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PERIODONTAL
THERAPYConsists of:PHASE I
PHASE II
PHASE III
PHASE IV
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E & D TREATMENTPLANNING
TREATMENT
INITIAL PHASE REASSESSMENT CORRECTIVE
PHASE
SURGICAL
PROCEDURES
RECONSTRUCTIVEPROCEDURES
OHE BEHAVIORAL
CHANGE
PROPHYLAXIS DEBRIDEMENT
OTHER DENTAL
TREATMENT
SUPPORTIVE PERIODONTAL CARE
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PHASE 1
Phase I therapy is referred to by many names;Initial / first line therapyNonsurgical periodontal therapyCause-related therapyEtiotropic phase of therapy
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PHASE 1
AIM of Therapy;
Elimination & prevention of recurrence ofsupra / subgingivally located bacterialdeposits.
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PHASE 1
Components:
Relief pain Patient education &
motivation
Behavioral change Plaque control & oral
hygiene care Prophylaxis Scaling & root
debridement Chemical control of
plaque deposition
Correction/ replacementof poorly fittingrestorations & prostheticdevices
Restorations of cariouslesions
Orthodontic toothmovements
Treatment of occlusaltrauma
Endodontic treatment Extraction of hopeless
teeth
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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.
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OHE Patient Motivation
- Change in knowledge
- Change in understanding- Change in attitude
- Change in habit
- Use simple everyday language & avoidjargons
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Behavioral Change
- Diet counseling encourage balanced dietand frequency.
- Smoking cessation (smoking risk factorfor periodontitis), it will increase inprogression of disease, alter the fibroblastfunction & impair wound healing.
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OHI
- Tooth brushing method:
PHASE 1
Roll roll method or Modified Stillman technique
Vibratory Bass Technique
Circular Fones Technique
Vertical Leonard Technique
Horizontal Scrub Technique
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OHI
Recommendation of toothbrush design:
- Soft- Nylon bristle
- Toothbrushes need to be replaced about
every 3 months (or replace when it start toshow sign of matting).
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OHI
- Powered toothbrush also can removeplaque effectively (properly used).
- Patients need to be instructed in the properuse of powered devices.
- Patients who are poor brushers, children &caregivers may particularly benefit fromusing powered toothbrushes.
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OHI Interdental Cleaning Aids
- Cleans the interdental region (most commonsite for plaque retention).
- Most inaccessible site to tooth brushing.
- Dental floss
- Interdental space brush
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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 gentlythrough 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 theadjacent tooth.
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Prophylaxis
- Removal of supragingival plaque & calculus(scaling & polishing).
- Removal of plaque retentive factors;Smooth roughness of restoration
Removal of overhangs
Ill-fitting / rough prosthesisRemoval of staining
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Non
surgical Instrumentation
- Chemotherapeutic approaches
Topical application of antiseptics to prevent
plaque accumulation & to disinfect the rootsurfaces.
Mouthrinses
ChlorhexidineChip-perio chip
Solution injection elyzol/periocline
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Non
surgical Instrumentation- Chemotherapeutic approaches
Systemic approach selective use of antibiotic
or host modulation of tissue destructiveenzymes (Doxycycline).
Rationale;
Pathogenic organisms that were not accessibleto mechanical removal by hand/power driveninstruments can be reduced/eliminated.
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Treatment Sessions
- The following conditions must considered toplan Phase 1 treatment sessions needed;
PHASE 1
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)
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Step 1 (Limited Plaque Control Instruction)
- Should start in 1stappointment & shouldinclude only the correct use of toothbrushon all surfaces of the teeth.
- Use of dental floss should await the removalof calculus & overhanging restorations.
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Step 2 (Supragingival Removal of Calculus)
- Can be done by scalers, curettes orultrasonic instrumentation.
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Step 3 (Recountouring DefectiveRestorations & Crowns)
- May require replacing the entire restorationor crown or correcting it with finishing bursor diamond-coated files mounted on thespecial handpiece.
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Step 4 (Obturation of Carious Lesion)
- Involves complete removal of the carioustissue & placement of final or a temporaryrestoration.
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Step 5 (Comprehensive Plaque ControlInstrumentation)
- Patient should learn to remove plaquecompletely from all supragingival areas,using toothbrush, floss & other necessarycomplementary method.
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Step 6 (Subgingival Root Treatment)
- Complete calculus removal & root planningcan be effectively performed.
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Step 7 (Tissue Reevaluation)
- The periodontal tissue reexamined todetermine the need for further therapy.
- Pocket are reprobed & all related anatomicalconditions are carefully evaluated to decidewhether surgical treatment is indicated.
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CHEMICALPERIODONTAL THERAPY
Roles of chemical agents (antiseptic &
antibiotic) in periodonticsThe different of chemical plaque agent
Content, indication, limitation & effects of useof these agents
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CHEMICAL PERIODONTALTHERAPY
GOAL
Removal of supragingival & subgingivalbacteria.
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Supragingival plaque accessible to patient(can effectively disrupted / removed usingtoothbrush/ interproximal cleaning devices).
Mechanical plaque control can be effectivein preventing / reversing gingivitis.
If patient unable to perform mechanical
plaque removal use of chemotherapeuticagents as an adjunctmay be warranted.
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TERMINOLOGY:
- Plaque inhibitory effect: reducing plaque to a levelinsufficientto prevent the development of
gingivitis.- Anti-plaque effect: produces a prolonged &
profound reduction in plaque sufficient to preventthe development of gingivitis.
- Anti-gingivitis: anti-inflammatory effect on thegingival health notnecessarily mediated throughan effect on plaque.
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Antimicrobial agents;
- Antiseptics
- Antibiotics
Miscellaneous agents;
- Matrix protein- Growth factor
- Hydrogen peroxide
CHEMICAL PERIODONTALTHERAPY
Can be used:
topically, locally
applied &
systemically
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ANTISEPTICS
Topically (mouthwashes)
- Oradex chlorhexidine 0.12%
- Listerine antiseptic mouthwash (phenoliccompound/ essential oil)
- Plax (triclosan)
Typically act supra-gingivally.
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ANTISEPTICS Locally applied
- Slow release devices (biodegradable polymer, gel, fibers,collagen)
- Applied into periodontal pockets:
Perio Chip (2.5 mg chloroxedine in gelatinmatrix)
Atrigel (5% sanguinarine)
Typically act sub-gingivally.
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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
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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.
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CHEMICAL PERIODONTALTHERAPY
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
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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 theplaque in untreated mouth.
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CHLORHEXIDINE
Broad spectrum antiseptic which possess anti-plaqueactivity.
Mostly available in digluconate salts formulations.
Strong base & dicationic at pH levels above 3.5 with 2positive charges on either side of hexamethylene bridge.
At low concentration cause increase in cell membranepermeability & leakage of intracellular components.
At high concentration precipitation of bacterial cytoplasm& cell death.
CHEMICAL PERIODONTALTHERAPY
C C O O
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PHENOLIC COMPOUNDS
Eg: Listerine
Have moderate plaque-inhibitory effects &some anti-gingivitis effect.
Less effective than chlorhexidine but morepowerful than triclosan.
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CHX
- As a broad spectrum antimicrobial agent,have no bacterial resistance reported & noevidence of superinfection by fungi / viruses.
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INDICATION:
CHX m/w indicated to post perio-surgical patient to reducethe bacterial load / to prevent plaque formation at timewhen mechanical cleaning may be difficult due discomfort.
Patient with mental & physically disabilities lack of manualdexterity 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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INDICATION:
CHX m/w can be prescribed to patientwearing orthodontic appliance & also forpatient with intermaxillary fixation followingtrauma / orthognathic surgery.
As an adjunct to mechanical instrumentation
in case such as refractory periodontitis &locally applied antimicrobial agents can beused.
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LIMITATION:
CHX particular inhibit plaque formation in aclean mouth but not significantly reducebacterial load in untreated mouth.
CHX m/w cannot penetrate into gingivalcrevice, therefore have no place in control of
chronic periodontitis presence of deeppocket of >5 mm.
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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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ANTIBIOTICS1. Use of antibiotics (systemically / local application) mainly
directed against specific bacteria & sub-gingival plaque totarget 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 & aggressiveperiodontitis.
3. While mechanical removal of plaque aimed at reduction ofbacterial load for non-specific plaque theory.
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ANTIBIOTICS
4. If unresponsive pockets (after reassessment therapy done& no response to therapy), chlorhexidine in slow releaseof polymer can be used locally, advantage of that, agents
can be sustained release within the pocket. Locally appliedantibiotics also can be used in this situation.
5. Used of antibiotics in periodontal abscess usually notnecessary if the abscess only localized unlessthere are
signs of spread of infection to systemic area / sign ofcellulitis/ lymphadenopathy.
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ANTIBIOTICS
6. Post surgical rinsing with chlorhexidine mouthwashmainly due to inability to mechanically removed
plaque because discomfort.7. Post surgical systemic antibiotic prescription may
not indicated, unlesscomplex surgical proceduresbeen carried out (post-implant surgery) / patient is
medically compromised.
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ANTIBIOTICS
8. Indication of use of antimicrobial agents topatient with lack of manual dexterity or
with patients with mental disability is clear.
9. Patient wearing orthodontics appliancescannot used chlorhexidine mouthwash for
a long term due to tooth & tongue stainingside effects.
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ANTIBIOTIC Local Application
Antibiotics can be in form of:
Gel for topical application onto surface orsub-gingival application.
May present in polymer.
Also present in the form of biodegradableslow, release gel, hollow or solid fibers.
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ANTIBIOTIC Local Application
Examples:
a. Elyzol gel - 25% of Metronidazole
b. Dentomycin gel - 2% of minocycline
c. Actisitetetracycline fibers (hollow/solid)
d. Periocline- 2% minocyclinee. Atridox- 42.5 mg Doxycycline
f. Arestin- 1 mg minocycline
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ANTIBIOTIC Systemic Uses
In the form of liquid, tablets or capsules suitable if patients diagnosed with
aggressive periodontitis ONLY.
Must finish antibiotic simultaneously withthe therapy/ root debridement.
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ANTIBIOTICSystemic 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 daybecause half of it will bind to plasma & another half will be in blood).
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ANTIBIOTIC Systemic Uses(ANUG/P)
In case of ANUG/P, Metronidazolemay be needed
for 3 4 days only.- 200 mg Metronidazole tds for 3 4 days.
- Analgesic may be prescribed to patient diagnosedwith ANUG/P due to pain.
- Since the ANUG/P lesions being very painful tomechanical plaque control, chlorhexidinemay begiven.
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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.
- Chlorhexidinemouthwashes must be givensince the wound may be painful tomechanical plaque removal.
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CHEMICAL PERIODONTALTHERAPY
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.
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INDICATION:
Antibiotic prophylactic agents in which the risks ofbacterimia & infective endocarditis is high.
Systemic antibiotics prescribed are directed against specific
microorganisms as an adjunct to mechanicalinstrumentation in aggressive periodontitis & ANUG/P.
The used of systemic antibiotic without cautions can lead todevelopment of bacterial resistance.
Certain individual may suffered from immediatehypersensitivity which can be fatal.
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General terms for a chemical substancesprovides a clinical therapeutic benefit.
CHEMOTHERAPEUTICAGENTS
COMMON ANTIBIOTIC REGIMENS TO TREAT PERIODONTAL
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Regimen Dosage/Duration
Single Agent
Amoxicillin 500 mg tds for 8 days
Azithromycin 500 mg Once daily for 47 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
Combination TherapyMetronidazole + amoxicillin 250 mg of each tds for 8 days
Metrinidazole + ciprofloxacin 500 mg of each Twice daily for 8 days
COMMON ANTIBIOTIC REGIMENS TO TREAT PERIODONTAL
DISEASES
Data from Jorgensen MG, Slots J: Compend Contin Educ Dent 21:111, 2000
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CHEMOTHERAPEUTIC AGENTS
Monocycline
Effective against broadspectrum ofmicroorganisms.
Suppresses spirochetes &motile rods as effectivelyscaling & rootdebridement.
Less phototoxicity & renaltoxicity than tetracyclinebut may cause reversedvertigo.
Doxycycline
Same spectrum of activityas minocycline & may beequally effective.
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Metronidazole
Bactericidal to anaerobicorganisms & is believed todisrupt bacterial DNA synthesis
in conditions with a lowreduction potential.
Effective against Porphyromonasgingivalis & provetellaintermedia.
Used in ANUG, chronicperiodontitis & aggressiveperiodontitis
Clindamycin
Effective against anaerobicbacteria.
Effective in situations inpatient is allergic topenicillin.
Shown efficacy in patientwith refractoryperiodontitis.
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Ciprofloxacin
Quinolone active againstgram-negative rods,including all facultative &some anaerobic putativeperiodontal pathogens.
Minimal effect onStreptococcusspecies.
To fight AA.
Amoxicillin
Semisynthetic penicillinwith extendedantiinfective spectrum thatincludes gram-positive &gram-negative bacteria.
Used in management ofaggressive periodontitis in
both localized &generalized forms.
Susceptible topenicillinase.
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Amoxicillin
Clavulanatepotassium
= Augmentin
Useful in managing patient
with localized aggressiveperiodontitis or refractoryperiodontitis.
This antiinfective agent isresistant to penicillinaseenzymes produced bysome bacteria.
CHEMOTHERAPEUTIC AGENTS
Guidelines for use of antimicrobial therapy
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Clinical diagnosis
Health Chronic periodontitis Aggressive, refractory or medicallyrelated 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
Microbial analysis
Effective Ineffective
Supportive periodontal treatment
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PHASE 2
Assessment of Periodontal Treatment Outcome
Periodontal Risk Assessment
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PERIODONTAL RISK ASSESSMENT
DEFINITION: Risk
probabilitythat an event will occur in the future/ probability that an individualdevelops a given disease.
Can divide into:
- Risk factor- Risk indicator (determinant)
- Risk predictor
Risk Assessment
it is a processwhich qualitative / quantitative assessment are made of likelihoodfor adverse effect to occur as a result of exposure to specified health hazards, soit can be reduced, avoided / managed.
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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 ofperiodontal 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 studyof well maintained 600 patients were followed for 22 years)
Successful of periodontal therapy.- Early & corrective diagnosis
- Risk management
- Effective treatment
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RISK TO LOOK FOR:
PERIODONTAL RISK ASSESSMENT
RISK FACTOR RISK INDICATOR RISK PREDICTOR
Biological plausible as a
causative agent for disease.
Biological plausible as a
causative agent for disease.
No current biological
plausible as a causative
agent.
Shown to precede the
development of the disease
in prospective clinical
studies & longitudinal
studies.
Where the associated only
show by cross-sectional
studies.
Shown to be associated
with disease on a cross-
sectional/ longitudinal
studies.
Eg: smoking & diabetes Eg: patient with HIV/ age/
gender/ race/
osteoporosis/ genetic
factors/ bacterial/ stress
Eg: markers/ historical
measure of disease/
number of missing teeth.
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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 environmentalrisk.
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PRA MODEL
PERIODONTAL RISK ASSESSMENT
RISK BOP
(%)
PPD
>5mm
TOOTH
LOSS
BL/AGE SMOKING/
day
GENETIC/
SYSTEMATIC
LOW 0-9 0-4 0-4 0.05 - -
MOD 10-25 5-8 5-8 >0.05
1.0
10 - 19 -
HIGH >25 >8 >8 >1.0 >19 +
Coding System For PRA:
LOWall low risk + 1 MOD risk
MOD 2 MOD + 1 HIGH risk
HIGH 2 HIGH risk
BOPbleeding on probing
PPDperiodontal pocket depth
BLbone loss
MODmoderate
Coding System For PRA (Lang & Tonetti 2003)
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