PERIODONTA L THERAPY Consists of: PHASE I PHASE II PHASE III PHASE IV •
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E&D
TREATMENT PLANNING
INITIAL PHASE OHE
PROPHYLA XIS
TREATMENT
REASSESSME NT
BEHAVIOR AL CHANGE DEBRIDEME NT
CORRECTIVE PHASE SURGICAL PROCEDU RES
RECONSTRUC TIVE PROCEDURES
OTHER DENTAL TREATMENT SUPPORTIVE PERIODONTAL CARE
Phase I therapy is referred to by many names; Initial / first line therapy Nonsurgical periodontal therapy Cause-related therapy Etiotropic phase of therapy •
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PHASE 1
PHASE 1 AIM of Therapy; Elimination & prevention of recurrence of supra / subgingivally located bacterial deposits.
PHASE 1 Rationale •
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Reduction & elimination of etiologic & contributing factors in periodontal treatment are achieved by; complete removal of calculus Correction of defective restoration Treatment of carious lesion Comprehensive daily plaque control regimen Provided to all patients with periodontal pockets who later will be evaluated for surgical intervention (gingivitis / mild chronic periodontitis).
PHASE 1 Components: Correction/ replacement of Relief pain poorly fitting Patient education restorations & prosthetic devices & motivation Behavioral change Restorations of carious lesions Plaque control & Orthodontic tooth oral hygiene care movements Prophylaxis Treatment of occlusal Scaling & root trauma debridement Endodontic treatment Chemical control of Extraction of plaque deposition hopeless teeth •
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PHASE 1 OHE – Patient Information Indications: - Low oral health knowledge, awareness, motivation & compliance. - Poor self performed plaque control, smoking & other psychosocial behaviors. - Hig High h risk risk ind individ ividual uals s to to plaq plaque ue – indu induce ced d diseases.
PHASE 1 OHE – Patient Information - To provide information about dental health – demonstration to the patient of the disease present in the mouth. - To provide information & guidance about the techniques of plaque control. •
PHASE 1 •
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OHE – Patient Motivation Change in knowledge Change in understanding Change in attitude Change in habit Use simple everyday language & avoid jargons
PHASE 1 Behavioral Change - Diet counseling – encourage balanced diet and frequency. - Smoking cessation (smoking – risk factor for periodontitis), it will increase in progression of disease, alter the fibroblast function & impair wound healing. •
PHASE 1 OHI - Tooth brushing method: •
Roll – roll method or Modified Stillman technique Vibratory – Bass Technique Circular – Fones Technique Vertical – Leonard Technique Horizontal – Scrub Technique •
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PHASE 1 OHI Recommendation of toothbrush design: - Soft - Nylon bristle - Toothbrushes need to be replaced about every 3 months (or replace when it start to show sign of matting). •
PHASE 1 OHI - Powered toothbrush – also can remove plaque effectively (properly used). - Patients need to be instructed in the proper use of powered devices. - Patients who are poor brushers, children & caregivers may particularly benefit from using powered toothbrushes. •
PHASE 1 •
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OHI – Interdental Cleaning Aids Cleans the interdental region (most common site for plaque retention). Most inaccessible site to tooth brushing. Dental floss Interdental space brush
PHASE 1 OHI – Interdental Cleaning Aids (Dental Floss) Technique; - 12 – 18 inches of floss wrapped around the fingers / the ends may be tied together in a loop. - Stretch the floss tightly between the thumb & forefinger/ between both forefingers & pass it gently through each contact area with a firm back-and-forth motion. - Move the floss across the interdental gingiva & repeat the procedure on the proximal surface of the adjacent tooth. •
PHASE 1 Prophylaxis - Removal of supragingival plaque & calculus (scaling & polishing). - Removal of plaque retentive factors; Smooth roughness of restoration Removal of overhangs Ill-fitting / rough prosthesis Removal of staining •
PHASE 1 Non – surgical Instrumentation Scaling – procedure of removal of plaque & calculus from the tooth surface. Root debridement – hard/ powered driven subgingivally instrumentation aimed at removal of toxic substances without overinstrumentation / intentional removal of cementum to produce a root that is biologically acceptable for a healthy attachment.
PHASE 1 Non – surgical Instrumentation - Chemotherapeutic approaches Topical application of antiseptics – to prevent plaque accumulation & to disinfect the root surfaces. Mouthrinses – Chlorhexidine Chip-perio chip Solution injection – elyzol/periocline
PHASE 1 Non – surgical Instrumentation - Chemotherapeutic approaches Systemic approach – selective use of antibiotic or host modulation of tissue destructive enzymes (Doxycycline). Rationale; Pathogenic organisms that were not accessible to mechanical removal by hand/power driven instruments can be reduced/eliminated.
PHASE 1 Treatment Sessions - The following conditions must considered to plan Phase 1 treatment sessions needed;
General health & tolerance of treatment Number of teeth present amount of subgingival calculus Probing pocket depths & attachment loss Furcation involvement
Alignment of teeth Margins of restorations Developmental anomalies Physical barriers to access (limited opening / tendency to gag) Patient cooperation & sensitivity (requiring anesthesia / analgesia)
PHASE 1 Step 1 (Limited Plaque Control Instruction) - Should start in 1st appointment & should include only the correct use of toothbrush on all surfaces of the teeth. - Use of dental floss should await the removal of calculus & overhanging restorations. •
PHASE 1 Step 2 (Supragingival Removal of Calculus) - Can be done by scalers, curettes or ultrasonic instrumentation. •
PHASE 1 Step 3 (Recountouring Defective Restorations & Crowns) - May require replacing the entire restoration or crown or correcting it with finishing burs or diamondcoated files mounted on the special handpiece. •
PHASE 1 Step 4 (Obturation of Carious Lesion) - Involves complete removal of the carious tissue & placement of final or a temporary restoration. •
PHASE 1 Step 5 (Comprehensive Plaque Control Instrumentation) - Patient should learn to remove plaque completely from all supragingival areas, using toothbrush, floss & other necessary complementary method. •
PHASE 1 Step 6 (Subgingival Root Treatment) - Complete calculus removal & root planning can be effectively performed. •
PHASE 1 Step 7 (Tissue Reevaluation) - The periodontal tissue reexamined to determine the need for further therapy. - Pocket are reprobed & all related anatomical conditions are carefully evaluated to decide whether surgical treatment is indicated. •
PHASE 1 LIMITATIONS of NON-SURGICAL TREATMENT Requires skill, practice & patience – ‘blind’ tactile sensibility has to be developed to achieve smooth root surface. Root proximity & rotation, concavities & ridges, groove, furcation & pits all causing cleaning problems. •
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Roles of chemical agents (antiseptic & antibiotic) in periodontics The different of chemical plaque agent Content, indication, limitation & effects of use of these agents •
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CHEMICAL PERIODONTAL THERAPY
CHEMICAL PERIODONTAL THERAPY GOAL – •
Removal of supragingival & subgingival bacteria.
CHEMICAL PERIODONTAL THERAPY •
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Supragingival plaque – accessible to patient (can effectively disrupted / removed using toothbrush/ interproximal cleaning devices). Mechanical plaque control can be effective in preventing / reversing gingivitis. If patient unable to perform mechanical plaque removal – use of chemotherapeutic agents as an adjunct may be warranted.
CHEMICAL PERIODONTAL THERAPY TERMINOLOGY: - Plaque inhibitory effect: reducing plaque to a level insufficient to prevent the development of gingivitis. - Anti-plaque effect: produces a prolonged & profound reduction in plaque sufficient to prevent the development of gingivitis. anti-inflammatory ory effect on - Anti-gingivitis: anti-inflammat the gingival health not necessarily mediated through an effect on plaque.
CHEMICAL PERIODONTAL THERAPY Antimicrobial agents; be used: - Antiseptics Can topically, applied - Antibiotics &locally systemically Miscellaneous agents; - Matrix protein - Growth factor - Hydrogen peroxide
CHEMICAL PERIODONTAL THERAPY ANTISEPTIC AGENTS - Directed against supra-gingival plaque development - Directed against sub-gingival bacteria
CHEMICAL PERIODONTAL THERAPY ANTISEPTICS Topically (mouthwashes) - Or Orad adex ex – chl chlor orhe hexi xidi dine ne 0. 0.12 12% % - Listerine® antiseptic mouthwash (phenolic compound/ essential oil) - Plax® (triclosan) •
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Typically act supra-gingivally.
CHEMICAL PERIODONTAL THERAPY ANTISEPTICS Locally applied - Slow release devices (biodegradable polymer, gel, fibers, collagen) - Applied into periodontal pockets: Perio Chip® (2.5 mg chloroxedine in gelatin matrix) Atrigel® (5% sanguinarine) •
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Typically act sub-gingivally.
CHEMICAL PERIODONTAL THERAPY TOPICALLY ACTING CHEMICAL AGENTS Requirement: - Effective in reducing plaque & gingivitis - Effective & remains for a sufficient amount of time to accomplish the desired results (substantivity) - Without development of resistant bacterial strains or damage to the oral tissues. - Cost-effective - Pleasant to use - Low toxicity – without adverse effects - High potency - Good permeability & intrinsic efficacy •
CHEMICAL PERIODONTAL THERAPY ANTISEPTICS – Mouthwashes Quaternary ammonium compound (cetylpyridium chloride) Hexidine – Bactidol® Oxygenating agents – hydrogen peroxide Amine alcohols – Delminol Povidone iodine natural products – sanguinarin sanguinarines es •
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All these available either as mouthwashes, irrigation, toothpaste, gel/ spray.
CHEMICAL PERIODONTAL THERAPY TOPICALLY ACTING CHEMICAL AGENTS CHEMICAL SUPRAGINGIVAL PLAQUE CONTROL Bisguanides
Chlorhexidine, Alexidine
Phenolic compounds
Listerine, Thymol & other essential oils
Quartenary ammonium compound
Amyloglucosidase, Glucose oxidase
Enzymes
Cetylpyridium chloride, Benzalconium chloride
Oxygenating agents
Hydrogen peroxide, Peroxyborate
Fluorides
Sodium fluoride, Stannus fluoride, Sodium MFP
Other antiseptics
Triclosan, Povidone Iodine, Hexetine
CHEMICAL PERIODONTAL THERAPY CHLORHEXIDINE Bisguanide compound Dicationic and strong base Prolonged action Concentration – 0.2% or equivalent The only product to kill bacteria Not act as anti-adhesive Only can penetrate into thin plaque not thick /mature (calculus) plaque. Can inhibit the plaque formation but cannot eliminate the plaque in untreated mouth. •
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CHEMICAL PERIODONTAL THERAPY CHLORHEXIDINE Broad spectrum antiseptic which possess antiplaque activity. Mostly available in digluconate salts formulations. Strong base & dicationic at pH levels above 3.5 with 2 positive charges on either side of hexamethylene bridge. At low concentration – cause increase in cell membrane permeability & leakage of intracellular components. At high concentration – precipitation of bacterial cytoplasm & cell death. •
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CHEMICAL PERIODONTAL THERAPY PHENOLIC COMPOUNDS Eg: Listerine ® Have moderate plaque-inhibitory effects & some anti-gingivitis effect. Less effective than chlorhexidine but more powerful than triclosan. •
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CHEMICAL PERIODONTAL THERAPY CHX - As a broad spectrum antimicrobial agent, have no bacterial resistance reported & no evidence of superinfection by fungi / viruses.
CHEMICAL PERIODONTAL THERAPY INDICATION: CHX m/w indicated to post perio-surgical patient to reduce the bacterial load / to prevent plaque formation at time when mechanical cleaning may be difficult due discomfort. Patient with mental & physically disabilities lack of manual dexterity in; - Parkinson disease - Adjunct to immunocompromised such as HIV/AIDS - Cerebral palsy In this situation, advisable agent would be CHX m/w. •
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CHEMICAL PERIODONTAL THERAPY INDICATION: CHX m/w can be prescribed to patient wearing orthodontic appliance & also for patient with intermaxillary fixation following trauma / orthognathic surgery. As an adjunct to mechanical instrumentation in case such as refractory periodontitis & locally applied antimicrobial agents can be used. •
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CHEMICAL PERIODONTAL THERAPY LIMITATION: CHX particular inhibit plaque formation in a clean mouth but not significantly reduce bacterial load in untreated mouth. CHX m/w cannot penetrate into gingival crevice, therefore have no place in control of chronic periodontitis – presence of deep pocket of >5 mm. •
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CHEMICAL PERIODONTAL THERAPY LIMITATION: CHX have local side effects such as; - Tooth & tongue staining - Staining tooth-colored restorations (composite & porcelain) Reversible parotid swelling Numbness of tongue – taste disturbance Bitter taste Mucosal erosion are also reported •
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CHEMICAL PERIODONTAL THERAPY Periodontitis can be classified by: Disease activity (chronic/aggressive) Cause (specific bacterial, fungal / viral infection) Site (localized or generalized) Extent (size & morphology defects) Type of associated gingivitis (chronic/necrotizing) Type of patient (child, adolescent, adult/ compromised) •
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Non-specific plaque theory (reduction of bacterial load) Specific plaque theory (specific plaque therapy)
CHEMICAL PERIODONTAL THERAPY
ANTIBIOTICS 1. Use of antibiotics (systemically / local application) mainly directed against specific bacteria & sub-gingival plaque to target identified periodontal pathogens. Eg. In ANUG & localized aggressive periodontitis. 2. Antibiotics is directed against specific microorganisms, eg. AA in specific plaque hypothesis in ANUG/P & aggressive periodontitis. periodontitis. 3. While mechanical removal removal of plaque aimed at reduction of bacterial load for non-specific plaque theory.
CHEMICAL PERIODONTAL THERAPY ANTIBIOTICS 4. If unresponsive unresponsive pockets pockets (after (after reassessment reassessment therapy done & no response to therapy), chlorhexidine in slow release of polymer can be used locally, locally, advantage of that, agents can be sustained release within the pocket. Locally applied antibiotics also can be used in this situation. 5. Used of antibiotics in periodontal abscess usually not necessary if the abscess only localized unless there are signs of spread of infection to systemic area / sign of cellulitis/ lymphadenopathy.
CHEMICAL PERIODONTAL THERAPY ANTIBIOTICS 6.Post surgical rinsing with chlorhexidine mouthwash mainly due to inability to mechanically removed plaque because discomfort. 7.Post surgical systemic antibiotic prescription may not indicated, unless complex surgical procedures been carried out (post-implant surgery) / patient is medically compromised.
CHEMICAL PERIODONTAL THERAPY ANTIBIOTICS 8. Indication Indication of use of antimicr antimicrobial obial agents to patient with lack of manual dexterity or with patients with mental disability is clear. 9. Patient wearing orthodonti orthodontics cs applianc appliances es cannot cannot used chlorhexidine mouthwash for a long term due to tooth & tongue staining side effects.
CHEMICAL PERIODONTAL THERAPY Antibiotics agents: Local application •
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Systemic use
CHEMICAL PERIODONTAL THERAPY ANTIBIOTIC – Local Application Antibiotics can be in form of: Gel – for topical application onto surface or sub-gingival application. May present in polymer. Also present in the form for m of biodegradable slow, release gel, hollow or solid fibers. •
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CHEMICAL PERIODONTAL THERAPY ANTIBIOTIC – Local Application Examples: a.Elyzol a. Elyzol gel - 25% of Metronidazole b.Dentomycin b. Dentomycin gel - 2% of minocycline c.Actisite c. Actisite – tetracycline fibers (hollow/solid (hollow/solid)) d.Periocline d. Periocline - 2% minocycline e.Atridox e. Atridox - 42.5 mg Doxycycline f. Arestin - 1 mg minocycline
CHEMICAL PERIODONTAL THERAPY ANTIBIOTIC – Systemic Uses In the form of liquid, tablets or capsules –suitable if patients diagnosed with aggressive periodontitis ONLY . Must finish antibiotic simultaneously with the therapy/ root debridement. debridement . •
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CHEMICAL PERIODONTAL THERAPY ANTIBIOTIC– Systemic Uses (Aggressive Periodontitis ) •
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Amoxicillin in combination with Metronidazole (if allergic to penicillin give clindamycin); 250 25 0 mg am amox oxic icil illi lin n & 200 200 mg Me Metro troni nida dazo zole le tds tds for 4 to 7 days.
Tetracycline - 25 250 0 mg mg te tetr trac acyc ycli line ne fo forr 14 14 day days s - Doxycycline 100 mg once a day for 14 days (double dose for first day because half of it will bind to plasma & another half will be in blood). •
CHEMICAL PERIODONTAL THERAPY ANTIBIOTIC – Systemic Uses (ANUG/P) In case of ANUG/P, Metronidazole may be needed for 3 – 4 days only. - 200 mg Metronidazole tds for 3 – 4 days. - Analgesic may be prescribed to patient diagnosed with ANUG/P due to pain. - Since the ANUG/P lesions being very painful to mechanical plaque control, chlorhexidine may be given. •
CHEMICAL PERIODONTAL THERAPY ANTIBIOTIC – Systemic Uses For post-surgical systemic antibiotic, Metronidazole may be needed for 1 – 7 days. day . - 400 mg Metronidazole tds for 1 day. - Analgesic may also prescribed. - Chlorhexidine mouthwashes must be given since the wound may be painful to mechanical plaque removal. •
CHEMICAL PERIODONTAL THERAPY ANTIBIOTIC – Systemic Uses Periostat® is available as a - 20 mg doxycycline taken twice daily about an hour before or 2 hours after meals. - Adjunct to scaling & root planning. - Act as collagenase inhibitor (degrade collagen at periodontal ligament/gingiva but not to controlled the bacteria) at low concentration. - Danger to develop bacterial resistance. - Take about a month. •
CHEMICAL PERIODONTAL THERAPY INDICATION: Antibiotic prophylactic agents in which the risks of bacterimia & infective endocarditis is high. Systemic antibiotics prescribed are directed against specific microorganisms as an adjunct to mechanical instrumentation in aggressive periodontitis & ANUG/P. The used of systemic antibiotic without cautions can lead to development of bacterial resistance. Certain individual may suffered from immediate hypersensitivity which can be fatal. •
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General terms for a chemical substances provides a clinical therapeutic benefit.
CHEMOTHERAPEU TIC AGENTS
COMMON ANTIBIOTIC REGIMENS TO TREAT PERIODONTAL DISEASES Regimen
Dosage/Duration
Single Agent Amoxicillin
500 mg
tds for 8 days
Azithromycin
500 mg
Once daily for 4 – 7 days
Ciprofloxacin
500 mg
Twice daily for 8 days
Clindamycin
300 mg
tds daily for 10 days
Doxycycline or Minocycline
100- 200 mg
Once daily for 21 days
Metronidazole
500 mg
tds for 8 days
250 mg of each
tds for 8 days
Combination Therapy Metronidazole + amoxicillin
Metrinidazole 500 mg of eacContin h TwicDent 21:111, e dai21:111, ly for 82000 days Data from+ Jorgensen MG, Slots J: Compend Educ Dent ciprofloxacin
CHEMOTHERAPEUTIC AGENTS Monocycline •
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Effective against broad spectrum of microorganisms. Suppresses spirochetes & motile rods as effectively scaling & root debridement. Less phototoxicity & renal toxicity than tetracycline but may cause reversed vertigo.
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Same spectrum of activity as minocycline & may be equally effective.
CHEMOTHERAPEUTIC AGENTS Metronidazole •
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Bactericidal to anaerobic organisms & is believed to disrupt bacterial DNA synthesis in conditions with a low reduction potential. Effective against Porphyromonas gingivalis & provetella intermedia. Used in ANUG, chronic periodontitis & aggressive periodontitis
Clindamycin •
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Effective against anaerobic bacteria. Effective in situations in patient is allergic to penicillin. Shown efficacy in patient with refractory periodontitis.
CHEMOTHERAPEUTIC AGENTS Ciprofloxacin •
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Quinolone active against gram-negative rods, including all facultative & some anaerobic putative periodontal pathogens. Minimal effect on Streptococcus species. To fight AA.
Amoxicillin •
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Semisynthetic penicillin with extended antiinfective spectrum that includes grampositive & gram-negative bacteria. Used in management of aggressive periodontitis in both localized & generalized forms. Susceptible to penicillinase.
CHEMOTHERAPEUTIC AGENTS Amoxicillin – Clavulanate Clavulanate potassium •
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= Augmentin Useful in managing patient with localized aggressive periodontitis or refractory periodontitis. This antiinfective agent is resistant to penicillinase enzymes produced by some bacteria.
Guidelines for use of antimicrobial therapy Clinical diagnosis Health
Chronic periodontitis
Aggressive, refractory or medically related periodontitis
Periodontal therapy including: -Oral hygiene -Root debridement -Supportive periodontal treatment -Surgical excess for root debridement or -Regenerative therapy -Antibiotic as indicated by microbial analysis Effective Ineffective
Supportive periodontal treatment
Microbial analysis
Sequencing of antimicrobial agents (modified from Jorgensen MG, Slots J: Compend Contin Educ Dent 21:111, Dent 21:111, 2000) Medically related, aggressive, or refractory periodontiti s (diagnosis) -Periodonta l evaluation -Review medical history -Plaque sampling
Periodontal therapy -Scaling & root planning -Place subgingival antimicrobials -Betadine irrigation -OHI -Periodontal surgery
Periodontal therapy
- 8 days regimen antibiotics at completion of root debridement if recommended by reference lab -Intraoral irrigation at home -Chlorhexidine rinse for 2 weeks Day 0
Reevaluatio n -Evaluation of response to therapy -Reinforce oral hygiene -Plaque sampling as clinically indicated
6 – 8 weeks
Supportive Periodontal Therapy -Periodonta l evaluation -Review medical history -OHI -Scaling & root planning -Plaque sampling as indicated clinically Every 3 –
Assessment of Periodontal Treatment Outcome Periodontal Risk Assessment •
PHASE 2
PERIODONTAL RISK ASSESSMENT DEFINITION: Risk – probability that an event will occur in the future/ future/ probability that an individual develops a given disease. Can divide into: - Risk factor - Risk indicator (determinant) - Risk predictor •
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Risk Assessment – it is a process which qualitative / quantitative assessment are made of likelihood for adverse effect to occur as a result of exposure to specified health hazards, so it can be reduced, avoided / managed.
PERIODONTAL RISK ASSESSMENT IMPORTANCE OF PRA Periodontal disease is an imbalance of bacterial plaque & host susceptibility. Role of the bacteria as initiator to periodontal disease & 1 etiology of periodontal disease. Host – related factors (influence the presentation & progression of periodontal disease). All people are not equally susceptible to periodontal disease. (in longitudinal study of Sri Lankan tea plantation) All people are not equally response to periodontal therapy .(in longitudinal study of well maintained 600 patients were followed for 22 years) Successful of periodontal therapy. - Early & corrective diagnosis - Risk management - Effective treatment •
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PERIODONTAL RISK ASSESSMENT PURPOSE OF PRA •
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Identify disease severity Identify the patient likelihood of developing the disease Understand future disease progression For When comprehensive treatment To Perform: 1. To all all new peri period odon ontal tal pati patient ent.. planning.
2. After After active active trea treatme tment nt before before Supporti Supportive ve Periodontal Therapy
PERIODONTAL RISK ASSESSMENT RISK TO LOOK FOR: RISK FACTOR
RISK INDICATOR
RISK PREDICTOR
Biological plausible as a Biological plausible as a No current biological causative agent for causative agent for plausible as a causative disease. disease. agent. Shown to precede the development of the disease in prospective clinical studies & longitudinal studies.
Where the associated only show by crosssectional studies.
Shown to be associated with disease on a crosssectional/ longitudinal studies.
Eg: smoking smoking & diabe diabetes tes Eg: patient patient with with HIV/ Eg: markers/ historical age/ gender/ race/ measure of disease/ osteoporosis/ genetic number of missing factors/ bacterial/ stress teeth.
PERIODONTAL RISK ASSESSMENT CLINICAL PREDICTIVE FACTOR TOOTH FACTOR
BLEEDING ON PROBING
POCKETS DEPTH
Tooth position Low BOP <25%: Caries lower risk of Defective disease restoration margin progression Bacterial Furcation Type of bony defects
Increased number of remaining deep pocket ≥ 6mm following Initial Phase Therapy : greater risk for disease progression
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PERIODONTAL RISK ASSESSMENT METHOD TO IDENTIFY INDIVIDUAL AT RISK •
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Diagnostic test – Clinical parameters, PD, BOP & r/g. GCF analysis & saliva-oral microorganism, neutrophil defects, genetic markers & antibody. Subjective risk assessment – asking environmental risk.
PERIODONTAL RISK ASSESSMENT PRA MODEL RISK
BOP PPD TOOTH (%) >5mm LOSS
BL/AGE SMOKING/ day
GENETIC/ SYSTEMATIC
LOW
0-9
0-4
0-4
0.05
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MOD
10-25
5-8
5-8
>0.05 – 1.0
10 - 19
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HIGH
>25
>8
>8
>1.0
>19
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Coding System For PRA (Lang & Tonetti 2003)
Coding System For PRA:
BOP – bleeding on probing PPD – periodontal pocket depth BL – bone loss MOD – moderate •
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LOW – all low risk + 1 MOD risk MOD – ≥ 2 MOD + 1 HIGH risk HIGH – ≥ 2 HIGH risk
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PERIODONTAL RISK ASSESSMENT BL/Age •
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% of bone loss in the worst site of posterior tooth measured from PA / BW. Then devide it by patients age. Eg. If a 40 year old man suffered 20% of bone loss at mesial of 46: 20/40 = 0.5 = LOW RISK
