Normally BOP is the first sign that tells you the activity of the disease. Similarly PPD and Recession suggests severity of the disease. Based on these clinical parameters how would you diagnose if the situation is healthy or diseased. Lets suppose if a patient is having a pocket depth of 3mm and recession of 3mm (that makes attachment loss of 6mm) but there is no bleeding on probing and no signs of inflammation and radiographically u have observed 30% bone loss associated with few teeth. Would you consider this case as diseased situation and treat for periodontal issues?
Dear Maaz Assad,
I will answer your question based on academic background, but with more emphasis on daily practice, results and patient satisfaction.
The decision on the approach to the case you briefly described, will be not only based on the clinical records you just provided, but on the patient's expectations. If we are purely talking about the teeth periodontal condition ( the disease) then I would not consider that case for periodontal treatment as there is not sign of active disease. The patient, though, is still a periodontal patient and may be enrolled in a maintenance protocol that allows you to keep a closer look, in case the disease progresses and you want to intervene earlier.
On the other hand, patient's complaint might be the recession you mentioned, or sensivity due to root exposure. This would not need your intervention because of the periodontal condition, but rather because of the consequences of precious disease installation, that
Dear Bruno,
Yes I also think that this kind of case cannot be considered as active or disease. Recession and bone loss might be the history now and if the disease is not active it won't progress also. Patient should be on maintainance. But when you are teaching at undergraduate level what diagnosis would you suggest to your students. healthy but with non active periodontitis? And if that is non active why do we have to use term periodontitis when we have already stated healthy.Sometimes you have to be very specific with your students specially when they are new to this field.
Dear Dr Maaz;
The term that you need for description of this condition is " reduced periodontium". After active periodontal treatment and the resolution of periodontal inflammation in periodontitis, the periodontal tissue is healthy but with a reduced connective tissue attachment and alveolar bone height. If you get inflammation on the gingival margin in this case it can be diagnosed as "Plaque-induced gingivitis on a reduced periodontium" with no evidence of progressive attachment loss (no active disease).
Dear Dr Amir,
Yes I think your answer is very justified and these type of cases should br considered healthy but on a reduced periodontium..again asking a question from your above mentioned statement..as periodontitis is considered as an irreversible disease, how come the next tym patient had active periodontal disease could be considered as plaque induced gingivitis when structure of periodontium is already compromised. This may completely change the treatment plan also..any of the studies which have findings related to what we are discussing?
Dear Dr. Maaz;
I used the term "Plaque-induced gingivitis on a reduced periodontium" it means that there is no active periodontitis and the disease and inflammation is limited only to the gingival tissue and not extending to the supporting structures of teeth (CT, PDL, Bone).
Periodontal disease is a progressive in nature and by treating a patient with active periodontitis, you stop the progression of the disease and the patient considered periodontally stable. Now in this case, although the patient has bone loss from previously active perio disease but the disease progression is stopped and for the same reason we use the term "reduced periodontium". Gingivitis can develop on a reduced but stable periodontium.
To answer your question: the patient has no active disease in this case and he has reduced, but stable periodontium. This patient may get inflammation limited to the gingival tissue which will be considered as "Plaque-induced gingivitis on a reduced periodontium".
Very rightly said. But how do you analyze that it is only involving gingival margin and not extending to periodontium. As patient might come to you for the first time also and you cannot recognize how much loss he had previously. What clinical parameters would help us in this case?
This is an important point in diagnosis of periodontal disease. It is very important to check for the previous records of the patient (perio charting, xrays) or ask the previous clinician to provide you with that information. Cause you can follow the progression of the disease by having a good records.
If it is the first time then you should do your diagnosis and start the treatment and follow the patient over the time.
Dear Maaz Asad, I am sorry for the late reply.
Without determining the previous history that lead to the periodontal present state it turns impossible for you, following the the present classification systems, to attribute a correct designation. You might assume, even correctly, but you haven´t followed the patient. If you have the previous history you can do so. And if there is a further progression of the disease you might also call it refractory..., on top of the diagnose you´ve made.
If you could not collect this infomation, which is the most probable, then you are looking at a patient with a history of periodontal disease (because you have the clinical parameters to assess it and to determine there was a previous onset of disease), but with a present healthy situation.
So any treatment or diagnose you will make from that first evaluation onwards, will be based on the periodontal information you collected when you first met the patient and not from what might have happened before.
Kindest Regards
Dear Bruno,
So don't you think this can affect the treatment plan also. If patient had attended the last dentist who knew about the previous situation, obviously he would treat differently..and similarly if this kind of patient is coming to you for the first time, then you would diagnose differently and will definitely affect your treatment plan also. I think classification system should be revised then.
No, the case described is not the case of a subject having periodontitis, therefore he/she should not receive periodontal treatment, A pocket depth of 3 mm without signs of inflammation is not a periodontal pocket!
Any diagnosis prior to periodontal therapy would not be compete w/o consideration of a formidable anaerobic infection in the bone between teeth #8 & #9. Vitality tests of the centrals with Endo Ice is the most accurate. More than x-rays. Far too often, one or both are necrotic and has been so for decades with no apparent symptoms. We've studied 100s of cases, rapidly controlled and eliminated periodontal disease w/o anesthesia or surgeries. Calcium materials seem to be the only thing for a compete diagnosis. And yet, this has not been explained to dentists. Only then will a complete diagnosis be forthcoming.
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