72/73: DOD Perio Transcripts Lectures

Transcribed by Margaret Ferrara
Date of Lecture: 11/19/2014
[Diagnosis and Treatment of Oral Disease] [Lecture 70 &71]- Evaluation of

Initial Therapy & Perio CCP by Dr. Vera Tang
[Slide #1] Evaluation of Initial Therapy
[Dr. Tang] - Hello? Good Afternoon. Can you do me a favor and grab that door in
the back? Thank you. So we dont get any echoes. Good afternoon, Im Dr. Tang,
Im the course director of this course, for this section of the course. So youre
going to be spending the next two hours with me and um do you have any
questions before we start, since your exam is next Tuesday? (responding to
student) - Im sorry?
[student] - [unintelligible]
[Dr. Tang] - Well um if we pay attention, between the lectures weve given and
what were gonna go over today I think you should do fine. I wish I would be
seeing more of you guys but well be fine.
[student] - Are there gonna be pictures?
[Dr. Tang] - Are there gonna be pictures on the exam? Yes. My whole exam is
gonna be case based. Any other questions? The exam is gonna be 50 questions.
Theyre all case-based questions. So its gonna be a little from each lecture, with
the exception of the first lecture, which was informational. Any other questions?
[student] - Is this your exam?
[Dr. Tang] - This is my exam. Haha. Any other questions?
[student] - Are we ever gonna go over like a sample case?
[Dr. Tang] - Were gonna, were doing that in the second hour today. Our first
hour were gonna be talking about the evaluation of initial therapy, which youre..
you should be up to now, and the second hour were gonna spend um after
giving you guys a couple minutes, about 10 minutes break, were going to go
over a bunch of different cases, so youll know what to look for during the exam,
and how to pick out in the information. Any other questions before we start? Ok,
feel free to ask questions as we go along, because I know this is the tail end and
some of you guys have started to study, so if you have any questions, feel free,
raise your hand. Ok? (to student)- did you wave or you raised your hand? Youre
just waving?
[student] - So for the exam do you make up all the questions, or do each of the
professors kind of like...
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[Dr. Tang] - A little of each. They submit their questions and based on their
questions I work it into a case. Does that make sense? Ok. Any other questions?
Ok, were gonna go ahead and get started. If we can get this on.. Guess Im
standing behind the podium today, my clicker is off. Ok, alright. Are we not
synched? Oh here we go.
[Slide #3] Q1
[Dr. Tang] - Alright, its six minutes after, this is the first question for today. I want
you to think about it, write down the answer, and keep it somewhere safe. Raise
your hand when youre ready. Everyones ready? Ok Ill give you guys a few
more minutes. Raise the hands, everyone ready? Ok were gonna move on.
[Slide #4] Q2
[Dr. Tang] - Second question today. You know I posted this lecture already. I
posted this lecture about ten minutes ago so you should be able to retrieve
this. Are we ready to move on?
[Slide #5] Q3
[Dr. Tang] - You guys are writing down these answers somewhere, right? Are we
ready to move on? I got some nods. Yes, no maybe? Alright.
[Slide #6] To measure success you must first know your...
[Dr. Tang] - So the goals for periodontal therapy as weve discussed previously in
this lecture is basically to alternate, um alter the or eliminate the microbial
microflora. We cant totally eliminate it because theres no way to completely
sterilize the sulcus, correct? In addition we want to evaluate for risk factors, uh
we want to make sure the dentition is healthy enough for the patient to function.
We want to limit the amount of periodontal disease by preventing its
reoccurance, hopefully, and regeneration of any loss of attachment if and when
possible.
[Slide #7] Rationale for Initial Therapy (SRP)
[Dr. Tang] - So this is the rationale and this is actually comes straight out of your
competency, which youll be taking in your third and fourth year. And these are
the rationales, this is why we do SRP. So we want to change the microflora. So
what are we changing the microflora from, to? (students mumbling) Correct. So
gram negative to gram positive. And from anaerobes to aerobes. Correct? Ok.
So thats were trying to do. Were trying to also do that, were trying to eliminate
any or debride any of the infected tissue, and create a root surface thats
biologically compatible, so you can have the reattachment. And whats the
reattachment called?
[students] - (mumbling - sounds like theyre saying long juctional ...)

[Slide #8] Initial Therapy
[Dr. Tang] - Great! You guys have been studying! So initial therapy consists of
home care, which has the supragingival and subgingival effects. Now home care,
what is our limitation in terms of home care? Supragingivally, what can the
patient do? Brush, rinse. And how effect are they with subgingival?
Subgingivally? 1 mm. So were not very effective subgingivally. So as, as dentists
were going to be doing all the hard work, but our work is not successful unless
your patient takes care of it at home. So when I see a patient who has this type
of disease, and theyre in my office, I explain to them this is teamwork. You cant
let me do all the hard work and for you to do nothing and home. And we evaluate
that at each visit when they come in for their different visits for their cleanings,
because cleanings are not usually done completely in one visit, especially the
SRP visits. So some of the treatments, um some of the treatments for initial
therapy consist of scaling and root planing, Dr. Lehane talked to you about
antibiotics which includes the locals, local delivery systems. Which is the one we
use in the clinic here, or is available in the clinic here? Arestin, correct. Systemic
antibiotics, usually used for what type of periodontal cases?
[student] - Chronic?
[Dr. Tang]- Chronic? Not really, we dont use antibiotics for chronic.
[student] - Systemic?
[Dr. Tang]- Systemic? What kind of systemic cases.
[Dr. Tang]- Im sorry? Mmmm getting warmer.
[student] - Aggressive?
[Dr. Tang]- Aggressive cases we use antibiotics. We use a combination therapy.
What else?
[student] - Necrotizing?
[Dr. Tang]- Necrotizing, yup. How about another case that Dr. Yip talked to you
about? That we see in the clinic a lot. Abscesses. Ok, so thats what you want to
keep in mind. Also, Dr. Lehane talked about systemic host modifiers. Whats
that? Low dose. Ok, so thats called Periostat. And patients are usually on a 3month regimen for that
[Slide #9] The Reality of Re-evaluation
[Dr. Tang] - So, basically the re-evaluation is meant as a reality check. So the
patient comes back after youve done oral hygiene, youve done the treatment,
and you allow some time for it to heal. And the patient needs to come back and
we wanna look at the response to treatment, the patients response, how
compliant the patient is, and what do we mean by the patients compliance?
[Dr. Tang] - Exactly, making sure theyre doing the at-home care. And we wanna
review our initial treatment plan diagnosis to see if we need to make any
modifications in our treatment or not.
[Slide #10] Goal of Re-evaluation: Prognosis
[Dr. Tang - So, the major goal of re-evaluation is to determine the prognosis of
the teeth. Because what I get consults in the clinic often for are x-rays, where
students bring up an x-ray and theyre like, well, is this tooth restorable? We
cant really answer that question until the patient is fully treated, because we
need to clean up all the debris and subgingival debris and make it into a healthy
environment before we can even talk about restoring the tooth. So one of the
major goals of re-evaluation is to determine the prognosis of the teeth. And by
determining the prognosis of the teeth, that will dictate your treatment plan.
Whether youre going to do a fixed partial denture, a removable partial denture,
or even a denture. Because we wanna know if those teeth are gonna be strong
enough to withstand the forces, the chewing forces, or of a.. abutment, a denture
for an RPD or fixed partial denture. So these are different categories we have in
the clinic, depending on who you talk to, the category questionable could also
be substituted for poor.
[Slide #11] Periodontal Reevaluation
[Dr. Tang] - So, interestingly enough, last week I found this flow chart and I
figured this would probably make your life easier in terms of consolidating a lot of
the information weve given you. And this way it gives you a flow chart of what to
think about and what to consider when we do a reevaluation. So lets focus on
the initial evaluation, when your patient is in the chair, and what we need to look
for. So were gonna focus on the reexamination, reviewing and update any
medical history, record any clinical parameters, assess any of the inflammation,
and examine for any residual calculus.
[Slide #12] Office Visit
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[Dr. Tang] - So, heres the patient, the patient is in your chair. So this is what
were gonna start with, the re-examination.
[Slide #13] Was there sufficient time...
[Dr. Tang] - So, how long do we wait? Thats often the question. So this article
tells us, in 2002, that we should not bring the patient back earlier than 4 weeks.
[Slide #14] Re-examination
[Dr. Tang] - So, in the clinic we usually recommend 4-8 weeks. Why? What are
we waiting for? Healing, what kind of healing? Long junctional epithelium.
Correct.
[Slide #15] Why We Wait
[Dr. Tang] - That happens in about 1-2 weeks. So its still too early, so we usually
wait, um beyond 4 weeks, as recommended, so theres a reduction in the
inflammatory cells. The area continues to heal over the next couple weeks or
months. And this is the attachment that were talking about here (circles the long
junctional epithelium area on the picture). Any questions so far? Ok.
[Slide #16] Why We Wait
[Dr. Tang] - So this is the repair that we see, and thats called the long junctional
epithelium, as you guys mentioned earlier. So initially, in the first picture A, you
see the inflammatory cells and you see the long rete pegs, and you see that
angular defect here. B, this is after, immediately after scaling and root planing,
and as you slowly heal you see the tissue heal towards the tooth, the black line
being the tooth. And eventually we hope that the bone heals and you get the
reattachment, where you see D.
[Slide #17] Review & Update
[Dr. Tang] - Ok so, next step we have to review and update the medical history,
dental history, social history, and the risk assessment.
[Slide #18] Risk Assessment
[Dr. Tang] - Ok, so why is risk assessment important? Have you guys heard of
this term before? Earlier in the lecture? Dr. Yip talked about this? Dr.
Engebretson? So we have to assess the risk in the beginning and at the
reevaluation stage, because in the beginning what we need to look at the risk
factors for is to determine the diagnosis, and factor it in to our treatment plan. Not
every treatment plan is cookie cutter. Not every treatment plan do you need to do
scaling and root planing. Some treatment plans you need to modify the patients
risk factors. Its also important in this portion of our treatment in terms of
prognosis
[Slide #19] Risk Factors
[Dr. Tang] - This is also a document, this is from a document from your
competency which youll have next year, is.. youll see the highlighted items on
the right side of your screen, and those are the major risk factors for periodontal
disease. The previous attachment loss, smoking, uncontrolled diabetes, plaque
and local factors. Some of the lesser risk factors are the ones listed on the left.
[Slide #20] Record Clinical Parameters
[Dr. Tang] - So you wanna keep these items in mind. So when we go into the
clinic and the patient is seated, we start recording the clinical parameters to see
how well the patient has done in terms of their home care and healing.
[Slide #21] Disclosing Agent
[Dr. Tang] - So first things first, we start off with disclosing agent. Have you guys
used, done the plaque score on each other? Ok, so how did you guys do? So
so?
[Slide #22] Plaque Score- OLeary
[Dr. Tang] - Alright, so did Dr. Yip go over the plaque score, OLeary plaque
score with you? So what you really need to know is, based on the total number of
teeth, so for example I used the number 30, so assuming 2 teeth are missing,
you have 30 teeth times 4, is the denominator. The top is the number of plaque
surfaces. Now, OLeary, they either have 4 or 6 surfaces, for simplicitys sake
were just gonna count 4 surfaces. The mesial, distal, buccal, and lingual. And
you multiply that by 100 and that should be your plaque score.
[Slide #23] Plaque Score- OLeary
[Dr. Tang] - So this is an example I have for you, easy, 20 over 80 times 100 is
25%. So this patient has a pretty good plaque score, because only 25% of their
surfaces are covered with plaque.
[Slide #24] Value of the Plaque Score
[student] - (unintelligible)
[Dr. Tang] - Thats ideal, but Ive never seen it in the history of my practice. Even
if I took a survey of you guys, Im pretty sure we wouldnt find 10%.
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[Dr. Tang] - Even 20% is even pushing it.
[student] - Is that after brushing?
[Dr. Tang] - Even after brushing, believe it or not.
[student] - When you do it in clinic, is it before or after?
[Dr. Tang] - Before. Because this way you can assess how well the patient has
been taking care of their teeth on a regular basis. Ok? So as the number
increases to 100%, you have a higher tendency towards inflammation or disease.
So in terms of making this into a valuable piece of information for you, they did
something called a modified plaque score, where, when you report this to a
patient for example, going back to this case where its 25% (flips back to slide
#23), patients often want to do better. Like you guys do, you guys dont want to
have a score of 25%. So someone came up with the concept, a psychologist
came up with the concept, with a dentist, where if you take this number, subtract
it by 100, you get a score of 75%. Who wants to be 75%? Who wants to be C?
No one wants to be a C. So this way you help motivate the patient towards an A
or towards 100% compliant. Ok, so thats something to keep in mind. But the
actual plaque score itself is the lower number here. You follow? Or am I losing
you guys. Ok. So just motivationally, we subtract it by 100, just to give the patient
a score and they know how theyre doing.
[Slide #25] Probing Depths
[Dr. Tang] - So when I have the patient in the chair, both at the initial visit and the
reevaluation, I remind them the numbers that they should be hearing. So as Im
calling out the numbers, the patients should understand whats going in their
mouth. Because if its a one-way street, then the patient is not taking care of their
teeth, youre doing all the hard work. So its really important for them to be
educated in whats going on in their mouth and the disease and the process. So I
usually often tell the patients, the numbers you do want to hear is 1,2, and 3,
which is on the left side of the screen. When you get into 4s and 5s you start
being concerned, because thats the transition stage. And anything beyond 5
needs treatment. So just so you know, my patients pay very close attention when
I start reading off these numbers to my assistant and as theyre recording it. So
now I have my patients coming back for recall, theyre very, theyre very attuned
to the numbers I called out. So they know how well theyre doing. So its no
surprise when I tell them, they need to have additional treatment, or they need to
have surgery, or such and such.
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[Slide #26] Periodontal Charting

[Dr. Tang] - So these are things Id like you to do in the clinic, when youre doing
your charting. You have to complete all the items listed here in that left box on
the charting. You need to.. I think Dr. Yip went over this with you.. you need to
include the bleeding, the suppuration, include the free gingival margin, the
mucogingival lines, record any mobility and furcation, and any spacing. So this
goes for BOTH the initial consultation, the initial visit AND during your
reevaluation. So if you do it on the same sheet, you can use the second line for
the second exam here. Ok?
[Slide #27] Periodontal Charting
[Dr. Tang] - So this is what it would look like in the clinic. Um, on your charting
sheet. My pointer is off. But you see the gingival margin at the neck of the teeth,
the mucogingival line is above. You see the charting and all the bleeding points
indicated there. On the molars you see those small triangles, those are indication
of furcation involvements. Ok, this is what we like to see in the clinic.
[Slide #28] Probing depth v. Clinical Attachment Loss
[Dr. Tang] - So, do we know the difference between probing depth and clinical
attachment loss? Ok, so is a 6 mm pocket equivalent to 6mm of attachment loss?
No. Not necessarily, right? So it really depends on what? Sort of recession?
What does it depend on? Location of the Gingival margin, correct.
[Slide #29] Probing depth v. Clinical Attachment Loss
[Dr. Tang] - So this is really important to understand. So starting from the left,
moving toward the right, the probing depth on that first picture, the probing depth
is 6mm, however, the gingival is 6 mm above the CEJ. So thats why you have 0
attachment loss. I cant stress this enough, because sometimes in clinic some of
the general faculty get confused. So, my job is to train you, and you guys can
convey the message to some of the practitioners. The second picture we have,
you have a probing depth of 6mm, however the gingiva is 3mm above the CEJ.
Thats why you only have 3mm of attachment loss. Got it? Ok, so moving on, the
gingival margin is now at the CEJ and youre probing 6mm, and thats why you
have 6mm of attachment loss. In the last picture you have 3 mm of recession and
6mm probing depth, so thats 9 mm of attachment loss.
[Slide #30] Gingival Inflammation with Various Probing Depths
[Dr. Tang] - So clinically this is what this would look like. You see a 2mm healthy
sulcus on the far left, and thats what you would see clinically. Whereas where
you see gingivitis in the middle picture, you may be probing 3-4mm but theres
still no attachment loss, because most of that is inflammation. Ok? And the last
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picture, you have, be probing 5-6mm, however thats supragingival. And that
could be due to hormonal changes, birth control pills, or it could be due to
medication, like Dilantin or Procardia. Ok? So thats important to know. Because
often times in the clinic, if youre doing probing depths and they see 5-6mm
probing depths on your charting, however, the gingival margin is not recorded in
the correct position, you may treatment plan for scaling and root planing for a
patient who has no attachment loss. What would that do to attachment if you do
scaling root planing when its not needed? What would happen to attachment?
You would damage it. Youre gonna rip the attachment. The original attachment
of the epithelium, the junctional epithelium, is much stronger than the long
junctional epithelium. So it is important to diagnose correctly so we can treat
correctly. Ok?
[Slide #31] Mucogingival Defect
[Dr. Tang] - So mucogingival defect, have you guys talked about this? Do you
guys know what this is? Can someone tell me what it is? (silence) Ok so it seems
like were not really sure.
[Slide #32] Millers Class I

[Dr. Tang] - So lets talk about this a little bit. Did we talk about Millers Class I?
You guys are familiar with this? Ok, so Millers Class I is something like this.
Where you have recession, whether its narrow or wide, it is above the
mucogingival junction, and there is no interproximal bone loss.
[Slide #33] Millers Class II
[Dr. Tang] - Millers Class II is beyond the CEJ, and it can be narrow or wide. And
this is what it looks like clinically. So you see here that.. you see the keratinized
tissue here, and then theres no keratinized tissue here, you just have a tiny
collar of tissue here. And this is the mucosa right in here. Do you see that? Ok,
great.
[Slide #34] Millers Class III
[Dr. Tang] - This is Millers Class III. Its usually beyond the mucogingival junction
and you have a slight amount of bone loss, interproximally, and maybe facially or
buccally.
[Slide #35] Millers Class IV
[Dr. Tang] - And Millers IV is generalized bone loss, whether its wide like this
(pointing to bottom) or just localized like this (pointing to top). Ok so this comes
into play when we go in to reevaluation and we need to determine what treatment
needs to be done for these teeth, if it is needed at all. Ok?
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[Slide #36] Local Factors

[Dr. Tang] - So now we turn to local factors. After weve done all the charting,
now we have to look out for all the different local factors. What could be holding
up all this plaque and debris and calculus that you may have missed on your
initial therapy? We wanna look for residual plaque and calculus, maybe the
pocket was too deep and you werent allowed to instrument all the way to the
base of the pocket. Or that the teeth were malpositioned. What that means is that
the teeth are crowded and theyre on top of each other. So often times on the
lower anteriors theyre overlapping each other, so it makes it very difficult for the
patient to clean. Or if the restorations are defective. So, for example, (pointing to
top radiograph) this is a case, in this case there was a very deep pocket on the
distal of tooth #18 here... you see this vertical defect here? And despite all
efforts, this was probing probably 8mm, theres still a piece of calculus right here.
Can you guys see that? Ok. So thats one area that we need to identify. Other
areas we need to look at is how about here? (pointing to the bottom picture, right
side) you see we have a bulky margin on this side, theres a discrepancy
between this red line and this red line, and theres a space underneath this crown
on the mesial.
[Slide #37] Local Factors
[Dr. Tang] - Other local factors you wanna look for, is they could be anatomical
factors, or soft tissue factors. So what about this? (pointing to left picture) This
patient came in, probably came into the school, probably 4 years ago. Patient
had a lip ring. This lip ring was rubbing right against this canine tooth. And
usually on the anterior teeth theres a large amount of keratinized tissue... all that
was rubbed away. Sometimes local factors contributing could be occlusion, you
need to consider. Or in this particular case (points to bottom right) this was
actually a tongue ring. This picture is a little on the dark side, Im sorry. Its a little
bright in this room. But there are about 4 mm of recession right in this area, and
thats from the patient using a tongue ring.
[student]- so based on Millers classification, how can we decide which
classification... class IV?
[Dr. Tang] - For which, this one? (pointing to left picture) This one would not be a
class IV because theres no adjacent bone loss. What would this be? How many
people say 1, raise your hand? Wheres the mucogingival line? Its kind of hard to
see here. It looks like its right about here. Its right here and right here. It looks
like theres a little bit of keratinized tissue in here.
[student]- (unintelligible)
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[Dr. Tang] - I would probably guess around II because theres not a lot of
keratinized tissue here. I dont have a probing picture of there but it probably
goes into the mucosa, if I had to probe. It would not be a 3 because theres no
interproximal bone loss. You see how the papilla comes in between the teeth,
pretty high up. Ok? And well talk about the restorability and what treatment we
can do later in the lecture.
[Slide #38] Plaque Retentive Factors
[Dr. Tang] - So we talked about plaque retentive factors.
[student] - Can you back to Millers classes, and then describe the difference
between the top and bottom pictures?
[Dr. Tang] - Sure. (flips back to slide #32) Yes, one is narrow and the other is
wide. This ones beyond the mucogingival junction, so the dotted line
represents... the dotted areas, the shaded areas on the bottom represent the
mucosa. And this is what it would look like. Does that make sense?
[Dr. Tang] - [flips to slide #34- Millers class III] (student - unintelligible) Yes, this
is a mild amount of bone loss.
[Dr. Tang] - (in response to student question) It could be extruded, doesnt have
to be extruded. And this is IV (flips to IV)
[Slide #39] Assess
[Dr. Tang] - So now that weve taken the measurements, taken the plaque score,
now we have to look at the tissue inflammation. So thats gonna determine what
we do next. So thats really important to look at. So we wanna look at the color,
the contour and consistency. And that, I would refer back to Dr. Yips lecture,
when she talks about erythema, rolled margin, bulbous papilla, remember those
terms? So these are the things were looking at when were looking at the gingiva
at this point.
[Slide #40] What are you looking at when re-evaluating...
[Dr. Tang] - So we want to look at erythema, and redness. We want to look at
edema, any swelling in the area. Bleeding on probing, thats self explanatory, and
any suppuration. So you see in this picture, the person with the glove. What
theyre doing is, theyre running their finger from apically/coronally, and that
would tell you if the area has any suppuration. Ok that would be the technique to
detect any suppuration in that area.
[Slide #41] What are you looking at when re-evaluating...
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[Dr. Tang] - So these are the things were looking for when were doing a
reevaluation. Were looking for any pockets that are greater than 5mm, displaying
continued inflammation, which is redness or swelling in the area. Any class II or
III furcations. And what do we use to detect a furcation? (students- Nabers
probe) Great. Any mucogingival defects, which we talked about, any planned
restorative therapy, because were gonna need to determine the prognosis to see
if theyre good abutments, and any systemic factors. Like, if their diabetes is
improving. Their uncontrolled diabetes. So if they have a HBA1-C of 9.5, what
would that mean? Controlled or uncontrolled? Uncontrolled. Whats the normal
HBA1-C range? About 6. Ok, so thats a number you wanna hear. Ok? Other
systemic factors could be influenced by smoking, or they are... did Dr.
Engebretson talk about any other systemic diseases, like arthritis, and...? No.
Ok, so we wont go into that today.
[Slide #42] Examine
[Dr. Tang] - So now were looking at the patient, and we wanna see if theres any
residual calculus in the area, after weve done our scaling and root planing. So
the study by Robertson showed us that a closed SRP, which is the SRP we do in
our initial therapy, 40% of the calculus is usually left behind. SRP open is when
we do the surgery, open up a flap, and theres a chance of us leaving 20%
behind, because theres a lot of nooks and crannies around these teeth.
[Slide #43] Can we remove all...
[Dr. Tang] - So, the question is can we remove all the calculus? So this study
showed the SRP is efficient in what parameters. So the parameters of 1-3mm,
those are probing depth numbers. Ok, so were efficient at 1-3, were okay at 4-6,
but greater than 6mm were really not efficient. So in order to improve that, we
really need to open a flap, and even when we open a flap, with pockets that deep
its very difficult to remove 100% of the plaque and calculus. Ok?
[Slide #44] Scaling and Root Planing: Expected Impact
[Dr. Tang] - So, when were scaling and root planing, were trying to reduce the
amount of clinical inflammation. Were trying to shift the microflora, decrease
probing depth, gain attachment, and decrease the level of disease. So thats our
goal. However, when you have gingival enlargement, especially the medication
induced, you dont see as a dramatic improvement as you would with a patient
who doesnt have the gingival enlargement from the calcium channel blockers, or
birth control pills, and such.
[Slide #45] Limitations of SRP
[Dr. Tang] - So these are some of our limitations to SRP. Not only the probing
depths, but the anatomy of the roots, the depths of the pocket, maybe the teeth
position. Mesial concavities of the premolars, maxillary molars.. (she corrects
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herself) uh maxillary premolars are very difficult to access. Maybe the patient has
a very limited opening, they cant open very wide, they have a third molar that
you need to instrument.
[Slide #46] Literature
[Dr. Tang] - So, in one of the studies back in 79, I know its super old, it just goes
to show us, they measure the area, the furcation entry of the first molar, in about
50% of the furcations, like the widths, the space between the furcation roots, its
usually less than 7.5. But the average width of the curette is between 0.75 to
1mm. So how effectively are we cleaning or instrumenting those furcation areas?
Its very limited. Okay, so were very limited into what we can do blindly with the
instruments.
[Slide #47] Reconfirm Periodontal Diagnosis
[Dr. Tang] - So our next step is to reconfirm our periodontal diagnosis. See how
were doing.
[Slide #48] What does clinical success look like?
[Dr. Tang] - So this is what clinical success, so to say, should look like. You
wanna see a significant reduction in inflammation, reductions in the probing
depths, ideally, stabilization or gain in attachment level, and reduce amount of
plaque in the area, toward gingival health.
[Slide #49] [No Title]
[Dr. Tang] - So we have a picture on the bottom, but this ones a little more
dramatic. You see how the contours and the colors of the tissue, this is from your
Carranza textbook. You see the redness, the redness has disappeared. What
else do you notice between the right and left picture? Less edema. What else?
What about the color? Its more coral pink. Does that ring a bell? What else? No
bleeding, what else? (student- unintelligible) Mmmm.. you see some healing, but
you dont see a gain in attachment loss, necessarily, in the picture. How about
the length of the teeth? What do you notice? Longer, on the right side, right?
(student- unintelligible) Yes, less, less what? Less inflammation and less
calculus. You can imagine, a patients gonna come into your office looking like
the patient on the left. Okay, and patients gonna, as a result of scaling and root
planing, youre gonna see the patient on the right. Now, the patients gonna come
to you, Doc Ive never had all these spaces between my teeth. What did you do
to me? So its really important for you to predict what youre going to see.
Because the problem is, when you predict it, and you tell the patient, listen, its
not my fault, that youre gonna have more spacing between your teeth, because
the calculus was artificially holding your gum tissue up. And once you remove it,
and the tissue heals, like we saw in that progression picture, after SRP, the
tissue heals and it falls back a little, in order to form that attachment to the tooth.
13
So doesnt that make sense? So the patients not gonna be happy, because in
this right picture, theyre gonna notice more foods gonna get stuck between their
teeth. But youre trading one thing for another. So the patients gonna need to be
a little bit more diligent about cleaning their teeth, and flossing their teeth. So its
important to tell the patient before you get started with the SRP.
[Slide #50] Ginigivitis
[Dr. Tang] - So gingivitis, so after all this, we determine the patient has gingivitis.
We didnt need to do SRP, everything is healthy. Or we did SRP and the area is
stabilized now. What we determine is if the patient has good oral hygiene. So in
the gingivitis case, if the patient has good oral hygiene, yes, and the inflammation
has resolved, the patient goes on a 4 to 6 month recall. If the patients oral
hygiene is, lets say 50%, then you may need to, you may need to go back down
and perform additional SRP, and reevaluate in 4 to 6 weeks. 4 to 8 weeks, Im
sorry.
[Slide #51] Mild Periodontitis
[Dr. Tang] - So in a mild gingivitis (she corrects herself) .. mild periodontitis case,
similarly, if you see that the inflammation has improved, and the oral hygiene is
good, you would determine if the inflammation has resolved, and we would do
that by bleeding on probing, and checking for the gingival contours. If it hasnt
improved, you wanna assess any of the crown lengthening or mucogingival
defects. If theres any surgical concerns, you can either refer to a periodontist, or
if theres no surgical concerns, you can just keep them on recall. So if the
inflammation has not resolved, has not been resolved, you would need to go
through oral hygiene again and work on those areas before you go back and
treat this patient. Does that make sense? Sort of, yes. Youll just need to look at
this and if you have any questions you can always email me.
[Slide #52] Treatment of Periodontitis
[Dr. Tang] - So this is an area, therapeutically the perio treatment falls into two
categories. The anti-infective, and the regenerative. So, infection control usually
comes in the first phase, which is called initial therapy, or phase I therapy, you
may have heard in several different lectures. Regeneration usually happens in
phase II, or surgical therapy section, and thats after re-evaluation, and this is
where we determine whether the patient needs to move onto surgery or not.
[Slide #53] Local Delivery Pharmacotherapeutics
[Dr. Tang] - This is also a time where we consider whether were gonna use local
delivery antibiotics or not, okay? And in Dr. Lehanes lecture, he talked about if
theres any residual defects, if theyre isolated in 1 or 2 sites, to use Arestin or
any of the local delivery systems. And the goal is to alter the microflora in that
area. Localized in that area.
14
[Slide #54] Moderate-Severe Periodontitis

[Dr. Tang] - So if were looking at a moderate to severe periodontitis, chronic
periodontitis, and were talking about greater than 5 mm probing depths or
attachment loss anywhere from 3 or greater. Were looking at the oral hygiene
again, so we either have to reinforce it, until the hygiene is adequate. So you
need to reinforce the oral hygiene, determine if the inflammation has resolved. If
it has resolved, you have to determine if theres any surgical needs. And then we
would put the patient on a 3 month recall. Do you know why we put the patient on
a 3 month recall? Do you recall from Dr. Craigs lecture? (student - unintelligible)
Correct. So when we do initial therapy, we are disrupting the flora. However, it is
not a permanent situation, because theres over 300 species of bacteria in your
mouth. So it really depends on the host-response, whether youre gonna be
susceptible to the breakdown or not. So in a 3 month interval, the studies have
found that if we disrupt the repopulation, its adequate to try to control the
periodontal disease progression.
[Slide #55] Phase II...
[Dr. Tang] - So things we need to think about when we think about the next
phase of treatment, for phase II or the surgical phase. We wanna think about
their compliance. Are they good, do they have good home care? Or
professionally, do they come in for their recalls, are they compliant? Are they
coming in every 3 months or every 6months, despite what you recommended of
the every 3 month recall. You wanna find out if theres any systemic health
issues that have changed in the past 3 or 4 months. So thats a first question you
should ask your patient, has there ben any change in your medical history. Any
other additional risk factors, maybe they just went to the doctor and they found
out they have diabetes. Or they have borderline diabetes. So you may need to
keep an eye on them a little bit more closely. So this really affects the additional
treatment plan, treatment plan consideration for the restorative, or any other
needs the patient may have, whether its orthodontics or a complex prosthetic
work.
[Slide #56] Other Factors to Consider at Re-Eval: Smoking & the
Periodontium
[Dr. Tang] - So smoking we need to reconsider at reevaluation, we need to factor
in if the patient is ready to stop smoking or not, because these are some of the
effects that may affect your success. Because of the vasoconstriction, youre
really not gonna see the traditional signs of inflammation. Because of the
vasoconstriction. And its also gonna affect your microbial repopulation or
microbial environment in the gingival sulcus because the decreased oxygen
15
tension. Okay, so theres not enough oxygen going to the gingival sulcus, so
youre gonna have an upswing, and upregulation of those red complex bacteria.
[Slide #57] Other Factors to Consider at Re-Eval: Is there undiagnosed
systemic disease?
[Dr. Tang] - And diagnosis of systemic if disease, if theres a suspected
underlying disease like borderline diabetes I mentioned, you really need to send
the patient for a consult. You also need to think about if the patient has any
physical disabilities, what if they have Parkinsons, and they cant hold a
toothbrush correctly? You need to alter your oral hygiene recommendations,
maybe to possibly use a larger toothbrush to help the patient keep their teeth
clean.
[Slide #58] Risk factor: Increased pocket depth
[Dr. Tang] - Increased pocket depth. So, following initial therapy, there may be a
tendency for deeper sites to break down more readily. Because you may not be
reaching the deeper sites, as we talked about and I showed you in some of the
articles earlier.
[Slide #59] Motivation...
[Dr. Tang] - So we need to motivate our patients to be more compliant. So this
article talks about the patients and how compliant they are. With motivation for
oral hygiene and motivation for recall, you can turn a patient from a 16%
compliant, whos never compliant, to a 32%. So motivation does help. So our
goal is to motivate our patients to do a better job. Because a lot of these
infections that the patient has in their mouth, if it was on their hand they would be
in to see the dentist much sooner. The fact that its in their mouth, out of site and
out of mind, they dont come in until it hurts. And unfortunately, periodontal
disease doesnt hurt until the later stages.
[Slide #60] Maintenance Therapy
[Dr. Tang] - So this is a flow chart that I found for maintenance therapy, similarly
it goes thru steps of which you should be looking for, its very similar to the flow
chart that we went over. Ill leave this for you to go over. It basically goes over,
really emphasizes oral hygiene and evaluating patients for their plaque control
and what needs to be done and do they need to be considered for surgical
therapy, be considered for just routine maintenance, or discuss surgical options.
[Slide #61] Part I: Exam
[Dr. Tang] - So, an article written by Shellhorn (sp?) he actually talked about
whats involved in terms of doing a maintenance recall. So this is a breakdown.
He timed it down to 40 minutes to greet the patient and examine the patient,
similarly to what we discussed for the reevaluation.
16
[Slide #62] Part II: Treatment

[Dr. Tang] - Treatment time is 36 minutes, including oral hygiene.
[Slide #63] Part III
[Dr. Tang] - And writing your notes and going over treatment options with your
patient. So this is just something to keep in mind. Youre not gonna be tested on
the last 3 slides. Its just information for you, so you can see how everything is
outlined and this is what you should keep in mind especially when you go into
clinic in a few months.
[Slide #64] Re-evaluation...
[Dr. Tang] - This comes from your competency. During reevaluation these are the
things you should be looking for. This is reinforced. You wanna make sure most
of the calculus is removed, use sharp instruments, because if its not effective
then youre not really doing a good job and youre burnishing the calculus against
the root surfaces.
[Slide #65] Would you recommend...
[Dr. Tang] - So would you recommend periodontal surgical therapy for this
patient? Do you expect this patient to need surgical therapy? Yes. Okay so...
[Slide #66] Why surgery?
[Dr. Tang] - The goals of surgical therapy are to preserve health, function, and
aesthetics. So we wanna increase the longevity of these teeth by removing any
of the surface debridement, pocket reduction, and reduce and recontour any hard
tissue or soft tissue defects.
[Slide #67] What about gingival recession...
[Dr. Tang] - So we talked about gingival recession earlier. So these are the things
we need to consider about whether we need to treat this gingival recession or
not. What the etiology is. For example, in this picture (pointing to far left), the
etiology is a frenum. A frenum pull. The attachment is a little high. So even if we
try to correct this surgically, this is always gonna be a problem. So unless this is
fixed, this will not resolve. Ok? In this particular case (pointing to second picture
from left) you see how thin the buccal plate is, and this is a CT scan. So a lot of
the bone on the facial of the lower anterior teeth tends to be very very thin.
[Slide #68] If we treat...
[Dr. Tang] - So, I think this goes into the question that someone alluded to earlier
in terms of treatment. So class I and class II are usually very predictable in terms
of how successful your treatment is. And thats determined by the level of bone
on these adjacent teeth. In terms of class III, it is not very predictable. So if
17
theres a restoration that you need to place here, you can go ahead and place
this restoration, because in terms of growing back bone or covering this
recession youll probably achieve about 50%, whereas in class IV you can put all
the class V restorations you like because theres no way I will be able to cover
this recession for you. Does that make sense? Ok.
[Slide #69] Do we need to treat...
[Dr. Tang] - So when you consider whether you need to treat gingival recession
or not... do you guys want a break now? Ok. Well take a break, I think I only
have like 4 more slides here and then well continue.
[BREAK]
[Slide #68] If we treat...
[Dr. Tang] - So when I talk about class I and II, were not talking about repairing it
with bone, Im talking about repairing it with soft tissue. Okay, because lets talk
about the soft tissue first. In these two pictures, the bone is very high. So the
bone basically sets the tone of the tissue. So if the bone is here, Im gonna get
100% coverage. However, where the bone is, its about 1-2 mm apical to where
that tissue is. So Im only gonna be able to cover as much adjacent bone is
available. Whereas here, the bone level is flat. I cant add anything here. So if the
patient is complaining about sensitivity in this area, you can go ahead and put a
restoration there to try to help with the sensitivity. Bone graft? Thats a great
question. Thats actually gonna be in your advanced perio class but I can cover it
briefly. When you guys talk about infrabony defects, or vertical defects, I was just
talking to one of your classmates about it. So growing up in New York, or if you
guys didnt grow up in New York maybe you grew up somewhere cold, when you
have, have you guys seen potholes? Ok so potholes, when theyre shallow, the
city usually tries to repair it, but within a week or two, when its cold, what
happens to that pothole? It cracks again. What happens is, its not deep enough,
theres not enough retention for this material. So we have something like an
extraction socket, when its long and narrow and you have enough to hold the
bone, its more predictable. So if you have a vertical defect, the more walls you
have to hold the bone graft in there, the more likely it is to repair. So for example,
in a situation where you have this class IV, So imagine if you opened up this
bone, you would see a very flat bone. I cant add anything on that. Because if i
were to add anything on that and try to close it up, its just gonna all wash away.
Does that answer your question? Great.
[Slide #69] Do we need to treat...
[Dr. Tang] - So I think this is the slide we were up to, yes? Okay, so gingival
recession, do we really need to treat it? It depends. Was there a history of
progression? Has it gotten worse over the past couple years? Is the risk factor
18
still present? What risk factor could it be? It could be that tongue piercing or that
lip piercing we saw earlier. Or maybe the frenum attachment. So these things
need to be corrected, you need to have them take out their piercing or you know
have the frenectomy done before we can even talk about repairing this area. Is
there any restorations treatment planned in this area? Okay, you wanna know if
theres any restorations because you wanna make the tissue healthier, especially
around in implant, because if theres no keratinized tissue around an implant,
then theres really nothing to prevent the bacteria from going straight down into
the sulcus and eating away at the bone around the bacteria (I think she meant to
say implant). Is root sensitivity a chronic problem? If the patient is not sensitive,
you really dont need to treat it. Or if the patients not concerned about aesthetics,
you really dont need to treat it. Its not a necessary thing. But if its bothering the
patient, its progressing, its bleeding, you wanna consider treating this area.
[Slide #70] Implants and Periodontal Disease

[Dr. Tang] - Implants and periodontal disease. So this is a common question we
have. So you know, in the studies that weve looked at, bacteria colonize in the
area within 30 minutes of placing the implant. Because theres so much bacteria,
over 300 bacteria, species of bacteria in the mouth. But usually within two weeks,
it resolves itself. Provided the patient is healthy, and the patient is not an
uncontrolled diabetic, and is not a major smoker, so everything boils back down
to host response and risk factors. Okay? Also you wanna try to control any
periodontal disease before we even talk about placing implants. Because if
youre placing an implant into a dirty environment, the chances of this implant
integrating and succeeding is very low. Okay?
[Slide #71] Would this patient
[Dr. Tang] - So, before you consider if the patient would benefit from periodontal
surgery, you wanna look at their dental history. You wanna see if the patient is
compliant with their maintenance. If the patient is not really good with their
plaque control, or theyre not very good with coming in for recall, theres really no
point. Because if I do surgery on this patient and the patient is not gonna take
care of it, Im actually doing the patient a disservice. Because the tissue and the
amount of attachment is gonna be lower, however its gonna be more stable. But
if the patients not keeping it up, its going to lead to more breakdown, and faster.
Okay, so it has to be the right patient for the surgery. So plaque control is poor
and theres plenty of BOP, you need to stabilize the initial environment. So for
example, medically, if the patient wanted a facelift, but they have a heart
condition, they would always stabilize a heart condition first, correct? So this is
what were looking at. My job is to stabilize the patient before anything beautiful
is built on top of these teeth. Okay? Is the periodontium inflamed or healthy? Are
19
old radiographs available? So thats really important. We recently had a case in

the clinic where they were able to digitally send x-rays from Japan for a patient
who had the very unusual situation where they had the teeth reimplanted, and
there was a periapical lesion. And it turns out, thats what the patient looked like,
four years ago, when it was done. So theres really no need for us to do a root
canal treatment for this patient. It was just a scar that was left behind after the
treatment. So thats really good to know. Or if a past perio charting is available.
We wanna know if its progressed or stayed the same over the past 3-5 years.
Okay?
[Slide #72] What happens if we dont do surgery?
[Dr. Tang] - So, what happens if we dont do surgery? So the studies tell us that
the amount of attachment loss will continue to progress over 5 years. So this
study was specifically 5 years but it will continue to increase. So that was the end
of the first lecture. Alright, lets shift gears to the clinical presentation.
DOD - Lecture 71 Periodontal Clinical Case Presentation - Dr. Tang
[Slide #2] Case 1
[Dr. Tang] - Okay, so this is our first case. Actually, Im gonna go back for a
second, Im sorry. Are you guys not curious about the answers to those
questions? No ones asking me! Whats going on here? There was a method to
my madness but you guys didnt fall for it, Im very sad. (students talking) You
missed your window, Im sorry.
[goes back to previous lecture slides ]
[Dr. Tang] Yeah, I closed the presentation too early cuz you guys didnt ask me. How could
you guys take a test and not want to know the answers? (students responding)
But you didnt ask! But that lecture was over. Okay, so this is what I want you
guys to think about. How is this exam different from that exam. Yes, this one
doesnt have multiple choice. So how are they different? You still wanna know
the answer, right? But you still want the answer, you want the prognosis. So you
bring the patient in, you give them the diagnosis, you treat them, dont they
wanna know what happens? Yeah, ok, so I want you, when you guys get into
clinic, present it that way to patients. I want you to tell the patients, the numbers
you wanna hear are 1s, 2s, and 3s. 4 is danger, and 5 and aboves gonna need
treatment. So when the patient comes back to you, theyre gonna want to hear
those numbers. Because Im tired of you guys telling me my patient wont come
back. Im like, how can you not come back? How can you not want to know how
you did? You come in, you have 80% plaque, with a score of 20%, you know,
you got a 20 on your exam. Youre really gonna accept that? Theyre gonna want
20
to come in. So I want you to the hardest part of periodontal treatment is

educating the patient. I want you to tell them you dont wanna hear these
numbers, 5-8, or 12. I do have patients with 12. So you wanna go thru these
numbers because you want the patient to ask, Oh my God, Doc, those molars,
theyre 6s, they havent improved. You wanna hear that. You wanna know that
theyre invested in their treatment. Does that make sense? Okay, because you
need to change your patients mindset. Its not a one-way street. It has to be a 2way street, because its very difficult to have a relationship that way. So you
wanna tell them what their plaque score is. Mrs. Jones, your score today is 25%.
I would really like to see you at 80%, so you need to work on your home care.
So, I want you to work on brushing and flossing, heres a mirror. Im gonna show
you how to floss the right way. Im gonna show you how to brush the right way.
Maybe you need to use interproximal brushes. Maybe you need to use an
electric toothbrush. So these are things that you guys need to do, you need to
teach your patient the right way to clean their teeth.
[Slide #3] Q1
[Dr. Tang] - So, this is question 1. Was this the answer you guys had? Yes?
Okay. This is not on the test.
[Slide #4] Q2
[Dr. Tang] - How about this one? Did you guys get this right? Do you know why
this answer is the answer? (students- salivary glands) Yes, just checking.
[Slide #5] Q3
[Dr. Tang] - How about this? Dr. Lehane drilled this one into you guys. You guys
should know this very well. Okay, so. Now were finished with this lecture.
(student question- could you put all of the above?) Okay, the answer is no,
because it asks about treating periodontitis. In gingivitis yes, but not periodontitis.
Got it? This is why its none of the above choices. None of the choices. Okay,
now we can go back to this lecture. Feel better now? Okay.
[returns to current lecture slides]
[Slide #3] Medical History
[Dr. Tang] - Alright, we have a patient, hes a 61 year old male, type II diabetic,
diagnosed about 12 years ago, hes on metformin. He has no known drug
allergies. His blood pressure, right arm sitting, thats what RAS stands for, is
162/97. His pulse is 66, his lab results, his fasting blood glucose is 189 and his
HbA1C is 8.7. So this is something similar you will find in a narrative on your
exam on Tuesday.
[Slide #4] Dental/Social History
21
[Dr. Tang] - Dental and social history, his last appointment was 2 years ago,
periodontal therapy about 3 years ago. Plaque score is 50%, and his social
history is 1 pack of cigarettes per day for 15 years.
[Slide #5] Clinical Presentation
[Dr. Tang] - So this is what he looks like. What is his presentation? What do you
see in this picture? (students answering) Calculus? Okay, what else do you see.
A lot of restorations. Recession. How about the gingival concours? Rolled
margins, what else? What about the papilla space? Blunted, yet. What else?
What about the color? What about the consistency? Hes a smoker, yup.
(answering student question) Its reddish youre not gonna see a lot of bleeding
on probing but its reddish
[Slide #6] [no title]
[Dr. Tang] - This is a closeup view. Great, huh? Lot of plaque there, buildup
there.
[Slide #7] Periodontal Exam
[Dr. Tang] - So this is the perio exam. We have probing depths ranging from 3-7.
Clinical attachment loss ranging from 1-6. Generalized bleeding on probing at
50% of the sites. Generalized mobility and furcation involvement.
[Slide #8] Radiographs
[Dr. Tang] - This is what his x-rays look like.
[Dr. Tang] - This is what his whole mouth looks like.
[Dr. Tang] - So, this is the medical history again. What catches your eye? What
bothers you about this case?
[students] - High blood pressure
[Dr. Tang] -High blood pressure, okay.
[students] - Uncontrolled diabetes
[Dr. Tang] - Yup. So whats your next step? Am I gonna start scaling and root
planing his teeth? (students mumbling) Medical consult, that would be really
important, okay?
[Slide #11] Uncontrolled diabetes
22
[Dr. Tang] - So uncontrolled diabetes is really, really important. Theres studies

been shown that theres a bi-directional relationship. Do you guys know what that
means? Dr. Engebretson spoke about this. And his studies show a little bit
different results than the established studies that came out more than 10 years
ago, about treating patients with uncontrolled diabetes, with initial therapy,
scaling and root planing. And what this does is decrease the microbial
environment and decrease the infection in the mouth, so the body doesnt have
to fight multiple infections at one time. So with patients with diabetes, they have a
decreased immune response. So this way it helps with their healing. So this way
by doing the initial therapy and decreasing the bacteria, the patient is healthier so
theyre only fighting one thing at a time, so theyre just working on the blood
sugar. Because what happens is, if the patients lets talk about their HbA1C.
Whats the HBA molecule? Hemoglobin. Whats the major function of
hemoglobin? Oxygen. So if the hemoglobin is glycosylated to the sugar, what is it
not doing? Its not carrying oxygen. So when this blood, when the blood goes to
the gingival sulcus, what happens to the microbial environment in the gingival
sulcus? It what? It becomes more anaerobic. So, we dont want it to be more
anaerobic. Right? Because what happens when its more anaerobic? More
breakdown, more periodontal destruction. So we dont want that.
[Slide #12] Dental/Social History
[Dr. Tang] - So what can we tell from the social history? The patient received
non-surgical periodontal treatment 3 years ago. So this patient has periodontitis.
The patient has had treatment before. His last appointment was 2 years ago. Is
that a good thing or a bad thing? Thats a bad thing, because for patients who
have periodontal disease, especially chronic periodontitis, they really need to be
placed on a tighter recall, like we talked about. 3 months is the ideal interval for
them. So the fact that the patient hasnt been to a dentist in 2 years, theres a lot
of bacteria in those gingival sulci
[student] - (asks a question about diabetes what do we really need to know
about that?)
[Dr. Tang]- okay, so its a risk factor, diabetes is a risk factor, in his recent study,
it shows that his specific study shows that its not a bidirectional relationship.
So, umwere going with the bidirectional relationship until (students laughing)
No, for now, all due respect, hes presented both views for you, its in his recent
studies and its in the process of being published, but the AAP position is that its
still a bidirectional relationship, so it hasnt changed their views yet. So this is a
new development. So, for all intensive purposes, it is a risk factor. Im not gonna
ask you if treating periodontal disease is going to decrease the blood sugar.
Would be a question that I could potentially ask about that, but Im not going to
specifically ask you that. To prevent any further confusion. Okay? But the current
23
understanding is, it is a bidirectional relationship. Does that answer your

question? Um the plaque score is 50%, and the patient smokes 1 pack of
cigarettes per day for 15 years. So has any of your classes discussed calculating
pack/year history? Yes, so, if you have, what is a pack/year history here? I hear a
lot of whispering 15 is correct.
[Slide #13] Disclosing Agent
[Dr. Tang] - So, disclosing agents, we talked about this earlier, in our last lecture
[Slide #14,15] Plaque Score
[Dr. Tang] - We want to calculate the amount of plaque score. This is how we
calculate it
[Slide #16] Smoking
[Dr. Tang] - Smoking, we mentioned in our previous lectures, suppresses the
immune response, constricts, its a vasoconstrictor, suppresses osteoblasts, and
decreases the oxygen tension.
[Slide #17] Smoking History
[Dr. Tang] - So, if a patient has quit smoking, you also need to update that in your
medical history, because even though the patient, if the patient has quit, in some
studies they show that if the patient has smoked greater than 10 pack years, it
changes their chemistry in their body where it may not necessarily mean that if
they quit 2 years versus 10 years, if their immune response will be back to
normal. So its important to know, even if they quit, to know that it may be
possibly, consider that a possible risk factor still, even though the patient has
quit. So keep that in mind.
[Slide #18] Which of the following
[Dr. Tang] - So based on that, which of the following risk factors is least
associated with the patients periodontal condition? How many people say A?
How many people say B? How many people say C? How many people say D?
Alright. You guys are right.
[Slide #19] Diagnosis of Periodontal Diseases
[Dr. Tang] - Okay, so looking at the diagnosis of periodontal disease, which Dr.
Loomer already went over with you, Im just reviewing quickly with you, you want
to look at both the patients age, medical history, if you can detect inflammation,
clinical attachment loss, rate of progression, all that fun stuff.
[Slide #20] Diagnosis
[Dr. Tang] - So, in terms of diagnosis, you wanna determine first if its gingivitis or
periodontitis, if its chronic or aggressive. If its generalized or localized.
24
[Slide #21] Gingivitis or Periodontitis

[Dr. Tang] - So, whats the difference between gingivitis and periodontitis? How
many people say bone loss? How many people say attachment loss? Very good.
[Slide #22] Chronic or Aggressive
[Dr. Tang] - Alright, chronic versus aggressive. It depends on the onset. Chronic
is usually more long-standing. Whats the major difference between chronic and
aggressive? (students answering) No, thats not the main difference. Age is
important, yes, what else? Pain? No. Dentition is very important, its usually the
first molars and incisors. Lack of plaque. Lack of plaque is really important. And
also the teeth commonly affected is very important, too. Why does it affect the
incisor and the first molars? (students mumbling) What about eruption? Those
are the first ones that come in. So theyve been in the mouth the longest. And if
you have, theres usually a genetic component, theres usually a family history.
So if you see a patient with aggressive, its really important to ask if their parents
have all their teeth in their mouth, or if their siblings have multiple missing teeth.
Because its usually very likely.
[Slide #23] Generalized or Localized
[Dr. Tang] - Okay, so were down to generalized versus localized. So we
discussed generalized is usually greater than 30% of the sites, and localized is
less than 30%. So, to make your life easy, what I like to do is take the total
number of teeth, divide it by 3, and thats your critical number. So if you have
more than, for example if your patient has 30 teeth in their mouth, okay, and you
take a third of that, thats 10 teeth. So if you have more than 10 teeth involved, I
would say generalized. The quick and dirty way. Okay, so this way you dont
have to do a whole lot of math.
[Slide #24] Severity
[Dr. Tang] - And again its based on attachment loss and not probing depth. I
understand there was a little bit of confusion on Dr. Davidsons lecture. So
make sure these are the parameters youre looking at for the exam.
[Slide #25] Chronic or Aggressive
[Dr. Tang] - Clinical attachment loss, we already discussed. Im not gonna go
over that again.
[Slide #26] Case 1
[Dr. Tang] - I shouldve modified this slide, because theres more severe sites, I
would call this more accurately, generalized severe chronic periodontitis. Im not
a big fan of the range. This was from a previous lecture, unfortunately, Im sorry I
25
didnt take this out, because this severe encompasses the 3-4 mm of attachment.
So I would more appropriately call this generalized severe chronic periodontitis.
[student] - what if you have 10 teeth that are affected but 7 or 6 of them are like
localized within one quadrant. Would that be generalized?
[Dr. Tang] - That would still be generalized. Yup.
[Slide #27] What is the MOST appropriate diagnosis
[Dr. Tang] - So again sorry, this should read generalized, severe
[Slide #28] Risk Assesment
[Dr. Tang] - So we talked about risk assessment being very important. It helps
with both your prognosis and your diagnosis.
[Slide #29] Risk Factors
[Dr. Tang] - Risk factors we talked about in our previous slide. Uh, previous
lecture, Im sorry.
[Slide #30 ] Previous Attachment Loss
[Dr. Tang] - Previous attachment loss is a very good indicator of future risk. Why?
[Dr. Tang]- correct. It comes, it boils down to host response. So if theyre
susceptible then, theyre still susceptible now. Because you could put the same
bugs in a healthy person. If theyre not susceptible, theyre not susceptible
[Slide #31] Chronic Periodontitis
[Dr. Tang] - Chronic periodontitis, we talked about.
[Slide #32] Chronic Periodontitis
[Dr. Tang] - So chronic periodontitis is NOT age dependent, it has a slow
progression, they may have periods of rapid progression, but its usually,
generally slow. And the amount of destruction is consistent with their local
factors. What does that mean? If theres a lot of plaque and a lot of calculus,
theres a lot of destruction. Thats what that means, okay?
[Slide #33] Patient Management Issues
[Dr. Tang] - So, in terms of patient management issues, we wanna look at their
glycemic control, especially in this first case. Their uncontrolled hypertension, it
was like 162 over something or other, I dont remember the exact number. The
smoking history, we wanna talk about smoking cessation for this patient.
26
Whether the patient wants to or not, just put a note in your file, if the patient is a
smoker, that youve discussed it. You don't have to force the patient to quit
smoking, it would be best but you dont have to, but as long as you discuss it with
the patient, thats important, and make sure you note it in your file. And any
medication that the patient may be taking.
[Slide #34] Recommended Treatment Plan
[Dr. Tang] - So this would be an example of a treatment plan for this patient that
we were discussing. Oral hygiene instructions, a medical consult, modify or
eliminate the risk factors, that would be smoking, working on the diabetes control,
scaling and root planing, and reevaluating the patient in 4-6 weeks. Ok? So if the
patient was stable after 4-6 weeks or 4-8 weeks what would we do next? What
would be the next step? Recall. Every 3 months. It would be called maintenance
therapy.
[Dr. Tang] - This patient will probably be a surgical patient, based on the amount
of destruction. And then maintenance every 3 months.
[Dr. Tang] - Okay, moving on to case two. 15 year old female who was referred
from a general dentist had suddenly occurring periodontal defects around the
permanent first molars
[Dr. Tang] - You see those vertical defects around the first molars? Anyone who
does not see them, I will go to the screen and point them out. Everyone sees it,
on the distal aspects? [student- can you point it out] Of course. These pictures
are kind of dark. But the bone level is here. So the bone level should be here, but
you see the dark shadow in here. Also see it in this area here, and the same on
the top, I cant reach.
[Slide #39] Clinical Examination
[Dr. Tang] - So all permanent first molars have probing depths up to 8 mm.
Clinical attachment loss up to 6. Grade I furcation, and I mobility. However,
theres no evidence of attachment loss on the incisors.
[Dr. Tang] - Heres what the charting looked like. So you notice theres 7s and
8s on around #14, 7s around #3, around 18 and 19 theres 7s and 8s, and on
tooth # 30 theres a 6 and 7mm pocket there. So this is ideally what you would
see, but all the numbers are pretty normal, and you see how the gingival margin
is a little more coronal.
27

[Dr. Tang] - And if you look at this patient, if I didnt tell you this patient had those
bone loss in the first molars, you would think this patient is a healthy patient, no?
Patient doesnt have a whole lot of plaque. Its not like that first patient we saw.
Correct?
[Slide #42] What is the MOST appropriate diagnosis?
[Dr. Tang] - So, this would be the most appropriate diagnosis. Agreed? Because
theres less than this is 32 teeth, so divide by 3. So theres only about 4 or 5
teeth involved, so this would be a localized situation. Were on the same page?
Great.
[Slide #43] In patients with this
[Dr. Tang] - Ok. So whats the answer to this? What bacteria is found in these
areas? How many people say A? B? C? D? Alright. Okay, you guys have been
studying, thats good.
[Slide #44] Case 2
[Dr. Tang] - Alright, so this would be a local aggressive case
[Dr. Tang] - So these are the things we wanna look for. These are the key words
you should be looking for when you read my narrative.
[Slide #46] Specific Features
[Dr. Tang] - So theyre usually healthy patients. Its usually around puberty,
theres usually a rapid onset. Usually its hormonally influenced, but not
necessarily. And theres a genetic component, like we talked about.
[Slide #47] Specific Features
[Dr. Tang] - These are some of the specific features. Its the first molars and
incisors. Usually no more than 2 teeth other than the molars/ incisors. Frequently
associated with A. a, neutrophil function abnormalities, and theres usually a
huge serum antibody response.
[Slide #48] Secondary Features
[Dr. Tang] - Microbial deposits are inconsistent, which means there isnt a whole
lot of plaque deposits. Oftentimes these are self-limiting. Usually they heal on
their own or they stop on their own. Not that they heal on their ownI meant that
they stop on their own. And it usually converts over to a chronic case over time.
28
[Dr. Tang] - So this would be a recommended treatment plan. You would start
with a medical consult to make sure theres no systemic issues. Oral hygiene,
bacteria culture and sensitivity, because this patient will probably need to go on
antibiotics.
[student] - What was A. a?
[Dr. Tang] - That one the one that you answered on that previous quiz
question. Okay 4 quadrant scaling and root planing probably with antibiotics,
based on the culture and sensitivity, and then reevaluate.
[Dr. Tang] - Usually the patient responds very well to bone grafting in these
areas. So bone grafting is usually recommended, especially for those infrabony
defects, theyre usually deep and deep and narrow so we can usually graft in
these areas. And definitely keep the patient on a recall.
[Dr. Tang] - Ok so were still doing good on time. This is our third case. 33 year
old African American male. Past history of pneumonia and jaw surgery. Family
history of hypertension. Family history of periodontal disease. Blood pressure is
within normal limits, and a pulse of 60.
[Dr. Tang] - Probing depths are 5-10. Clinical attachment loss 3-9. BOP is
generalized on 80% of the sites. Generalized mobility, and class III furcation uh
(corrects herself) class III mobility. And furcation involvements.
[Dr. Tang] - So this is what we have radiographically.
[Slide #55] What is the MOST
[Dr. Tang] - So, based on the information, what do you think the answer is? A?
No takers. B? C? D? You guys are very non-committal on this one.
[Slide #56] Specific features
[Dr. Tang] - Sure. So usually Its a usually healthy patient. The first molars and
the incisors have a considerable amount of attachment loss.
[Slide #57] Specific features
[Dr. Tang] - It has the A. a, the bacteria you just mentioned. You just questioned
about. These are the pathogens we found. He had a poor antibody response.
29
[Slide #58] Secondary features

[Dr. Tang] - His teeth are clean, guys. Theres really not a whole lot going on. I
dont see a lot of inflammation. It looks pretty healthy. If you looked at this, this
clinical picture, you wouldnt think this patient has mobility on all his teeth. No?
Yes, no, maybe? Were confused? Okay theres a lot of murmuring, so Im not
sure what that means. j
[Dr. Tang] - Right. So you cant there was bleeding on probing, but could be
just from the periodontal pockets. It doesnt necessarily mean that its associated
with the plaque. Were very confused, arent we? What are we confused about?
[flipping thru slides]
[Dr. Tang] - (answering a student question) Because he has those really deep
pockets. You cant see the inflammation, but bleeding on probing, you bleeding
on probing is measured after you with the probe, and you come back to see the
areas still bleeding. The bleeding might not be immediate when you put the
probe, place the probe into the gingival sulcus
[Dr. Tang] - It may not reflect the clinic photo, correct. Are we clearer? Are we still
confused?
[student] - Could you just point out the points that are pertaining to the
aggressive versus (unintelligible)
[Dr. Tang] - Correct, so based on that previous, I think the second case, we
talked about the age of the patient. Usually under the age of 40, yes? We all got
that? The patient has a family history, didnt we also mention that aggressive has
a very large family, genetic component? Yes? The blood pressure is normal. We
have quite a bit of attachment loss for a patient that young. So when you see
things that dont match or do not quite add up, you really need to look at some
systemic issues. So this patient may have some systemic issues. You might
wanna consider sending this patient for a consult.
30
[Dr. Tang] - Nope, it doesnt usually have an influence. That was one of the
previous quiz questions you had. Yes, no? I think. Yeah.
[Dr. Tang] - [flips thru slides] Im sorry, I didnt understand the question. The
picture is definitive?
[flips to slide #58 - Secondary Features]
[student] - without the picture, for me, its still kinda hard to differentiate.
[Dr. Tang] - Correct. Because I didnt give you the plaque score. So the plaque,
you could get from this picture. I couldve given you the plaque score. I may not
always give you the plaque score. Stretching or question? Any other questions?
[student] - Yeah, so to distinguish from aggressive (unintelligible) you would
need more than just the periodontal examination and the medical history
[Dr. Tang] - You would put all these different factors together. So in this particular
case it was the patients lack of plaque, the patients age. The genetic
component. I think that was it.
[student] - And the specific features, would we be given that on the exam?
[Dr. Tang] - Um, like I did here. Does that help?
[Dr. Tang] - It would be unlikely that it would be aggressive if they had a lot of
plaque.
[student] - So if a patient came in, and they had just brushed their teeth and got
rid of all the plaque
[Dr. Tang] - So they could get rid of it supragingivally but not subgingivally. Any
other questions?
[student] - etiology?
[Dr. Tang] - Its usually genetic. And the A. a bacteria. Theres really no rhyme or
reason to it, its very highly correlated to genetic tendencies.
31
[Dr. Tang] - Um nope, I would probably go with chronic because of the age. And
this couldve been an aggressive case, if this patient was 60 years old. To some
degree you get some attachment loss over age, but not like this. So if this patient
walked in and told me that they didnt have any significant medical history, I
would send them for a medical consult and test them for leukemia, I would test
them for diabetes. Because it just doesnt match up. Because theres something
wrong here. Does that make sense? Because theres something else going on.
Theres a host component that were not clear about. Does that help? Are we
clear on this case? Okay, I know were getting tired, only a few more minutes to
go.
[Slide #61] Clinical Case
[Dr. Tang] - So this is the last case, this is a little more complicated. But I just
wanna run through a little more complicated case and how to make it easy for
you. So this is a 58 year old female and she wanted just to get this missing tooth,
on tooth numberI think its tooth #10 replaced.
[Dr. Tang] - This is the medication shes on. Shes hypertensive, postmenopausal. And her blood pressure is pretty normal.
[Slide #63] Social History
[Dr. Tang] - She stopped using tobacco 5 years ago but she smoked 25 pack
years 1 pack a day for 25 years. So theres probably some residual effects
from her smoking.
[Slide #64] Intraoral Exam
[Dr. Tang] - This is what she looks like clinically. She is wearing a flipper here.
Shes wearing a partial denture here to replace that tooth.
[Slide #65] Occlusal Views
[Dr. Tang] - This is what she looks like clinically. Notice that there is a bony
defect here. Theres no bone here. So its very thin there.
[Slide #66] Lateral Views
[Dr. Tang] - This is what she looks like. So you notice all the bone loss in here,
theres probably a furcation involvement here. Theres a vertical defect in here.
[Dr. Tang] - And this is what the whole x-ray looks like. So I love patients that
come in and they tell me that they just want an implant in this one spot.
32
Meanwhile, you can see whats going on here? A lot of bone loss. Okay. What
about this tooth here, what about tooth #17? Okay, so
[Slide #69] Mandibular anterior
[Dr. Tang] - This is what her front teeth look like. The bottom front are not terrible.
Theres quite a bit of attachment loss. You see some plaque and calculus on
those lower anterior teeth, especially interproximally.
[Dr. Tang] - So we would call this generalized moderate, localized severe.
Localized severe meaning those teeth, especially in those anterior teeth with
more than 50% bone loss, that would be severe.
[Dr. Tang] - Most of the back teeth, without giving you probing depths, from the
level of the CEJ to the bone loss, its less than 50%. I would say theyre more in
the 50% on the anterior teeth, but on the posterior teeth you have less
attachment loss, less bone loss.
[Dr. Tang] - Occlusal trauma would also be a diagnosis here. Caries and the risk
factor of smoking.
[Slide #71] Prognosis
[Dr. Tang] - So to make this case easier, what you would do at reevaluation, or
you can do a draft during your treatment planning is to break these teeth down
and put them into categories. So, hopeless teeth are teeth you cannot hold onto,
and they need to be extracted yesterday. Poor teeth you could probably hold
onto, probably for a transitional denture or something non-permanent. But these
are teeth that are not very strong teeth; you would never use these teeth for
abutment. Fair teeth are probably teeth you need to do maybe some SRP,
maybe some restorative work. But you can hold onto them. And good teeth are
very strong teeth, theyre stable, theres not a whole lot of bone loss. Okay? So
once we break these up, the fair and good categories are highlighted here.
Theyre bolded here for you, because these are the teeth youre gonna use to
make your permanent restoration with. You would never put any permanent
restoration on any hopeless teeth or poor teeth. Does that make sense? So you
turn a very complicated looking case, from that previous x-rays, and youre
gonna get these cases when you come into clinic that look really complex like
this. And youre going to be very worried. You may even freak out. But if you
break it down into simple parts like this, it makes your life a lot easier. Okay? So
[Slide #72] Treatment Plan
33
[Dr. Tang] - So simple treatment plan would be just some consultations, oral
hygiene, scaling and root planing, reevaluation. Surgical phase to try to stabilize
some of those defects, especially in the posterior segments. Restorative.
Occlusal guard for the parafunction, and perio maintenance.
[Slide #73] Thank You!
[Dr. Tang] - Oh were done! Ok. Any questions? You have 3 more minutes.
[student] - unintelligible (question about exam)
[Dr. Tang] - Of course I will.
[student] - for every case?
[Dr. Tang] - Of course I will.
34

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Transcribed by Margaret Ferrara

Date of Lecture: 11/19/2014

[Diagnosis and Treatment of Oral Disease] [Lecture 70 &71]- Evaluation of

Transcribed by Margaret Ferrara

Date of Lecture: 11/19/2014

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[students] - (mumbling - sounds like theyre saying long juctional ...)

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[Slide #26] Periodontal Charting

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[Slide #32] Millers Class I

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[Slide #36] Local Factors

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[Slide #54] Moderate-Severe Periodontitis

Transcribed by Margaret Ferrara

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[Slide #62] Part II: Treatment

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[Slide #70] Implants and Periodontal Disease

Transcribed by Margaret Ferrara

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old radiographs available? So thats really important. We recently had a case in

Transcribed by Margaret Ferrara

Date of Lecture: 11/19/2014

to come in. So I want you to the hardest part of periodontal treatment is

Transcribed by Margaret Ferrara

Date of Lecture: 11/19/2014

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[Dr. Tang] - So uncontrolled diabetes is really, really important. Theres studies

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Date of Lecture: 11/19/2014

understanding is, it is a bidirectional relationship. Does that answer your

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Date of Lecture: 11/19/2014

[Slide #21] Gingivitis or Periodontitis

Transcribed by Margaret Ferrara