnosis & Care Plan** | Diagnosis | Periodontal Health | Gingivitis | Periodontitis | | :--- | :--- | :--- | :--- | | | | | Extract teeth with hopeless prognosis or unsavable teeth – e.g. grade III mobile | **STEP 1** – Building foundations for optimal treatment outcomes I: Explain disease, risk factors & treatment alternatives, risks & benefits including no treatment II: Encourage and support behaviour change for OH improvement. Explain importance of Oral Hygiene (OH), encourage and support behaviour change for OH improvement III: Reduction of risk factors including removal of plaque retentive features, smoking cessation and diabetes control interventions IV: Provide individually tailored OH advice including interdental cleaning, +/- adjunctive efficacious toothpaste & mouthwash, +/- Professional Mechanical Plaque Removal (PMPR) including supra and subgingival scaling of the clinical crown V: Select recall period following published guidance and considering risk factors such as smoking and diabetes VI: Oral Health Educator (I, II), Hygienist, Therapist (I – IV), Dentist, Practitioner accredited for Level 2 and 3 care (I – V) **BSP** – British Society of Periodontology and Implant Dentistry Re-evaluate - Non-engaging patient – return to **STEP 1** & repeat - Engaging patient – move to **STEP 2** - Consider referral **STEP 2** (see over) © The British Society of Periodontology and Implant Dentistry 2021 A clinical flowchart titled 'ORAL HEALTH AND RISK ASSESSMENT, DIAGNOSIS & CARE PLAN'. The diagram illustrates a decision-making process starting with diagnosis categories: Periodontal Health, Gingivitis, and Periodontitis. It details 'STEP 1' for building foundations for optimal treatment outcomes, listing six specific actions (I-VI) regarding patient education, oral hygiene advice, risk reduction, and professional mechanical plaque removal. A QR code is present on the left side next to the BSP logo. The bottom section outlines a 'Re-evaluate' step branching into paths for non-engaging patients (return to STEP 1) or engaging patients (move to STEP 2), with an option to consider referral. <table><tr><td colspan="7"><b>Periodontitis (continued)</b></td></tr><tr><td rowspan="3">STEP 2</td><td colspan="6"><b>Subgingival Instrumentation</b> (root surface debridement / PMPR on root)</td></tr><tr><td><b>I:</b></td><td colspan="5">Reinforce OH, risk factor control, behaviour change</td></tr><tr><td><b>II:</b></td><td colspan="5">Subgingival instrumentation, hand or powered (sonic / ultrasonic), either alone or in combination</td></tr><tr><td><b>III:</b></td><td colspan="5">Use of adjunctive systemic antimicrobials determined by Practitioner accredited for Level 2 and 3 care</td></tr><tr><td colspan="2">BSP</td><td>British Society</td><td colspan="4"><b>Supported by</b></td></tr><tr><td> </td><td>of</td><td>Periodontology and</td><td></td><td></td><td></td><td><b>HALEON</b></td><td> </td></tr><tr><td> </td><td>Implant</td><td>Dentistry</td><td> </td><td></td><td></td><td> </td><td> </td></tr><tr><td rowspan="2">STEP 3</td><td></td><td>Unstable</td><td>Re-evaluate after 3 months</td><td>Stable</td><td></td><td></td><td>STEP 4</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td colspan="4"><b>Managing non-responding sites:</b><br><b>I:</b><br>Reinforce OH, risk factor control, behaviour change<br><b>II:</b><br>Moderate (4–5mm) residual pockets – re-perform<br>subgingival instrumentation<br><b>III:</b><br>Deep residual pocketing (≥6mm). Consider alternative causes<br><b>IV</b><br>Consider referral for pocket management or<br>regenerative surgery<br><b>V:</b><br>If referral not possible, re-perform subgingival instrumentation<br>(If all sites stable after **STEP 3** proceed to **STEP 4**)</td><td colspan="4"><b>Maintenance</b><br><b>I:</b><br>Supportive periodontal care strongly encouraged<br><b>II:</b><br>Reinforce OH, risk factor control, behaviour change<br><b>III:</b><br>Regular targeted PMPR as required to limit tooth loss<br><b>IV:</b><br>Consider evidence based adjunctive efficacious toothpaste<br>and / or mouthwash to control gingival inflammation</td></tr><tr><td colspan="8"><b>Maintenance recall (STEP 4)</b> – individually tailored intervals from 3–12 months</td></tr><tr><td colspan="8"><b>BSP top tips</b><br><b>I:</b><br>Patients should be made aware that regular effective self-performed plaque removal offers the largest treatment benefit – engage the patient<br>in a verbal contract to perform daily plaque control<br><b>II:</b><br>Toothbrushing should be supplemented by the use of interdental brushes (where anatomically possible)<br><b>III:</b><br>Individual patient’s abilities, needs, preferences and manual dexterity should be considered when selecting toothbrush & interlemlal brush<br><b>IV:</b><br>Refer to BSP website for further clarification and glossary of terms</td></tr><tr><td colspan="5"><b>I:</b><br>Favourable improvement in OH – indicated by ≥50%<br>improvement in plaque and marginal bleeding scores OR<br><b>II.</b><br>Plaque levels ≤20% & bleeding levels ≤30% OR<br><b>III.</b><br>Patient has met targets outlined in their personal self-care plan as determined by their healthcare practitioner</td><td rowspan="2"><b>Defining engaging &<br>non-engaging patients</b><br>(this is a guide)</td><td colspan="3"><b>I:</b><br>Insufficient improvement in OH – indicated by <50%<br>improvement in plaque and marginal bleeding scores OR<br><b>II.</b><br>Plaque levels >20% & bleeding levels >30% OR<br><b>III.</b><br>Patient states preference to a palliative approach to<br>periodontal care</td></tr><tr><td colspan="5"></td><td colspan="3"></td></tr><tr><td colspan="8" style="text-align:right;">30</td></tr></table>  **Periodontitis (continued)** **STEP 2 – Subgingival Instrumentation** (root surface debridement / PMPR on root) I: Reinforce OH, risk factor control, behaviour change II: Subgingival instrumentation, hand or powered (sonic / ultrasonic), either alone or in combination III: Use of adjunctive systemic antimicrobials determined by Practitioner accredited for Level 2 and 3 care **BSP** – British Society of Periodontology and Implant Dentistry – **Supported by HALEON** **STEP 3** – Managing non-responding sites: I: Reinforce OH, risk factor control, behaviour change II: Moderate (4–5 mm) residual pockets – re-perform subgingival instrumentation III: Deep residual pocketing (≥6 mm). Consider alternative causes IV: Consider referral for pocket management or regenerative surgery V: If referral not possible, re-perform subgingival instrumentation (If all sites stable after **STEP 3** proceed to **STEP 4**) **Re-evaluate after 3 months** – Unstable → Stable → **STEP 4** **STEP 4 – Maintenance** I: Supportive periodontal care strongly encouraged II: Reinforce OH, risk factor control, behaviour change III: Regular targeted PMPR as required to limit tooth loss IV: Consider evidence based adjunctive efficacious toothpaste and / or mouthwash to control gingival inflammation **Maintenance recall (STEP 4)** – individually tailored intervals from 3–12 months **BSP top tips** I: Patients should be made aware that regular effective self-performed plaque removal offers the largest treatment benefit – engage the patient in a verbal contract to perform daily plaque control II: Toothbrushing should be supplemented by the use of interdental brushes (where anatomically possible) III: Individual patient’s abilities, needs, preferences and manual dexterity should be considered when selecting toothbrush & interdental brush IV: Refer to BSP website for further clarification and glossary of terms **Defining engaging & non-engaging patients** (this is a guide) **Engaging patient:** I: Favourable improvement in OH – indicated by ≥50% improvement in plaque and marginal bleeding scores OR II: Plaque levels ≤20% & bleeding levels ≤30% OR III: Patient has met targets outlined in their personal self-care plan as determined by their healthcare practitioner **Non-engaging patient:** I: Insufficient improvement in OH – indicated by <50% improvement in plaque and marginal bleeding scores OR II: Plaque levels >20% & bleeding levels >30% OR III: Patient states preference to a palliative approach to periodontal care BSP Treatment Flow Chart for Periodontitis. The visual demonstrates a clinical decision-making process starting with 'STEP 2: Subgingival Instrumentation'. It flows into 'STEP 3' where patients are re-evaluated after 3 months. A branching path is shown based on stability: if 'Unstable', the patient returns to Step 3 for management of non-responding sites; if 'Stable', they proceed to 'STEP 4'. Below this, sections detail 'Managing non-responding sites' (I-V) and 'Maintenance' protocols (I-IV). The chart concludes with a section on 'Defining engaging & non-engaging patients' using specific plaque and bleeding score thresholds. 111 **Removal of plaque and/or stain #** Removal of dental plaque and/or stain from the surfaces of all teeth and/or implants. This item is included in procedures described by items 114, 115, 250 and 251. 113 **Recontouring and polishing of pre-existing restoration(s) – per tooth** The reshaping and polishing of pre-existing restorations. 114 **Removal of calculus – first appointment** Removal of calculus from the surfaces of teeth and/or implants. 115 **Removal of calculus – subsequent appointment** This item describes procedures in item 114 when, because of the extent or degree of calculus, an additional appointment(s) is required to remove deposits from the teeth and/or implants. 250 **Active non-surgical periodontal therapy – per quadrant** Non-surgical management of uncontrolled periodontal disease in a quadrant with at least three teeth with clinical attachment loss of at least 3 mm or pocketing of at least 4 mm. This includes procedures described in items 111, 114, 115 and 222 for the quadrant. Items such as 113, 131 and 142 may be itemised separately. 251 **Supportive periodontal therapy – per appointment** Maintenance of periodontal health subsequent to active, non-surgical or surgical periodontal therapy. This includes procedures described in items 111, 114, 115 and 222. Items such as 113, 131 and 142 may be itemised separately. 213 **Treatment of acute periodontal infection – per appointment** This item describes the treatment of acute periodontal infection(s). It may include establishing drainage and the removal of calculus from the affected tooth (teeth) or implant. 221 **Clinical periodontal analysis and recording** This is a special examination performed as part of the diagnosis and management of periodontal disease. The procedure consists of assessing and recording a patient’s periodontal condition. 222 **Periodontal debridement – per tooth** The mechanical removal of biofilm and calculus from a periodontally diseased tooth to a level consistent with periodontal health. Where calculus removal is undertaken for other teeth at the same or a subsequent appointment that do not require debridement, it is appropriate to itemise 114/115 for these teeth in conjunction with but separate from the teeth that have undergone periodontal debridement. 223 **Non-surgical treatment of peri-implant disease – per implant** The process of debridement using specialised instrumentation to remove the microbial biofilm from the implant and/or abutment surface, which may include localised application of medicaments.  111 **Removal of plaque and/or stain** – Removal of dental plaque and/or stain from the surfaces of all teeth and/or implants. This item is included in procedures described by items 114, 115, 250 and 251. 113 **Recontouring and polishing of pre-existing restoration(s) – per tooth** – The reshaping and polishing of pre-existing restorations. 114 **Removal of calculus – first appointment** – Removal of calculus from the surfaces of teeth and/or implants. 115 **Removal of calculus – subsequent appointment** – This item describes procedures in item 114 when, because of the extent or degree of calculus, an additional appointment(s) is required to remove deposits from the teeth and/or implants. 250 **Active non-surgical periodontal therapy – per quadrant** – Non-surgical management of uncontrolled periodontal disease in a quadrant with at least three teeth with clinical attachment loss of at least 3 mm or pocketing of at least 4 mm. This includes procedures described in items 111, 114, 115 and 222 for the quadrant. Items such as 113, 131 and 142 may be itemised separately. 251 **Supportive periodontal therapy – per appointment** – Maintenance of periodontal health subsequent to active, non-surgical or surgical periodontal therapy. This includes procedures described in items 111, 114, 115 and 222. Items such as 113, 131 and 142 may be itemised separately. 213 **Treatment of acute periodontal infection – per appointment** – This item describes the treatment of acute periodontal infection(s). It may include establishing drainage and the removal of calculus from the affected tooth (teeth) or implant. 221 **Clinical periodontal analysis and recording** – This is a special examination performed as part of the diagnosis and management of periodontal disease. The procedure consists of assessing and recording a patient’s periodontal condition. 222 **Periodontal debridement – per tooth** – The mechanical removal of biofilm and calculus from a periodontally diseased tooth to a level consistent with periodontal health. Where calculus removal is undertaken for other teeth at the same or a subsequent appointment that do not require debridement, it is appropriate to itemise 114/115 for these teeth in conjunction with but separate from the teeth that have undergone periodontal debridement. 223 **Non-surgical treatment of peri-implant disease – per implant** – The process of debridement using specialised instrumentation to remove the microbial biofilm from the implant and/or abutment surface, which may include localised application of medicaments. Photograph showing the cover of 'The Australian Schedule of Dental Services and Glossary', Thirteenth Edition. The book is being held by a person, displaying its orange and white design with the ADA logo. # CASE PRESENTATION AND TREATMENT PLANNING EXAMPLE 32  Clinical photo: A professional consultation scene showing two individuals at a desk reviewing dental case materials. On the left, a person in a grey shirt holds a pen and points toward a laptop displaying a panoramic dental radiograph (X-ray). In the center of the table sits a dental study model with red wax indicating occlusion or bite relationship. The right side shows another individual's hands resting on papers. This visual supports the context of 'CASE PRESENTATION AND TREATMENT PLANNING EXAMPLE' by demonstrating how clinicians review diagnostic imaging and physical models during treatment planning discussions. <table> <tr> <td colspan="2"><b>PATIENT PROFILE</b></td> </tr> <tr> <td colspan="2"><b>About:</b></td> </tr> <tr> <td colspan="2">Mrs Smith, 37 yrs old, female</td> </tr> <tr> <td colspan="2"><b>Referral from:</b></td> </tr> <tr> <td colspan="2">OHCWA DMD Clinic (Jan 2023)</td> </tr> <tr> <td colspan="2"><b>First Periodontal Consultation:</b></td> </tr> <tr> <td colspan="2">24-Apr-2023</td> </tr> <tr> <td colspan="2"><b>Patient Concerns:</b></td> </tr> <tr> <td colspan="2">○</td> </tr> <tr> <td colspan="2">Doesn’t want to lose any more teeth and wants to take better care of herself.</td> </tr> <tr> <td colspan="2">○</td> </tr> <tr> <td colspan="2">Notices bleeding while brushing.</td> </tr> <tr> <td colspan="2">○</td> </tr> <tr> <td colspan="2">Feels that her lower front teeth are moving.</td> </tr> <tr> <td colspan="2">○</td> </tr> <tr> <td colspan="2">Reports a bad taste and bad breath.</td> </tr> <tr> <td colspan="2">○</td> </tr> <tr> <td colspan="2">Feels that her teeth and gums are sensitive.</td> </tr> <tr> <td colspan="2">33</td> </tr> </table>  **PATIENT PROFILE** **About:** Mrs Smith, 37 yrs old, female **Referral from:** OHCWA DMD Clinic (Jan 2023) **First Periodontal Consultation:** 24-Apr-2023 **Patient Concerns:** - Doesn’t want to lose any more teeth and wants to take better care of herself. - Notices bleeding while brushing. - Feels that her lower front teeth are moving. - Reports a bad taste and bad breath. - Feels that her teeth and gums are sensitive. Table: Patient Profile summary. The table contains the following sections and data points: 'About' lists Mrs Smith, 37 yrs old, female; 'Referral from' is OHCWA DMD Clinic (Jan 2023); 'First Periodontal Consultation' date is 24-Apr-2023. The 'Patient Concerns' section lists five bullet points detailing patient complaints: doesn't want to lose more teeth, notices bleeding while brushing, feels lower front teeth are moving, reports bad taste and bad breath, and feels teeth and gums are sensitive. CLINICAL PHOTOGRAPHS – INITIAL EXAMINATION: 34          CLINICAL PHOTOGRAPHS – INITIAL EXAMINATION: Clinical photograph showing a frontal view of the patient's dentition. The image displays generalized plaque accumulation and calculus deposits on the cervical margins of both upper and lower anterior teeth. Clinical photograph showing a frontal view of the patient's occlusion with retraction devices in place. The image highlights significant gingival inflammation and periodontal recession on multiple teeth. Clinical photograph of the maxillary left posterior region (premolars and molars). A large black amalgam restoration is visible on the occlusal surface of the second molar. Generalized staining is noted. Clinical photograph of the mandibular left posterior region (premolars and molars). A black amalgam restoration is present on the first premolar or second premolar. Evidence of periodontal disease is visible. Clinical photograph of the mandibular right posterior region. A black amalgam restoration is clearly visible on the occlusal surface of the first molar. Significant calculus buildup is observed on the buccal surfaces. Clinical photograph of the maxillary right posterior region. A black amalgam restoration is visible on the first molar. The image captures the alignment of the posterior teeth. Clinical photograph of the complete mandibular arch viewed from the lingual aspect. This view reveals the palatal contours of the teeth and the attached gingiva. A black amalgam restoration is visible on the lingual surface of a posterior tooth. Clinical photograph of the complete mandibular arch viewed from the labial aspect. The image shows the alignment of the lower teeth and the presence of a black amalgam restoration on a central incisor. Clinical photograph of the complete maxillary arch viewed from the occlusal aspect. This view demonstrates the transverse width of the dental arch and the presence of a black amalgam restoration on a posterior tooth. <table><thead><tr><th>SOCIAL</th><th>DENTAL</th><th>MEDICAL</th></tr></thead><tbody><tr><td>Single</td><td>Sporadic attendance till 2022 only visit dentist in case of problems</td><td>Recent blood test revealed no medical condition</td></tr><tr><td>4 Children</td><td>Started being seen by DMD student since Jan 2023</td><td>Takes supplements</td></tr><tr><td>Doesn't work</td><td>Treatment provided in DMD Clinic since Jan 2023 include: -Periodontal tx -Extractions -Extensive restorative treatment requirements</td><td></td></tr><tr><td>Feels stressed</td><td></td><td></td></tr><tr><td>Highly motivated</td><td></td><td></td></tr><tr><td>Recently was released from prison</td><td></td><td></td></tr><tr><td>Smoking: She has been smoking 10-15 cigarettes per day for the past 20 years</td><td></td><td></td></tr><tr><td>Drug: Used Methamphetamine for 13 years. Quit drugs 3 years ago.</td><td></td><td></td></tr></tbody></table>  #### Social - Single - 4 Children - Doesn't work - Feels stressed - Highly motivated - Recently was released from prison - Smoking: She has been smoking 10-15 cigarettes per day for the past 20 years - Drug: Used Methamphetamine for 13 years. Quit drugs 3 years ago. #### Dental - Sporadic attendance till 2022 only visit dentist in case of problems - Started being seen by DMD student since Jan 2023 - Treatment provided in DMD Clinic since Jan 2023 include: - Periodontal tx - Extractions - Extensive restorative treatment requirements #### Medical - Recent blood test revealed no medical condition - Takes supplements A structured table titled 'PATIENT HISTORY' with three main column headers: SOCIAL, DENTAL, and MEDICAL. The table organizes patient data into rows corresponding to specific categories such as marital status ('Single'), family size ('4 Children'), employment ('Doesn't work'), stress levels ('Feels stressed'), motivation ('Highly motivated'), legal history ('Recently was released from prison'), smoking habits ('Smoking: She has been smoking 10-15 cigarettes per day for the past 20 years'), and drug use history ('Drug: Used Methamphetamine for 13 years. Quit drugs 3 years ago'). The content under the DENTAL column details attendance patterns and treatments provided since January 2023, including periodontal treatment, extractions, and restorative requirements.  Educational infographic titled 'Development of Periodontitis'. It features a section labeled 'The Stages of Dental disease' which displays four sequential diagrams illustrating the progression from 'Healthy Teeth and Gums' to 'Advanced Periodontitis'. Each stage shows a tooth cross-section with corresponding text descriptions (e.g., 'Plaque and tartar inflame the gum', 'Pockets deepen'). Below the diagrams are two columns: 'SYMPTOMS' listing signs like 'Breath odor' and 'Loose teeth', and 'WHEN TO SEE A DENTIST?' providing advice. A footer includes 'ALTERNATIVE NAMES' such as 'PYORRHEA - GUM DISEASE'. <table> <tr> <th colspan="2" style="text-align:center; font-size:30pt;">PERIODONTAL ASSESSMENT</th> </tr> <tr> <th colspan="2" style="text-align:center;">PATIENT SIGNS & SYMPTOMS</th> </tr> <tr> <td colspan="2" style="font-weight:bold; text-align:left;">SYMPTOMS:</td> </tr> <tr> <td>Pain/sensitivity</td> <td>Teeth are sensitive to cold drinks</td> </tr> <tr> <td>Bleeding</td> <td>Pt noticed bleeding while brushing</td> </tr> <tr> <td>Bad taste/smell</td> <td>Noticed bad breath / bad taste</td> </tr> <tr> <th colspan="2" style="text-align:center; font-weight:bold; font-size:20pt;">SIGNS:</th> </tr> <tr> <td>Suppuration</td> <td>Teeth # 31, 41, 43, 11, 21</td> </tr> <tr> <td>Migration</td> <td>Nil</td> </tr> <tr> <td>Mobility</td> <td>Lower / upper front teeth</td> </tr> <tr> <td>Food impaction/ chewing efficiency</td> <td>Nil</td> </tr> <tr> <td>Tooth loss</td> <td>4 (due to tooth decay)</td> </tr> <tr> <td>Parafunction</td> <td>She used to clench her teeth when she was on drugs</td> </tr> <tr> <th colspan="2" style="text-align:center; font-weight:bold; text-align:center;">ORAL HYGIENE ROUTINE</th> </tr> <tr> <td>Tooth brushing</td> <td>Soft electric toothbrush in morning and at night</td> </tr> <tr> <td>Toothpaste</td> <td>Oral B</td> </tr> <tr> <td>Flossing</td> <td>Nil</td> </tr> <tr> <td>Other interproximal tool(s)</td> <td>Piksters, Pink#00, every couple of days since seeing DMD students</td> </tr> <tr> <td>Mouth wash</td> <td>Colgate Plax</td> </tr> <tr> <td>Tongue brushing</td> <td>Yes</td> </tr> </table>   PERIODONTAL ASSESSMENT ### PATIENT SIGNS & SYMPTOMS **SYMPTOMS:** - **Pain/sensitivity:** Teeth are sensitive to cold drinks - **Bleeding:** Pt noticed bleeding while brushing - **Bad taste/smell:** Noticed bad breath / bad taste **SIGNS:** - **Suppuration:** Teeth # 31, 41, 43, 11, 21 - **Migration:** Nil - **Mobility:** Lower / upper front teeth - **Food impaction/ chewing efficiency:** Nil - **Tooth loss:** 4 (due to tooth decay) - **Parafunction:** She used to clench her teeth when she was on drugs ### ORAL HYGIENE ROUTINE - **Tooth brushing:** Soft electric toothbrush in morning and at night - **Toothpaste:** Oral B - **Flossing:** Nil - **Other interproximal tool(s):** Piksters, Pink#00, every couple of days since seeing DMD students - **Mouth wash:** Colgate Plax - **Tongue brushing:** Yes Table titled 'PATIENT SIGNS & SYMPTOMS' with two main sections: 'SYMPTOMS:' and 'SIGNS:'. Under 'SYMPTOMS:', it lists Pain/sensitivity (Teeth are sensitive to cold drinks), Bleeding (Pt noticed bleeding while brushing), and Bad taste/smell (Noticed bad breath / bad taste). Under 'SIGNS:', it details Suppuration (Teeth # 31, 41, 43, 11, 21), Migration (Nil), Mobility (Lower / upper front teeth), Food impaction/ chewing efficiency (Nil), Tooth loss (4 due to tooth decay), and Parafunction (She used to clench her teeth when she was on drugs). Table titled 'ORAL HYGIENE ROUTINE'. It lists various hygiene practices: Tooth brushing (Soft electric toothbrush in morning and at night), Toothpaste (Oral B), Flossing (Nil), Other interproximal tool(s) (Piksters, Pink#00, every couple of days since seeing DMD students), Mouth wash (Colgate Plax), and Tongue brushing (Yes). # INITIAL PERIODONTAL EXAM: ## Maxilla <table> <tr> <th></th> <th>18</th> <th>17</th> <th>16</th> <th>15</th> <th>14</th> <th>13</th> <th>12</th> <th>11</th> <th>21</th> <th>22</th> <th>23</th> <th>24</th> <th>25</th> <th>26</th> <th>27</th> <th>28</th> </tr> <tr> <td>Mobility</td> <td></td> <td></td> <td>0</td> <td>0</td> <td>0</td> <td>0</td> <td></td> <td>2</td> <td>2</td> <td></td> <td>0</td> <td>0</td> <td>0</td> <td>0</td> <td></td> <td></td> </tr> <tr> <td>Gingival Margin (Buccal)</td> <td></td> <td></td> <td>0 0 0</td> <td>0 0 0</td> <td>0 0 0</td> <td>0 0 0</td> <td>-3 -2</td> <td>-1 0 -1</td> <td>-1 0 -1</td> <td></td> <td>-2 -2 -1</td> <td>0 0 0</td> <td>0 0 0</td> <td>0 0 0</td> <td>0 0 0</td> <td></td> </tr> <tr> <td>Probing Depth (Buccal)</td> <td></td> <td></td> <td>6 2 7</td> <td>4 2 6</td> <td>10 2 6</td> <td>7 2 5</td> <td></td> <td>4 2 5</td> <td>7 2 3</td> <td></td> <td>4 2 8</td> <td>9 2 4</td> <td>6 2 6</td> <td>7 2 4</td> <td></td> <td></td> </tr> <tr> <td>Gingival Margin (Palatal)</td> <td></td> <td></td> <td>0 0 0</td> <td>0 0 0</td> <td>0 0 0</td> <td>0 0 0</td> <td>0 0 0</td> <td>-1 0 -1</td> <td>-1 0 -1</td> <td></td> <td>0 0 0</td> <td>0 0 0</td> <td>0 0 0</td> <td>0 0 0</td> <td></td> <td></td> </tr> <tr> <td>Probing Depth (Palatal)</td> <td></td> <td></td> <td>4 3 6</td> <td>6 3 6</td> <td>10 3 7</td> <td>8 8 8</td> <td></td> <td>4 4 6</td> <td>7 7 3</td> <td></td> <td>4 3 8</td> <td>9 3 4</td> <td>5 3 7</td> <td>8 2 5</td> <td></td> <td></td> </tr> <tr> <td>Note</td> <td></td> <td></td> <td></td> <td></td> <td></td> <td></td> <td></td> <td>SUP</td> <td>SUP</td> <td></td> <td></td> <td></td> <td></td> <td></td> <td></td> <td></td> </tr> </table> ## Mandible <table> <tr> <th></th> <th>48</th> <th>47</th> <th>46</th> <th>45</th> <th>44</th> <th>43</th> <th>42</th> <th>41</th> <th>31</th> <th>32</th> <th>33</th> <th>34</th> <th>35</th> <th>36</th> <th>37</th> <th>38</th> </tr> <tr> <td>Gingival Margin (Lingual)</td> <td></td> <td>0 0 0</td> <td>0 0 0</td> <td>0 0 0</td> <td>0 0 0</td> <td>0 0 0</td> <td>-1 -1 -1</td> <td>-1 -1 -2</td> <td>-2 -1 -1</td> <td>-1 -1 -1</td> <td>-1 -1 0</td> <td>0 0 0</td> <td>0 0 0</td> <td>0 0 0</td> <td>0 0 0</td> <td></td> </tr> <tr> <td>Probing Depth (Lingual)</td> <td></td> <td>6 2 6</td> <td>6 2 5</td> <td>8 2 3</td> <td>5 3 5</td> <td>5 4 6</td> <td>5 4 2</td> <td>2 2 7</td> <td>5 4 2</td> <td>2 3 6</td> <td>4 3 3</td> <td>3 2 6</td> <td>5 3 9</td> <td>6 2 5</td> <td>5 2 4</td> <td></td> </tr> <tr> <td>Gingival Margin (Buccal)</td> <td></td> <td>0 -1 -1</td> <td>0 -1 -1</td> <td>-1 -1 0</td> <td>0 -1 0</td> <td>0 0 -2</td> <td>-1 -1 -1</td> <td>-2 -4 -5</td> <td>-6 -4 -2</td> <td>-1 -1 -1</td> <td>-2 -2 0</td> <td>0 -2 0</td> <td>0 -1 0</td> <td>0 -1 0</td> <td>0 -1 0</td> <td></td> </tr> <tr> <td>Probing Depth (Buccal)</td> <td></td> <td>7 3 7</td> <td>7 2 8</td> <td>7 2 4</td> <td>4 2 3</td> <td>3 2 5</td> <td>7 3 3</td> <td>5 4 4</td> <td>4 3 3</td> <td>3 4 6</td> <td>7 2 3</td> <td>2 2 5</td> <td>4 2 7</td> <td>6 2 6</td> <td>5 2 7</td> <td></td> </tr> <tr> <td>Mobility</td> <td></td> <td>0</td> <td>0</td> <td>0</td> <td>0</td> <td>1</td> <td>1</td> <td>2</td> <td>2</td> <td>1</td> <td>0</td> <td>0</td> <td>0</td> <td>0</td> <td>0</td> <td></td> </tr> </table> <table> <tr> <th colspan="2">GINGIVA</th> </tr> <tr> <td colspan="2">Thick, scalloped Phenotype; Erythematous</td> </tr> <tr> <td>BIOFILM 3%</td> <td>BOP 44%</td> </tr> </table>      INITIAL PERIODONTAL EXAM ### Maxilla | | 18 | 17 | 16 | 15 | 14 | 13 | 12 | 11 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---| | Mobility | | | 0 | 0 | 0 | 0 | | 2 | 2 | | 0 | 0 | 0 | 0 | | | | Gingival Margin (Buccal) | | | 0 0 0 | 0 0 0 | 0 0 0 | 0 0 0 | -3 -2 | -1 0 -1 | -1 0 -1 | | -2 -2 -1 | 0 0 0 | 0 0 0 | 0 0 0 | 0 0 0 | | | Probing Depth (Buccal) | | | 6 2 7 | 4 2 6 | 10 2 6 | 7 2 5 | | 4 2 5 | 7 2 3 | | 4 2 8 | 9 2 4 | 6 2 6 | 7 2 4 | | | | Gingival Margin (Palatal) | | | 0 0 0 | 0 0 0 | 0 0 0 | 0 0 0 | 0 0 0 | -1 0 -1 | -1 0 -1 | | 0 0 0 | 0 0 0 | 0 0 0 | 0 0 0 | | | | Probing Depth (Palatal) | | | 4 3 6 | 6 3 6 | 10 3 7 | 8 8 8 | | 4 4 6 | 7 7 3 | | 4 3 8 | 9 3 4 | 5 3 7 | 8 2 5 | | | | Note | | | | | | | | SUP | SUP | | | | | | | | ### Mandible | | 48 | 47 | 46 | 45 | 44 | 43 | 42 | 41 | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---| | Gingival Margin (Lingual) | | 0 0 0 | 0 0 0 | 0 0 0 | 0 0 0 | 0 0 0 | -1 -1 -1 | -1 -1 -2 | -2 -1 -1 | -1 -1 -1 | -1 -1 0 | 0 0 0 | 0 0 0 | 0 0 0 | 0 0 0 | | | Probing Depth (Lingual) | | 6 2 6 | 6 2 5 | 8 2 3 | 5 3 5 | 5 4 6 | 5 4 2 | 2 2 7 | 5 4 2 | 2 3 6 | 4 3 3 | 3 2 6 | 5 3 9 | 6 2 5 | 5 2 4 | | | Gingival Margin (Buccal) | | 0 -1 -1 | 0 -1 -1 | -1 -1 0 | 0 -1 0 | 0 0 -2 | -1 -1 -1 | -2 -4 -5 | -6 -4 -2 | -1 -1 -1 | -2 -2 0 | 0 -2 0 | 0 -1 0 | 0 -1 0 | 0 -1 0 | | | Probing Depth (Buccal) | | 7 3 7 | 7 2 8 | 7 2 4 | 4 2 3 | 3 2 5 | 7 3 3 | 5 4 4 | 4 3 3 | 3 4 6 | 7 2 3 | 2 2 5 | 4 2 7 | 6 2 6 | 5 2 7 | | | Mobility | | 0 | 0 | 0 | 0 | 1 | 1 | 2 | 2 | 1 | 0 | 0 | 0 | 0 | 0 | | ### GINGIVA Thick, scalloped Phenotype; Erythematous - **BIOFILM 3%** - **BOP 44%** Periodontal chart for the Maxilla showing data for teeth 11-18. Includes tables for Mobility, Furcation, Bleeding on Probing, Plaque, Gingival Margin, and Probing Depth. Visual diagrams of tooth arches show Buccal and Palatal surfaces with blue shaded areas indicating pocket depths and red lines marking gingival margins. Periodontal chart for the Mandible showing data for teeth 31-48. Includes tables for Note, Furcation, Bleeding on Probing, Plaque, Gingival Margin, Probing Depth, Implant, and Mobility. Visual diagrams of tooth arches show Lingual and Buccal surfaces with blue shaded areas indicating pocket depths and red lines marking gingival margins. Visual representation of Bleeding on Probing (BOP) scores. Two rows of tooth icons are shown; red filled triangles indicate positive BOP results (bleeding), while grey circles indicate negative results. A percentage '44%' is noted in red at the bottom right. Visual representation of Biofilm presence. Two rows of tooth icons are shown; blue filled triangles indicate biofilm presence, while grey circles indicate absence. A percentage '3%' is noted in blue at the bottom right. Summary table titled GINGIVA. Lists three findings: Thick, scalloped Phenotype; Erythematous; BIOFILM 3%; BOP 44%. 39  Clinical panoramic radiograph showing the mandible and maxilla. Visible anatomical structures include teeth (some with restorations), mandibular canal, and ramus regions. The image is labeled 'L' for left side in the bottom right corner. # CLINICAL EXAMINATION (KEY FINDINGS) ### CARIES 43M, 42D, 21MDBP, 45DO, 46MO, 13MB, 11MBP, 31M, 32D, 34D ### PROSTHODONTIC Upper partial acrylic denture demonstrates insufficient adaptation, exhibiting bulkiness and improper fit ### ENDODONTIC 21 root-filling, slightly overfilled with no signs and symptoms ### OCCLUSAL Occlusal analysis: Missing 12, 22 Molar Class I RHS, class III LHS Crowded 13–23 Occlusal interferences: RHS lateral excursion: canine guidance, Nil interferences LHS lateral excursion: Canine guidance, Nil interferences Protrusion: Nil molar interference 40       CLINICAL EXAMINATION (KEY FINDINGS) #### CARIES 43M, 42D, 21MDBP, 45DO, 46MO, 13MB, 11MBP, 31M, 32D, 34D #### PROSTHODONTIC Upper partial acrylic denture demonstrates insufficient adaptation, exhibiting bulkiness and improper fit #### ENDODONTIC 21 root-filling, slightly overfilled with no signs and symptoms #### OCCLUSAL Occlusal analysis: Missing 12, 22 Molar Class I RHS, class III LHS Crowded 13–23 Occlusal interferences: - RHS lateral excursion: canine guidance, Nil interferences - LHS lateral excursion: Canine guidance, Nil interferences - Protrusion: Nil molar interference Radiograph showing dental anatomy with a visible restoration and occlusal relationship. Radiograph showing upper partial acrylic denture with insufficient adaptation, exhibiting bulkiness and improper fit as described in OCR context. Radiograph showing dental anatomy with visible caries or restorations on multiple teeth. Radiograph showing root canal treatment on tooth 21 with slightly overfilled material but no signs of pathology. Radiograph showing dental anatomy with possible occlusal interferences or crowding in the anterior region. Radiograph showing dental anatomy with possible missing teeth (12, 22) and occlusal analysis findings. # PERIODONTAL DIAGNOSIS ## Generalised Stage III, Grade C, Unstable Periodontitis ### Three Steps to Staging and Grading a Patient **Step 1: Initial Case Overview to Assess Disease** Screen: * Full mouth probing depths * Full mouth radiographs * Missing teeth Mild to moderate periodontitis will typically be either Stage I or Stage II Severe to very severe periodontitis will typically be either Stage III or Stage IV **Step 2: Establish Stage** For mild to moderate periodontitis (typically Stage I or Stage II): * Confirm clinical attachment loss (CAL) * Rule out non-periodontitis causes of CAL (e.g., cervical restorations or caries, root fractures, CAL due to traumatic causes) * Determine maximum CAL or radiographic bone loss (RBL) * Confirm RBL patterns For moderate to severe periodontitis (typically Stage III or Stage IV): * Determine maximum CAL or RBL * Confirm RBL patterns * Assess tooth loss due to periodontitis * Evaluate case complexity factors (e.g., severe CAL frequency, surgical challenges) **Step 3: Establish Grade** * Calculate RBL (% of root length x 100) divided by age * Assess risk factors (e.g., smoking, diabetes) * Measure response to scaling and root planing and plaque control * Assess expected rate of bone loss * Conduct detailed risk assessment * Account for medical and systemic inflammatory considerations <table> <thead> <tr> <th></th> <th>Periodontitis</th> <th>Stage I</th> <th>Stage II</th> <th>Stage III</th> <th>Stage IV</th> </tr> </thead> <tbody> <tr> <td rowspan="3"><strong>Severity</strong></td> <td>Interdental CAL (at site of greatest loss)</td> <td>1-2 mm</td> <td>3-4 mm</td> <td>≥5 mm</td> <td>≥5 mm</td> </tr> <tr> <td>RBL</td> <td>Coronal third (<15%)</td> <td>Coronal third (15% - 33%)</td> <td>Extending to middle third of root and beyond</td> <td>Extending to middle third of root and beyond</td> </tr> <tr> <td>Tooth loss (due to periodontitis)</td> <td>No tooth loss</td> <td></td> <td>≤4 teeth</td> <td>≥5 teeth</td> </tr> <tr> <td><strong>Complexity</strong></td> <td>Local</td> <td>* Max. probing depth ≤4 mm<br>* Mostly horizontal bone loss</td> <td>* Max. probing depth ≤5 mm<br>* Mostly horizontal bone loss</td> <td>In addition to Stage II complexity:<br>* Probing depths ≥6 mm<br>* Vertical bone loss ≥3 mm<br>* Furcation involvement Class II or III<br>* Moderate ridge defects</td> <td>In addition to Stage III complexity:<br>* Need for complex rehabilitation due to:<br>- Masticatory dysfunction<br>- Secondary occlusal trauma (tooth mobility degree ≥2)<br>- Severe ridge defects<br>- Bite collapse, drifting, flaring<br>- < 20 remaining teeth (10 opposing pairs)</td> </tr> <tr> <td><strong>Extent and distribution</strong></td> <td>Add to stage as descriptor</td> <td colspan="4">For each stage, describe extent as:<br>* Localized (<30% of teeth involved);<br>* Generalized; or<br>* Molar/incisor pattern</td> </tr> </tbody> </table> <table> <thead> <tr> <th></th> <th>Progression</th> <th></th> <th>Grade A: Slow rate</th> <th>Grade B: Moderate rate</th> <th>Grade C: Rapid rate</th> </tr> </thead> <tbody> <tr> <td rowspan="3"><strong>Primary criteria</strong><br><br>Whenever available, direct evidence should be used.</td> <td>Direct evidence of progression</td> <td>Radiographic bone loss or CAL</td> <td>No loss over 5 years</td> <td><2 mm over 5 years</td> <td>≥2 mm over 5 years</td> </tr> <tr> <td rowspan="2">Indirect evidence of progression</td> <td>% bone loss / age</td> <td><0.25</td> <td>0.25 to 1.0</td> <td>>1.0</td> </tr> <tr> <td>Case phenotype</td> <td>Heavy biofilm deposits with low levels of destruction</td> <td>Destruction commensurate with biofilm deposits</td> <td>Destruction exceeds expectations given biofilm deposits; specific clinical patterns suggestive of periods of rapid progression and/or early onset disease</td> </tr> <tr> <td rowspan="2"><strong>Grade modifiers</strong></td> <td rowspan="2">Risk factors</td> <td>Smoking</td> <td>Non-smoker</td> <td><10 cigarettes/day</td> <td>≥10 cigarettes/day</td> </tr> <tr> <td>Diabetes</td> <td>Normoglycemic/no diagnosis of diabetes</td> <td>HbA1c <7.0% in patients with diabetes</td> <td>HbA1c ≥7.0% in patients with diabetes</td> </tr> </tbody> </table>    PERIODONTAL DIAGNOSIS Generalised Stage III, Grade C, Unstable Periodontitis ### Three Steps to Staging and Grading a Patient **Step 1: Initial Case Overview to Assess Disease** Screen: - Full mouth probing depths - Full mouth radiographs - Missing teeth Mild to moderate periodontitis will typically be either Stage I or Stage II Severe to very severe periodontitis will typically be either Stage III or Stage IV **Step 2: Establish Stage** For mild to moderate periodontitis (typically Stage I or Stage II): - Confirm clinical attachment loss (CAL) - Rule out non-periodontitis causes of CAL (e.g., cervical restorations or caries, root fractures, CAL due to traumatic causes) - Determine maximum CAL or radiographic bone loss (RBL) - Confirm RBL patterns For moderate to severe periodontitis (typically Stage III or Stage IV): - Determine maximum CAL or RBL - Confirm RBL patterns - Assess tooth loss due to periodontitis - Evaluate case complexity factors (e.g., severe CAL frequency, surgical challenges) **Step 3: Establish Grade** - Calculate RBL (% of root length x 100) divided by age - Assess risk factors (e.g., smoking, diabetes) - Measure response to scaling and root planing and plaque control - Assess expected rate of bone loss - Conduct detailed risk assessment - Account for medical and systemic inflammatory considerations ### Staging Table | | Periodontitis | Stage I | Stage II | Stage III | Stage IV | |---|---|---|---|---|---| | **Severity** | Interdental CAL (at site of greatest loss) | 1-2 mm | 3-4 mm | ≥5 mm | ≥5 mm | | | RBL | Coronal third (<15%) | Coronal third (15% - 33%) | Extending to middle third of root and beyond | Extending to middle third of root and beyond | | | Tooth loss (due to periodontitis) | No tooth loss | | ≤4 teeth | ≥5 teeth | | **Complexity** | Local | Max. probing depth ≤4 mm; Mostly horizontal bone loss | Max. probing depth ≤5 mm; Mostly horizontal bone loss | In addition to Stage II complexity: Probing depths ≥6 mm; Vertical bone loss ≥3 mm; Furcation involvement Class II or III; Moderate ridge defects | In addition to Stage III complexity: Need for complex rehabilitation due to: Masticatory dysfunction; Secondary occlusal trauma (tooth mobility degree ≥2); Severe ridge defects; Bite collapse, drifting, flaring; < 20 remaining teeth (10 opposing pairs) | | **Extent and distribution** | Add to stage as descriptor | For each stage, describe extent as: Localized (<30% of teeth involved); Generalized; or Molar/incisor pattern | | | | ### Grading Table | | Progression | | Grade A: Slow rate | Grade B: Moderate rate | Grade C: Rapid rate | |---|---|---|---|---|---| | **Primary criteria** (Whenever available, direct evidence should be used.) | Direct evidence of progression | Radiographic bone loss or CAL | No loss over 5 years | <2 mm over 5 years | ≥2 mm over 5 years | | | Indirect evidence of progression | % bone loss / age | <0.25 | 0.25 to 1.0 | >1.0 | | | | Case phenotype | Heavy biofilm deposits with low levels of destruction | Destruction commensurate with biofilm deposits | Destruction exceeds expectations given biofilm deposits; specific clinical patterns suggestive of periods of rapid progression and/or early onset disease | | **Grade modifiers** | Risk factors | Smoking | Non-smoker | <10 cigarettes/day | ≥10 cigarettes/day | | | | Diabetes | Normoglycemic/no diagnosis of diabetes | HbA1c <7.0% in patients with diabetes | HbA1c ≥7.0% in patients with diabetes | A structured flowchart titled 'Three Steps to Staging and Grading a Patient' from the American Academy of Periodontology (AAP). It outlines three sequential steps: Step 1 involves screening for disease severity; Step 2 details how to establish the stage by assessing CAL, RBL patterns, tooth loss, and complexity factors; Step 3 covers establishing the grade based on progression rates, risk factors like smoking and diabetes, and clinical response. A detailed table defining the classification of Periodontitis stages. Columns represent Stage I through Stage IV, while rows categorize criteria into Severity (Interdental CAL, RBL, Tooth loss), Complexity (Local vs. Complex features), and Extent and distribution. Specific cells highlight diagnostic thresholds such as probing depths ≥6 mm and vertical bone loss ≥3 mm for Stage III. A matrix detailing the grading system for periodontitis progression. Columns distinguish between Grade A (Slow rate), Grade B (Moderate rate), and Grade C (Rapid rate). Rows evaluate primary criteria including direct radiographic evidence and indirect indicators like % bone loss/age ratio, alongside case phenotype descriptions and specific grade modifiers such as smoking levels (≥10 cigarettes/day) and HbA1c values for diabetes. # PERIODONTAL PROGNOSIS <table> <tr> <th>Prog</th> <td>-</td> <td>-</td> <td>Q</td> <td>F</td> <td>Q</td> <td>Q</td> <td>-</td> <td>Q</td> <td>Q</td> <td>-</td> <td>Q</td> <td>Q</td> <td>Q</td> <td>Q</td> <td>-</td> <td>-</td> </tr> <tr> <th>Max</th> <td>18</td> <td>17</td> <td>16</td> <td>15</td> <td>14</td> <td>13</td> <td>12</td> <td>11</td> <td>21</td> <td>22</td> <td>23</td> <td>24</td> <td>25</td> <td>26</td> <td>27</td> <td>28</td> </tr> <tr> <th>Man</th> <td>48</td> <td>47</td> <td>46</td> <td>45</td> <td>44</td> <td>43</td> <td>42</td> <td>41</td> <td>31</td> <td>32</td> <td>33</td> <td>34</td> <td>35</td> <td>36</td> <td>37</td> <td>38</td> </tr> <tr> <th>Prog</th> <td>-</td> <td>Q</td> <td>Q</td> <td>Q</td> <td>F</td> <td>Q</td> <td>Q</td> <td>U</td> <td>U</td> <td>Q</td> <td>Q</td> <td>Q</td> <td>Q</td> <td>F</td> <td>Q</td> <td>-</td> </tr> </table> F = Favourable Q = Questionable U = Unfavourable H = Hopeless 42   PERIODONTAL PROGNOSIS | Prog | - | - | Q | F | Q | Q | - | Q | Q | - | Q | Q | Q | Q | - | - | |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---| | Max | 18 | 17 | 16 | 15 | 14 | 13 | 12 | 11 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | | Man | 48 | 47 | 46 | 45 | 44 | 43 | 42 | 41 | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | | Prog | - | Q | Q | Q | F | Q | Q | U | U | Q | Q | Q | Q | F | Q | - | - F = Favourable - Q = Questionable - U = Unfavourable - H = Hopeless A periodontal prognosis table mapping tooth numbers to prognostic categories. The table is organized into four rows: 'Prog' (prognosis), 'Max' (maxillary teeth numbers), 'Man' (mandibular teeth numbers), and 'Prog' (prognosis). Columns correspond to individual tooth positions from 18 to 28 in the maxilla and 48 to 38 in the mandible. Cells are color-coded based on prognosis: Green for 'Favourable', Yellow for 'Questionable', Orange for 'Unfavourable', and Red for 'Hopeless'. A legend at the bottom defines these codes. A color-coded legend bar defining prognostic categories used in the adjacent table. It displays four colored blocks with corresponding labels: a green block for 'F = Favourable', a yellow block for 'Q = Questionable', an orange block for 'U = Unfavourable', and a red block for 'H = Hopeless'. **Step 1 EFP Guidelines / Risk Management Phase** Risk factor control: Encourage & discuss relationship between smoking and periodontal disease After our discussion about smoking, she demonstrated encouragement and determination. She sought additional support from her general practitioner (GP) during her smoking cessation journey and successfully quit smoking following her initial consultation with her GP. Began her journey to quit smoking in May 2023. Instructions on self-performed biofilm control Stress management Remove Plaque-retentive factors that impair oral hygiene practices **Step 1 and 2 EFP Guidelines / Cause-related/ Fundamental Phase** Supra and subgingival instrumentation (Quadrant-by-Quadrant under LA) Use of adjunctive systemic antimicrobials Azithromycin (500 mg once per day for 3 days) on 03-Jul-2023 Reassess biofilm control and motivate if necessary EFP Guidelines, Sanz et al. 2020 43  #### Step 1 EFP Guidelines / Risk Management Phase Risk factor control: - Encourage & discuss relationship between smoking and periodontal disease - After our discussion about smoking, she demonstrated encouragement and determination. - She sought additional support from her general practitioner (GP) during her smoking cessation journey and successfully quit smoking following her initial consultation with her GP. - Began her journey to quit smoking in May 2023. - Instructions on self-performed biofilm control - Stress management - Remove Plaque-retentive factors that impair oral hygiene practices #### Step 1 and 2 EFP Guidelines / Cause-related/ Fundamental Phase - Supra and subgingival instrumentation (Quadrant-by-Quadrant under LA) - Use of adjunctive systemic antimicrobials: Azithromycin (500 mg once per day for 3 days) on 03-Jul-2023 - Reassess biofilm control and motivate if necessary EFP Guidelines, Sanz et al. 2020 Flowchart diagram illustrating the 'NON-SURGICAL PERIODONTAL THERAPY' Treatment Plan based on EFP Guidelines. The chart is divided into two main sections: 'Step 1 EFP Guidelines / Risk Management Phase' and 'Step 1 and 2 EFP Guidelines / Cause-related/ Fundamental Phase'. It visually maps out specific interventions such as risk factor control (smoking cessation), biofilm control instructions, stress management, instrumentation procedures, and adjunctive antimicrobial use (Azithromycin). Lines connect these intervention nodes to corresponding patient outcomes or specific actions taken. | 1ST REASSESSMENT | | :--- | | Assessed Patient experience | | Reassessed systemic risk factors (Smoking) | Continued to avoid smoking | | Updated Medical history | | Reevaluated local risk factors and plaque-retentive factors | | Reassessed occlusion | | Performed Periodontal Analysis: Assessed patient response to NSPT | | PMPR (Provided professional mechanical plaque and supragingival calculus removal ) | | Assessed compliance |  #### 1ST REASSESSMENT - Assessed Patient experience - Reassessed systemic risk factors (Smoking): Continued to avoid smoking - Updated Medical history - Reevaluated local risk factors and plaque-retentive factors - Reassessed occlusion - Performed Periodontal Analysis: Assessed patient response to NSPT - PMPR (Provided professional mechanical plaque and supragingival calculus removal) - Assessed compliance Flowchart diagram illustrating the steps of a '1ST REASSESSMENT' in a periodontal treatment protocol. The main title is on the left, with a vertical line branching out to eight sequential rectangular nodes detailing specific clinical actions: 'Assessed Patient experience', 'Reassessed systemic risk factors (Smoking)' (which branches to a smaller node 'Continued to avoid smoking'), 'Updated Medical history', 'Reevaluated local risk factors and plaque-retentive factors', 'Reassessed occlusion', 'Performed Periodontal Analysis: Assessed patient response to NSPT', 'PMPR (Provided professional mechanical plaque and supragingival calculus removal)', and 'Assessed compliance'. The page number '44' is visible at the bottom right. **SURGICAL PERIODONTAL THERAPY** **Step 3 EFP Guidelines / Corrective Phase** **Repeating non-surgical debridement** **Access surgery** **Resective surgery** **Regenerative surgery** **Pockets ≥6 mm with associated Intrabony defects ≥3 mm** **Furcation defects class II** **Endpoint of therapy not reached : Consider modality of further treatment for residual PPD ≥4mm with BOP or ≥6mm.** EFP Guidelines, Sanz et al. 2020   #### SURGICAL PERIODONTAL THERAPY **Step 3 EFP Guidelines / Corrective Phase** - Repeating non-surgical debridement - Access surgery - Resective surgery - Regenerative surgery - Pockets ≥6 mm with associated Intrabony defects ≥3 mm - Furcation defects class II - Endpoint of therapy not reached: Consider modality of further treatment for residual PPD ≥4mm with BOP or ≥6mm. EFP Guidelines, Sanz et al. 2020 Clinical diagram showing four cross-sections of teeth illustrating different types of intrabony defects: '1-wall defect', '2-wall defect', '3-wall defect', and 'Interproximal crater'. Each image depicts the bone loss pattern relative to the tooth root structure. Table comparing positive and negative influences on periodontal defects. Columns include 'Positive Influence' (e.g., Deep infrabony component ≥3 mm, Narrow radiographic defect angle, Deep baseline pocket depth) and 'Negative Influence' (e.g., Shallow infrabony component <3 mm, Wide radiographic defect angle, Tooth mobility). <table> <tr> <td colspan="3"> <b>REASSESSMENT</b> </td> </tr> <tr> <td colspan="3"> <b>Step 4 EFP Guidelines / SPC</b> </td> </tr> <tr> <td> Conduct Periodontal Risk Assessment to determine and individualised maintenance interval </td> </tr> <tr> <td> Smoking Cessation Support:<br/> Continued encouragement to quit smoking, recognizing her motivation despite previous relapses </td> </tr> <tr> <td> Goal of Supportive Periodontal Care:<br/> To maintain periodontal stability in treated periodontitis patients through preventive and therapeutic interventions </td> </tr> <tr> <td> Ongoing support for oral hygiene practices and education to maintain periodontal health </td> </tr> <tr> <td> Regular maintenance appointments:<br/> Update medical history, examination, plaque removal, subgingival debridement, and monitoring of risk factors </td> </tr> <tr> <td> Re-treatment if recurrent disease is detected </td> </tr> <tr> <td> Tooth Extraction Consideration:<br/> Extraction may be an option for teeth with a hopeless prognosis </td> </tr> <tr> <td> EFP Guidelines, Sanz et al. 2020 </td> <td> 46 </td> </tr> </table>  #### REASSESSMENT **Step 4 EFP Guidelines / SPC** - Conduct Periodontal Risk Assessment to determine and individualised maintenance interval - Smoking Cessation Support: Continued encouragement to quit smoking, recognizing her motivation despite previous relapses - Goal of Supportive Periodontal Care: To maintain periodontal stability in treated periodontitis patients through preventive and therapeutic interventions - Ongoing support for oral hygiene practices and education to maintain periodontal health - Regular maintenance appointments: Update medical history, examination, plaque removal, subgingival debridement, and monitoring of risk factors - Re-treatment if recurrent disease is detected - Tooth Extraction Consideration: Extraction may be an option for teeth with a hopeless prognosis EFP Guidelines, Sanz et al. 2020 Flowchart diagram illustrating the 'REASSESSMENT' phase of Step 4 EFP Guidelines / SPC. The flow starts from a central node labeled 'Goal of Supportive Periodontal Care: To maintain periodontality stability in treated periodontitis patients through preventive and therapeutic interventions'. This connects to a vertical sequence of six blue rectangular nodes detailing specific actions: 'Conduct Periodontal Risk Assessment to determine and individualised maintenance interval', 'Smoking Cessation Support: Continued encouragement to quit smoking, recognizing her motivation despite previous relapses', 'Ongoing support for oral hygiene practices and education to maintain periodontal health', 'Regular maintenance appointments: Update medical history, examination, plaque removal, subgingival debridement, and monitoring of risk factors', 'Re-treatment if recurrent disease is detected', and 'Tooth Extraction Consideration: Extraction may be an option for teeth with a hopeless prognosis'. # Thank You ☺ 47 Thank You ☺ [^1]: Original PDF page 1: [[Treatment Planning-1.pdf#page=1|Treatment Planning-1, p.1]] [^2]: Original PDF page 2: [[Treatment Planning-1.pdf#page=2|Treatment Planning-1, p.2]] [^3]: Original PDF page 3: [[Treatment Planning-1.pdf#page=3|Treatment Planning-1, p.3]] 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p.46]] [^47]: Original PDF page 47: [[Treatment Planning-1.pdf#page=47|Treatment Planning-1, p.47]]