PERIODONTA

L THERAPY
Consists of:
•PHASE I
• PHASE II
• PHASE III
• PHASE IV
 E&D TREATMENT TREATMENT
PLANNING

INITIAL REASSESSME CORRECTIVE

PHASE NT PHASE

OHE BEHAVIOR
SURGICAL
AL CHANGE
PROCEDU
RES
PROPHYLA DEBRIDEME RECONSTRUC
XIS NT 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

PHASE 1
 PHASE 1
AIM of Therapy;

Elimination & prevention of

recurrence of supra /
subgingivally located bacterial
deposits.
 PHASE 1
Rationale

• 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 &
& motivation prosthetic devices
• Behavioral change• Restorations of
• carious lesions
Plaque control &
oral hygiene care • Orthodontic tooth
movements
• Prophylaxis • Treatment of occlusal
• Scaling & root trauma
debridement • Endodontic treatment
• Chemical control of
• Extraction of
plaque deposition hopeless teeth
 PHASE 1
OHE – Patient Information
Indications:
- Low oral health knowledge, awareness,
motivation & compliance.
- Poor self performed plaque control,
smoking & other psychosocial behaviors.
- High risk individuals to plaque – induced
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
• 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
 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
• 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  Alignment of teeth

of treatment
Number of teeth present
 amount of subgingival
calculus
Probing pocket depths &
attachment loss
Furcation involvement
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 diamond-
coated 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.
•Roles of chemical agents (antiseptic &
antibiotic) in periodontics
•The different of chemical plaque agent
•Content, indication, limitation & effects of
use of these agents

CHEMICAL
PERIODONTAL
THERAPY
CHEMICAL PERIODONTAL
THERAPY
GOAL –

• Removal of supragingival &

subgingival bacteria.
CHEMICAL PERIODONTAL
THERAPY
• 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-gingivitis: anti-inflammatory effect on
the gingival health not necessarily mediated
through an effect on plaque.
CHEMICAL PERIODONTAL
THERAPY
Antimicrobial agents;
- Antiseptics Can be used:
topically,
- Antibiotics locally applied
& 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)
- Oradex – chlorhexidine 0.12%
- Listerine® antiseptic mouthwash (phenolic
compound/ essential oil)
- Plax® (triclosan)

• 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)

• 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 – sanguinarines

• 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.
CHEMICAL PERIODONTAL
THERAPY
CHLORHEXIDINE
• Broad spectrum antiseptic which possess anti-
plaque 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.
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.
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.
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.
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.
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
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)

• Non-specific plaque theory (reduction of bacterial load)

• Specific plaque theory (specific plaque therapy)
CHEMICAL PERIODONTAL
ANTIBIOTICS
THERAPY
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.
3. While mechanical removal of plaque aimed at reduction
of bacterial load for non-specific plaque theory.
CHEMICAL PERIODONTAL
THERAPY
ANTIBIOTICS
4. If unresponsive pockets (after reassessment
therapy done & no response to therapy),
chlorhexidine in slow release of polymer can be
used 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 of use of antimicrobial agents to
patient with lack of manual dexterity or with
patients with mental disability is clear.
9. Patient wearing orthodontics appliances cannot
used chlorhexidine mouthwash for a long term
due to tooth & tongue staining side effects.
CHEMICAL PERIODONTAL
THERAPY
Antibiotics agents:
• Local application
• 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 of biodegradable
slow, release gel, hollow or solid fibers.
CHEMICAL PERIODONTAL
THERAPY
ANTIBIOTIC – Local Application
Examples:
a.Elyzol gel - 25% of Metronidazole
b.Dentomycin gel - 2% of minocycline
c.Actisite – tetracycline fibers (hollow/solid)
d.Periocline - 2% minocycline
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.
CHEMICAL PERIODONTAL
THERAPY
ANTIBIOTIC– Systemic Uses
(Aggressive Periodontitis )

• Amoxicillin in combination with Metronidazole (if allergic to

penicillin give clindamycin);
- 250 mg amoxicillin & 200 mg Metronidazole tds for 4 to 7 days.

• Tetracycline
- 250 mg tetracycline for 14 days
- 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.
- 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.
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 100- 200 mg Once daily for 21 days
Minocycline
Metronidazole 500 mg tds for 8 days

Combination Therapy
Metronidazole + 250 mg of each tds for 8 days
amoxicillin
Metrinidazole
Data from + 500
Jorgensen MG, Slots mg of each
J: Compend Twice
Contin Educ daily
Dent for 82000
21:111, days
ciprofloxacin
 CHEMOTHERAPEUTIC
AGENTS
Monocycline Doxycycline
• Effective against broad • Same spectrum of
spectrum of activity as minocycline
microorganisms.
& may be equally
• Suppresses spirochetes &
effective.
motile rods as effectively
scaling & root
debridement.
• Less phototoxicity & renal
toxicity than tetracycline
but may cause reversed
vertigo.
 CHEMOTHERAPEUTIC
AGENTS
Metronidazole Clindamycin
• Bactericidal to anaerobic • Effective against
organisms & is believed to anaerobic bacteria.
disrupt bacterial DNA
synthesis in conditions • Effective in situations
with a low reduction in patient is allergic to
potential. penicillin.
• Effective against • Shown efficacy in
Porphyromonas gingivalis
& provetella intermedia. patient with
• Used in ANUG, chronic refractory
periodontitis & aggressive periodontitis.
periodontitis
 CHEMOTHERAPEUTIC
AGENTS
Ciprofloxacin Amoxicillin
• Quinolone active • Semisynthetic penicillin with
extended antiinfective
against gram-negative spectrum that includes gram-
rods, including all positive & gram-negative
bacteria.
facultative & some
• Used in management of
anaerobic putative aggressive periodontitis in both
periodontal localized & generalized forms.
pathogens. • Susceptible to penicillinase.
• Minimal effect on
Streptococcus species.
• To fight AA.
 CHEMOTHERAPEUTIC
AGENTS
Amoxicillin – Clavulanate potassium

• = 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 Aggressive, refractory or

periodontitis medically related
periodontitis
Periodontal therapy including:
-Oral hygiene Microbial
-Root debridement analysis
-Supportive periodontal treatment
-Surgical excess for root
debridement or
-Regenerative therapy

-Antibiotic as indicated by microbial

analysis
Effective Ineffective

Supportive periodontal treatment

 Sequencing of antimicrobial agents (modified from Jorgensen MG, Slots
J: Compend Contin Educ Dent 21:111, 2000)

Medically Periodontal Periodontal Reevaluatio Supportive

related, therapy therapy n Periodontal
aggressive, Therapy
or -Scaling & -Evaluation
refractory root planning - 8 days of response -Periodonta
periodontiti -Place regimen to therapy l evaluation
s subgingival antibiotics at -Reinforce -Review
(diagnosis) antimicrobials completion of oral medical
-Betadine root hygiene history
-Periodonta irrigation debridement if -Plaque -OHI
l evaluation -OHI recommended sampling as -Scaling &
-Review -Periodontal by reference clinically root
medical surgery lab indicated planning
history -Intraoral -Plaque
-Plaque irrigation at sampling
sampling home as
-Chlorhexidine indicated
rinse for 2 clinically
weeks

Day 0 6 – 8 weeks Every 3 –

4 months
Assessment of Periodontal Treatment Outcome
• Periodontal Risk Assessment

PHASE 2
 PERIODONTAL RISK
ASSESSMENT
DEFINITION:
• Risk –
probability that an event will occur in the future/ probability that
an individual develops a given disease.
Can divide into:
- Risk factor
- Risk indicator (determinant)
- Risk predictor

• 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 & 1o 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
 PERIODONTAL RISK
ASSESSMENT
PURPOSE OF PRA
• Identify disease severity
• Identify the patient likelihood of
developing the disease
• Understand future disease
progression
• For When
comprehensive
To Perform: treatment
planning.
1. To all new periodontal patient.
2. After active treatment before Supportive
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 Where the associated Shown to be associated

development of the only show by cross- with disease on a cross-
disease in prospective sectional studies. sectional/ longitudinal
clinical studies & studies.
longitudinal studies.
Eg: smoking & diabetes Eg: patient 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 POCKETS DEPTH
PROBING

• Tooth position • Low BOP <25%: • Increased number

• Caries lower risk of of remaining deep
• Defective disease pocket ≥ 6mm
restoration margin progression following Initial
• Bacterial Phase Therapy :
• Furcation greater risk for
• Type of bony disease
defects progression
 PERIODONTAL RISK
ASSESSMENT
METHOD TO IDENTIFY INDIVIDUAL AT
RISK

• 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 BL/AGE SMOKING/ GENETIC/
(%) >5mm LOSS day SYSTEMATIC

LOW 0-9 0-4 0-4 0.05 - -

MOD 10-25 5-8 5-8 >0.05 – 10 - 19 -
1.0
HIGH >25 >8 >8 >1.0 >19 +

Coding System For PRA (Lang & Tonetti 2003)

Coding System For PRA: •BOP – bleeding on probing

•PPD – periodontal pocket
•LOW – all low risk + 1 MOD risk depth
•MOD – ≥ 2 MOD + 1 HIGH risk •BL – bone loss
•HIGH – ≥ 2 HIGH risk •MOD – moderate
 PERIODONTAL RISK
ASSESSMENT
BL/Age

• % 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