American Academy Of Periodontology Classification

Updates For Treating Oral Inflammation

By: Debbie Seidel-Bittke, RDH, BS

September 18, 2023

Periodontal disease, comprising gingivitis and periodontitis, is a common oral health issue affecting millions of people worldwide.1

As dental professionals, we play a vital role in managing and preventing this disease condition.

Our overarching reason for treating patients with oral inflammation, active gum disease, is because when we put a halt to oral inflammation and gingival diseases we can help our patients live a longer, healthier life.

This blog post will explore the latest research findings, treatment options, and effective prevention strategies for periodontal disease, including innovative approaches like Guided Biofilm Therapy and BioGaia ProBiotics.

This blog will also include sequencing of various appointments when treating oral inflammation.

Understanding Periodontal Disease:

Gum disease encompasses various conditions affecting the supporting tissues of the teeth, including gums, periodontal ligaments, and alveolar bone.

The two primary forms are:

Gingivitis:

Gingivitis, a milder form of gum disease, features inflamed, red, and bleeding gums and no alveolar bone loss.
Accumulation of dental plaque, a biofilm of bacteria, and is often the cause of early gum disease.
This early sign of gum disease can also be associated with various systemic diseases as outlined below.
Gingivitis is often reversible with regular dental hygiene preventive care appointments, and proper home care routines.

Periodontitis:

Periodontitis, a more severe form of gum disease includes alveolar bone loss.
Often this begins with gingivitis and can be associated with other systemic diseases such as: diabetes, high blood pressure, heart attack, stroke, high cholesterol, various cancers, Crohns’ disease and even Alzheimer’s Disease.
The most common risk factor is tobacco use.
It involves more severe inflammation, gum recession, and radiographic bone loss.
Recent research suggests potential systemic health links, such as diabetes, stroke heart disease, etc. See the list of systemic diseases and research website link outlined below.

Latest Research on Periodontal Disease:

Recent studies have uncovered crucial insights into periodontal disease, offering a deeper understanding of its etiology, progression, and systemic connections:

- Microbiome and Dysbiosis: Research has highlighted the role of the oral microbiome in gum disease development. Understanding specific bacteria involved can inform targeted treatments.
- Inflammation and Systemic Health: Emerging evidence suggests the inflammation associated with periodontal disease may contribute to systemic health issues.
- Dental professionals must consider the systemic links to gingival diseases during patient assessments and share this important message to help patients “live a longer, healthier life with optimal oral health.”

Treatment Options for Oral Inflammation:

Dentists and dental hygienists employ various approaches to treat gingival and periodontal diseases, tailored to its severity such as:

Gingivitis Treatment: Indicated for patients with generalized moderate to severe inflammation in the absence of radiographic bone loss.

Scaling and Root Planing: Indicated for patients with radiographic bone loss, and moderate to severe gingival inflammation.

Guided Biofilm Therapy (GBT): GBT focuses not only on prevention and maintenance of gingival, periodontal and peri-implant diseases in adults but is also the only proven protocol to manage biofilm around orthodontics and in non-surgical periodontal treatment. 2

This therapy utilizes an E.M.S. Electro Medical System.

1.Diode Laser:

Can reduce bacterial load without the side effects of antibiotics. There are clinical advantages for use of the diode laser therapy in the reduction of subgingival bacteria—the etiology of periodontitis. Evidence suggests that lasers can be bactericidal to subgingival pathogens. 3

2. Antibiotics: Dentists may prescribe antibiotics like doxycycline. Dental hyginists may use sub-dose microspheres of Arestin® (minocycline HCl), subgingivally, and/or antimicrobial mouth rinses during home care to manage inflammation and infection.

3. End-Point Therapy/Re-Evaluation:

Every patient who is treated for generalized moderate to severe inflammation, with or without radiographic bone loss will also have a follow-up appointment to re-evaluate the condition of this inflammation.

At the re-evaluation you will complete a comprehensive periodontal exam (CPE). This must include pocket depths, recession, bleeding, mucogingival involvement, furcations, etc.

You will use diode laser, ultrasonics, GBT, scale, polish (No need to polish when GBT is initiated), review of oral-systemic link & perio process ending with an update or continuation of homecare. When there is a halt of the disease process and no active gum disease is present you will determine the interval your patient will return for preventive care.

If your patient returns and active gum disease exists, you will refer to step 1 of this sequence of care.

For a gingivitis patient, you will refer the patient to their PCP for a full blood panel to rule out any systemic diseases; most common may be diabetes, high-cholesterol, or high blood pressure.

The patient will be scheduled to return for re-evaluation in 6 weeks and repeat the above listed protocol. See the above 1st step in treating gingivitis.

In the case of your periodontal patient, who returns with active disease, you will, 1. Re-treat these affected areas (see step 1 of the treatment plan) of active disease and according to each individual’s risk factors and perio status, you will refer to a periodontist for evaluation.

The purpose of this re-evaluation- (Purpose of an “end point” assessment is to be certain there is a halt of the gingival inflammation.

After therapy If we schedule a patient for three or six months without six weeks re-evaluation to check the “endpoint” of the disease, it’s possible that when the patient does return in three months of six months, active disease will progress to a more serious condition which will ultimately affect the patient’s total health and well-being. 4

End point therapy is considered the end of Phase I therapy.

Innovative Treatment Approaches:

Guided Biofilm Therapy (GBT):

GBT is a cutting-edge approach that uses advanced technology and devices to target and remove dental biofilm more effectively.
It utilizes air-polishing devices to dislodge biofilm from tooth surfaces and below the gumline, improving treatment outcomes.
This therapy is non-invasive, a great way to show patients where they are missing with their toothbrush and floss. You can also disclose to show acidic plaque, etc. Pain Free enamel-safe, plaque removal and a great way to inspire patients to “own their disease.”

Show patients what you see (Biofilm) because “seeing is believing!:”

BioGaia ProBiotics:

BioGaia ProBiotics are beneficial bacteria applied topically to the oral cavity to restore and maintain a healthy oral microbiome.
Research is ongoing, but preliminary studies suggest potential benefits in preventing and managing gum disease. 5

Effective Prevention Strategies:

Preventing periodontal disease is paramount, and as dental professionals we can guide patients using these preventive measures:

Oral Hygiene Education: Emphasize proper brushing, flossing, and the use of antimicrobial mouthwash.
Routine Dental Hygiene Appointments: Stress the importance of routine dental visits for professional preventive care and early detection of gum disease.
Lifestyle Adjustments: Educate and share information about tobacco cessation as necessary, maintain a balanced diet. Share information about systemic conditions, such as diabetes, heart disease and even Alzheimer’s Disease, which can exacerbate gum disease.

Conclusion:

Periodontal disease remains a significant oral health challenge, but ongoing research and evolving treatment modalities offer hope for improved patient outcomes. Dental professionals must stay informed about the latest developments to provide the best possible patient care.

Innovative approaches like Guided Biofilm Therapy and BioGaia ProBiotics show promise by enhancing treatment and prevention efforts. By working together, dental professionals and patients can effectively combat gum disease and our patients can live a longer, healthier life.

Our overarching message to patients is that optimal oral health leads to a longer-healthier life.

References.

Americans with Perio Disease. https://bit.ly/3PgUuI5 Accessed on September 15, 2015.
Guided Biofilm Therapy. https://www.ems-dental.com/en/guided-biofilm-therapy Accessed on September 18, 2023.
Effects of Diode Laser and mitochondria. https://bit.ly/LBRMitochondria Accessed September 18, 2023.
End Point Therapy. https://tinyurl.com/AAPEndPt See page 557. Accessed on September 18, 2023.
BioGaia ProBiotics. https://tinyurl.com/BIOGIA Accessed on September 18, 2023.

For more information about this consider a complimentary 30 minutes coaching session with Debbie Seidel Bittke, Founder and CEO of Dental Practice Solutions.

Click here to book your coaching session.

What is a Dental Hygienist to Do with The New AAP Classifications?!

By: admin

January 30, 2020

The American Academy of Periodontology has not updated their guidelines for categorizing periodontitis since 1999.

This should be a big deal; right?!

Most clinicians: dentists, dental hygienists and even periodontists tell me they are confused with the new staging and grading for categorizing periodontitis.

What is a dental hygienist to do with the new AAP classifications?

Are you using the new AAP classifications?

Most clinicians I speak to are not using the new classifications.

We are currently working with our client hygienists to embrace this. We show them how to laminate the forms and refer to these when making patient clinical notes.

Let me shed some light on the topic here.

If the AAP has not re-classified periodontitis since 1999, there is a good chance it will be at least ten or twenty years before we have new guidelines.

Let’s embrace the “change!”

The American Academy of Periodontology Classifications are created to help dental hygienists diagnose and treat periodontitis. Follow these guidelines so consistent diagnosis can occur.

The first step is to assess your hygiene patients and of course, every new dental patient must have a comprehensive periodontal exam.

Steps to Use the American Academy of Periodontology Staging and Grading

Step 1: Assessment

Up-to-date full mouth radiographs
Up-to-date comprehensive periodontal exam (CPE)
Chart missing teeth

Step 2: Establish the Stage

As you know cancer is categorized by stages. Think stages of cancer only this is oral inflammation causing destruction of the supporting bone that results in tooth loss.

When you are assessing the stage of periodontitis, explain to your patient and show them what you “see.” Refer to the mouth/body connection as you explain inflammation in your patients mouth.

Now is your opportunity to speak with your patient about the connection between inflammation in your patients mouth and inflammation in the body.

Inflammation in the body year after year contributes to other inflammatory disease such as (and not limited to) heart attack, stroke, rheumatoid arthritis, Crones, Alzheimer’s, diabetes, etc.

Confirm clinical attachment loss (CAL)
Rule-out non-periodontitis causes of CAL (cervical restorations, caries of root fractures)
Determine CAL or radiographic bone loss (RBL)
Confirm RBL patterns (Ex: Vertical or horizontal RBL)

For moderate to severe periodontitis (think Stage III or Stage IV):

Determine CAL or RBL
Confirm RBL patterns
Assess tooth loss due to periodontitis
Evaluate complexity factors (Ex: severe CAL frequency, surgical challenges)

Based on your findings from step 2, determination of mild-moderate periodontitis can be made, and this is considered Stage I or Stage II. Severe or very severe periodontitis is considered Stage III or Stage IV.

Step 3: Establish the Grade

What I like best about this new system to categorize periodontitis is we now bring into the picture: inflammatory diseases, systemic considerations and outcomes of non-surgical periodontal therapy.

What’s a Dental Hygienist to Do with the New Classifications?

So glad you asked!

Your first step is to print out this article including the staging and grading charts.
Take the staging and grading charts, add them to a plastic sleeve or laminate them. Keep these in your operatory.
When you evaluate your patients, refer to your staging chart.
1. In your clinical notes write, “Stage I, II, III or IV”.
2. Write as indicated
When a patient has 15%-30% RBL definitely consider writing clinical notes a category for the stage and refer to your Grading chart printed and on the flip side of your staging chart.
If a patient has <15% CAL but smokes 10 or more cigarettes, you will write in your clinical notes: Stage I, < 15% localized horizontal BL (Ex: @ #19 & 30), Grade C (Pt smokes 10+ cigarettes daily).
1. That is all. If you have a positive outlook on this, it won’t be difficult to write these chart notes
2. If you have templates add staging, horizontal, vertical < or >, etc.
3. Now using your template mark or indicate the correct description
4. Use the staging and grading charts to add these notes in your practice management templates
For patients who have diabetes and/or a tobacco user with RBL you will grade them B or C and this is your time to talk about their “potential” for tooth loss if things do not improve.

Conclusion

Many clinicians I meet are fearful about scaring patients ‘if” and “when” they do tell patients “the facts.”

Imagine this, if you have a colonoscopy or mammogram and the doctor finds a suspicious lesion, will the doctor not tell their patient about this for fear of the patient never returning?

Does a physician feel concerned that their patient’s insurance may not pay for removal of an abnormality?

I have never heard of a physician not telling a patient they have an abnormality because of the above mentioned.

Why do us dental professionals fear telling patients what is truly happening in their mouth?

We have a legal and ethical responsibility to tell our patients what we “see” happening in their mouth and body.

In 2020, dental hygienists are doing more than cleaning teeth.

Dental professionals are in the business of helping people live a longer and healthier life.

Will you join me and help conquer the disease process?

This…….is our JOB!

ABOUT THE AUTHOR

Debbie Seidel-Bittke, RDH, BS

is founder and CEO of Dental Practice Solutions. Debbie is also a former dental hygiene program director. Her expertise is optimizing the hygiene department by taking a total team approach; including the doctor as the leader.

Check out this FREE RESOURCE to treat the gingivitis patient which also includes a new patient appointment sequence of treatment here.