King Saud University, College of Dentistry

Department of Preventive Dental Sciences

DIVISION OF PERIODONTOLOGY

CLINICAL MANUAL
Edition 2003 2004

TABLE OF CONTENTS
PAGE
Preface

Introduction

General Clinical Protocol

Forms Used in Periodontal Clinics

Patient Examination

The Odontogram

I.

Gingival Diseases

12

II.

Periodontitis

13

III.

Necrotizing Periodontal Diseases

14

IV.

Abscesses of the Periodontium

14

V.

Periodontitis Associated with Endodontic Lesions

VI.

Developmental or acquired deformities and conditions

14

15

15

Initial Treatment Plan

15

Phases of Treatment

15

Phase II Re-Evaluation

17

18

The Treatment Plan

Case Presentation

Steps for Re-evaluation Procedure

Evaluation of a students clinical performance

20
21

PAGE
Appendix A: Periodontal Form 1

25

Periodontal Form 2

26

Appendix B: Radiographic Interpretation

27

Appendix C: Initial Preparation (Phase I Therapy)

29

Appendix D: Introduction and use of the oral hygiene Indices

32

36

Appendix E: Procedures for Scaling, Root Planning and Polishing

40

Appendix F: Surgical Treatment

42

Oral Hygiene Instruction (Chairside Procedure)

PREFACE
This manual has been written for the undergraduate students in the College of
Dentistry, King Saud University who will be Inshallah the next generation of dental
practitioners in the Kingdom. It is meant to guide the student through the procedures
to be followed in patient management in the undergraduate periodontal clinic. The
preventive basis underlying the management of periodontal diseases is highlighted
and great importance is placed on patient examination and treatment planning
objectives.
From this approach, a student dentist will achieve competence in the
techniques available to prevent the occurrence of diseases, treat the diseases should
they occur and finally to maintain the health of their patients and in that way to
minimize as much as possible the need for more radical and costly periodontal
surgical procedures.
The manual was prepared by Dr. basher J. Zulqarnain and Dr. Mohammed
Eid. Later on, it was reorganized by Dr. James E. Stakiw.
Thanks are due to the following current and past members of the Division of
Periodontology who contributed greatly in the preparation of this manual:

Dr. Khalid Almas

Prof. Nadir Babay

Dr. Nahed Ashri

Prof. Axel Bergenholtz

Dr. Farhad Atassi

Dr. Mark Zigoris

Dr. Fatin Awartani

Dr. Sameer Mokeem

Thanks also for PDS Department Secretary Ms. Elizabeth Posadas for her
help in typing and organizing of this manual.
Last, it revisited and updated by Dr. Abdulaziz Al-Rasheed (9th September
2003G [1424H].

INTRODUCTION
This manual has been prepared to assist you, the student dentist, to gain
competence in clinical techniques and administrative procedures, which once
mastered can provide the basis for the successful management of the periodontal
patient in your practices.
A description of general protocol and performance standards expected in the
clinic is presented and the importance of this manual as the reference source on most,
if not all clinical matters cannot be overstated.

It is mandatory to bring the clinical manual during clinical sessions.

Students should wear clean clinical uniform with I.D. badge.

Be professional and Good Luck.

GENERAL CLINICAL PROTOCOL

1.

The treatment cubicle must be clean and neat.

This is the students

responsibility. All papers, extraneous instruments etc. must be stored in

the cupboards provided or at the very least be as far removed in the
operatory from the work area as possible. THIS IS IMPORTANT.
2.

Students must be in the clinic on time and be ready to begin their work.
Students should wear clean clinic gowns/lab coats and appear wellgroomed and professional.

3.

Instruments required for the procedure planned must be available,

sharpened, in good working condition and properly arranged on the
bracket table.

4.

The patients file, evaluation forms etc. should be available with initial
entries already made before starting the actual procedures.

5.

Radiographs, preferably a full-mouth series should be available and in

place on the viewer.

6.

DO NOT BEGIN any treatment until the instructor is informed of what

you plan to do for the patient! You may take a medical/dental history that
will be reviewed by the instructor prior to treatment. The instructor will
check the periodontal treatment plan and if this has been properly
completed and signed by an instructor as it should be, then the student will
be given permission to begin treatment.

7.

The student should be prepared to discuss the treatment planned and the
rationale for the procedures drawing upon knowledge gained earlier
regarding etiology, progression of the disease, treatment planning, results
expected, prognosis of the dentition and other relevant topics.

8.

Time appreciation and management are important clinical considerations

and the student must develop skills in these areas.

9.

Evaluation of your clinical performance is based on your knowledge,

records (MUST BE ACCURATE!), patient management and clinical
skills. An instructor must check each stage of your clinical work so that
you may be adequately assessed. It is your responsibility to have an
instructor evaluate your clinical work and progress before dismissing your
patient. You will also be provided with a qualitative grade. Have your
daily record of treatment and case management completed and all
pertinent data on the evaluation forms filled in.

10.

Do not call an instructor to check your work at the last minute you
should leave at least 20 minutes for a worthwhile teaching learning
evaluation process. It is important that you do not RUSH through your
clinical work. There is nothing wrong in having an incomplete on your
daily record this likely means you are aware of what your treatment
goals are and are in the process of logically achieving these. There is
nothing more frustrating to everyone concerned than to see you have
rushed through your work leaving calculus undetected, tissues in poor
shape, instruments in disarray and then expect to have a good grade. Be
mature and professional about your work.

11.

This manual is your GUIDE for successful clinical management of

periodontal patients. Always have it available in the clinic. The penalty
for being errant in this regard on a consistent may be a zero grade for the
day.

FORMS USED IN PERIODONTAL CLINICS

PATIENT RECORDS THROUGHOUT THE WORLD ARE IMPORTANT
LEGAL DOCUMENTS AND STUDENTS MUST LEARN TO ACCURATELY
RECORD

ALL

INFORMATION

PERTIENNT

TO

THE

CLINICAL

MANAGEMENT OF PATIENTS UNDER THEIR CARE. THEREFORE, FORMS

USED IN PERIODONTOLOGY ARE TO BE CONSIDERED MOST IMPORTANT
BOTH IN THEIR INHERENT VALUE REGARDING THE PATIENT AND AS A
LEARNING TOOL IN UNDERSCORING THE VALUE OF CLINICAL
RECORDS.
ALL PERTIENTN RECORDS ARE TO BE WRITTTEN WITH A LEGIBLE
HAND IN INK.
The division of periodontology uses two (2) forms in the clinic (Appendix A).
These are:
1.

Periodontal Assessment and Treatment Plan (Perio Form 1).

2.

Hygiene Form (Perio Form 2).

The Perio Form 1 is used to record all clinical findings relevant to the

periodontal management of the patient. By developing a keen use of all the students
relevant senses, a correct diagnosis and treatment plan for the patient is arrived at for
the benefit of all concerned.

Much time (at least 1 hour) will be spent in

instructor/student analysis of this form for most patient PLAN YOUR TIME
ACCORDINGLY. You may do odontogram charting at the first appointment
followed by completion of the remainder of the form at a subsequent appointments.
Take your time on this form. Haste makes waste.
The Perio Form 2 is hygiene form. This form is used to record bleeding on
probing and plaque score (percentage) on initial and subsequent visits for recall and
re-evaluation.
6

PATIENT EXAMINATION
Remember, your periodontal examination must of necessity include a general
assessment of the overall health and disease status of the patient and a relevant
dental/oral/facial examination.

You must practice becoming the provider of

comprehensive dental/oral health care and disease management. That is why your
instructor will stress that you do a general and dental examination in addition to the
periodontal examination of your patient.

Examination Kit
This kit includes:
1.

Mouth mirror

2.

Periodontal probe

3.

Explorer #2

4.

Cotton pliers

5.

10 x 2 x 2 autoclave gauze sponges

6.

A white plastic lined paper bag or plastic cup taped to the right side of the
bracket table to receive waste.
The instruments and materials should be neatly arranged from left to right on

your bracket table. The patients file, current radiographs and student evaluation form
must be neatly displayed and readily available for the instructors use.
The following may also be required during patient examination and should be
available:
1.

Large hand mirror

2.

Disclosing tablets or solution

3.

Dental floss

4.

Ball point pen, lead and red/blue pencils

5.

Articulating paper (red and blue)

6.

Study casts

7.

Patient toothbrush (patients should bring their own toothbrushes for each
appointment).

Begin your professional relationship with your patient through completing the
oral hygiene section. You will want to determine your patients attitude to oral
hygiene since this will affect your management of the patient over the short and long
term.
Record your examination findings either:
1.

In the patients chart; or

2.

In the Perio Form 1.

General
A patient assigned to the periodontics clinic usually will have had much of the
dental chart completed by the screening/oral diagnosis divisions. It is important you
review this information. If this section is incomplete notify your instructor. It is
important you review the completed information at each visit asking the patient if
there have been any changes to their medical/dental status. Proceed on how to
complete the top part of the Perio Form 1. Any relevant medical history which may
compromise the patient on your treatment must be noted in the Medical Alert box.
Use red pencil for medical alert.
The next step is to complete the chief complaint, history of past treatment, and
summary of medical history sections particularly as to how the latter may affect the
clinical management of the patient. Under history of past treatment you will want to
know about history of the clinical complaint, when the patient last had dental
treatment, how long ago, what was done and were there any difficulties or
complications.
Call the instructor to obtain an approval to continue with patient examination.

Clinical Examination of a Patient

Remember a suggested approach to patient examination from the outside to
the inside, from the large to the small.
The aid memoire regarding oral hygiene in your clinic chart will allow you to
quickly ask the relevant questions. Ask the patient to bring the oral hygiene/plaque
control aids they use when they appear for the next appointment so you can verify the
instruments and techniques used.
8

General Appearance
Note the general appearance/personality of patient whether robust or sickly,
nervous, tense or relaxed and content. Approximate height and weight.

Extra-Oral
Examine the patient and record your findings regarding lymph nodes, TMJ
status and function, masticatory musculature etc.

Intra-Oral
Record if there is bad breath (foetid odor). This may alert you to possible
pathology being present. Begin your examination by recording any change of the
lips, commissures, then go on to alveolar/buccal mucosa, tongue, floor of mouth and
upper pharynx. Do a complete oral examination.
Describe all gingival surfaces including colour, contour, consistency etc.
Describe the worst areas first followed by those with decreasing pathology and
minimally describe normal tissue findings. At the beginning of your program you
may be asked to describe normal tissues in greater detail.

THE ODONTOGRAM
The Perio Form 1, Periodontal Assessment and Treatment Plan contains
portions of chief complaint, history oral, medical history, examination, extra-oral and
intra-oral. The odontogram provides space for writing sensitivity, pocket depth,
furcation, mobility, recession, and periodontal diagnosis.

Charting on the Odontogram (Perio Form 1)

Your periodontal charting must be done neatly in pen with mucogingival
pathology noted in red pencil. At re-evlauation, periodontal pockets greater than 3
mm should be noted in red pen.

Note: If bleeding on probing occurs, put a red dot in the square of the tooth where
bleeding occurred.
When you have completed the odontogram section of the chart, have an
instructor go over the information gathered so far.

Supplementary Tests
Indicate in this section tests which are indicated to confirm or verify the
potential problems discovered during examination of the patient.

Periodontal Radiographic Finding

Briefly describe C.M.S. findings as they are pertinent to your periodontal
examination. (For more detail see the Appendix B).

Calculus Present
Indicate the presence of calculus in each sextant by the appropriate sign as
follows:
S

Supragingival calculus

SS

Supra and subgingival calculus

SG

Subgingival calculus

Community Periodontal Index for Treatment Needs C.P.I.T.N. Classification

The student will record in the appropriate box, a number to indicate the
CPITN classification for each sextant and the aggregate score (only once). Examine
each sextant and assign a:
Code
0

If the gingival is healthy in the sextant, no bleeding upon gentle

probing of pocket depths.

When gingivitis is present without pocket formation (i.e. up to 3 mm

sulcus depth). There is bleeding upon gentle probing.

When gingivitis is present and supra and/or subgingival calculus is

present.

10

When pathologic pockets (4 or 5mm) are present in a sextant.

When pathologic pockets 6 mm or deeper are present in a sextant

(Exclude pockets on the distal aspect of the 3rd molars).

NOTE :

Missing sextant
You must have at least two (2) teeth in a sextant to be counted.

Etiologic Factors
Here you should list all of the factors which have and are accounting for the
periodontal pathology you have noted in the chart so far. These are discussed further
in your lecture series.

Periodontal Diagnosis
All the relevant and important facts regarding the patient have been collected
and neatly recorded in the chart. The CORRECT periodontal diagnosis must now be
arrived at by a process of reasoning and common sense.
You will note space has been allocated in the chart for a systemic/oral
diagnosis and above each tooth a square for periodontal diagnosis. Systemic diseases
having a direct/indirect bearing on the periodontium e.g. diabetes mellitus should be
included as well as oral diagnostic findings e.g. caries, multiple missing teeth (plus
tooth numbers) etc.
In the appropriate square above each tooth, indicate the diagnostic code for
the American Academy of Periodontology (AAP) 1999 classification from the
following list:
Diagnosis (Modified from American Academy of Periodontology AAP
classification 1999).
This is a brief description lists of the classification and student need to return
back to the lectures in the periodontal courses and the recommended textbook
(Chapter 4, Clinical Periodontology, Carranza, 9th Edition, 2002) for more details.

11

I.

GINGIVAL DISEASES:
I-A.

Plaque induced gingival diseases:

It include the followings:
I-A1. Gingival diseases (gingivitis) associated with dental plaque
only: State of plaque accumulation around the teeth which result in
inflammation of the gingival tissues (characterized by edema, cyanotic
bluish red color, gingival bleeding, rolled margins and bulbous
interdental papillae). The only factor here is the presence of dental
plaque, there is no systemic factors, medications or state of
malnutrition which may affect the response of the gingiva to dental
plaque.
I-A2. Gingival diseases modified by systemic factors:

There is

plaque accumulation around the teeth but the response of the gingival
tissue exaggerated due to presence of systemic factors such as
pregnancy, puberty and diabetic etc.
I-A3. Gingival diseases modified by medications:

response of

gingival tissue influence by medications such as anticonvulsant drug

(phenytoin), hypertensive drug (Nifidipine) and/or immunosuppressive
drugs (Cyclosporine) in addition to the presence of plaque.
I-A4. Gingival diseases modified by malnutrition:

response of

gingival tissue to plaque influence by malnutrition state such as bright

red, swollen, and bleeding gingival associated with severe Vit. C
deficiency or Scurvy.

I-B.

Non-plaque induced gingival lesions:

It include the followings:
I-B1. Gingival diseases of specific bacterial origin: such as sexually
transmitted disease (syphilis, gonorrhea, and streptococcal gingivitis)
the changes in the gingiva is the result of infection with specific
bacteria.
I-B2. Gingival diseases of viral origin:

such as Herpes virus

infections.
12

I-B3. Gingival diseases of fungal origin:

such as generalized

gingival candidosis.
I-B4. Gingival diseases of genetic origin:

such as Hereditary

gingival fibromatosis.
I-B5. Traumatic lesions of the gingiva: such as chemical, physical
and/or thermal injury to the gingival tissue.
I-B6. Foreign body reactions of the gingiva: such as changes of
gingival tissue as the result of introduction of amalgam into the
gingiva during the placement of a restoration.

II.

PERIODONTITIS:
It is an inflammatory disease of the supporting tissues of the teeth caused by

specific microorganisms or groups of specific microorganisms, resulting in

progressive destruction of connective tissue attachment, periodontal ligament and
alveolar bone with pocket formation, recession, or both (simply periodontitis
manifested clinically as Loss of Attachment around the teeth).

It include the

followings:
II-A. Chronic Periodontitis:
Most common form of perodontitis and it is associated with
accumulation of plaque and calculus and generally has a slow to moderate rate
of disease progression.
Extent:
-

Localized form:

less than 30% of sites involved (Note:

attachment usually examined around 6 sites per tooth in the

mouth).
-

Generalized form: more than 30% of sites involved.

Severity:
II-A1. Slight: 1-2 mm of clinical attachment loss.
II-A2. Moderate: 3-4 mm of clinical attachment loss.
II-A3. Severe: 5 mm or more of clinical attachment loss.

13

Note: Clinical attachment loss is measure from CEJ to the base of the pocket
i.e. recession + pocket depth.
Recession measure: from CEJ to gingival margin.
Pocket depth measure: from gingival margin to the base of the sulcus.
II-B. Aggressive periodontitis:
It is less frequent form of periodontitis.

Differ from chronic

periodontitis by an absence of large amount of plaque and calculus and has a

more rapid rate of disease progression.
-

Localized form: involved permanent 1st molars and/or incisors

with proximal attachment loss (at least two teeth are affected).

Generalized form: generalized proximal attachment loss affecting

at least three teeth other than 1st molars and incisors.

II-C. Periodontitis as a manifestation of systemic diseases:

Such as periodontitis observed in Hematological disorders (acquired
neutropenia, leukemias and other) and some genetic disorers (e.g. PapillonLefevre Syndrome).

III.

NECROTIZING PERIODONTAL DISEASES:

III-A. Necrotizing ulcerative gingivitis (NUG).
III-B. Necrotizing ulcerative periodontitis (NUP).

IV.

ABSCESSES OF THE PERIODONTIUM:

IV-A. Gingival abscess.
IV-B. Periodontal abscess.
IV-C. Pericoronal abscess.

V.

PERIODONTITIS ASSOCIATED WITH ENDODONTIC LESIONS:

V-A. Endodontic-Periodontal Lesion.
V-B.

Periodontal-Endodontic Lesion.

V-C. Combined Lesion.

14

VI.

DEVELOPMENTAL

OR

ACQUIRED

DEFORMITIES

AND

CONDITIONS:
VI-A. Localized tooth-related factors that predispose to plaque induced
gingival diseases or periodontitis.
VI-B. Mucogingival deformities and conditions around teeth.
VI-C. Mucogingival deformities and conditions on edentulous ridges.
VI-D. Occlusal trauma.

The Treatment Plan

The formulation of a treatment plan (initial) should be written on a plain sheet
of paper.

Initial Treatment Plan

The ultimate goal of periodontal treatment is the provision of a functional
dentition throughout the life of the individual.
To achieve this goal, treatment is rendered in a deliberately sequenced manner
usually divided into 4 or 5 phases.

The key stone to successful treatment and

management of the disease process is prevention and no phase of treatment will

achieve a successful result without a constant and repetitious adherence to the
Principles of Prevention.
The phases of treatment are as follows:
-

Emergency treatment:
Abscess
Endodontic Therapy RCT
Extraction of hopeless tooth
Trauma etc.
Emergency treatment rendered as necessary.

Phase I:

Initial Therapy (see Appendix C) for more details.

Patient motivation, oral physiotherapy/plaque control. (see Appendix

D).

Gross scaling, fine scaling, root planning. (see Appendix E).

15

Phase II:

Re-evaluate plaque control (3 weeks after initial therapy)

Re-evaluate results of initial therapy (4-6 weeks after initial therapy).
Re-evaluate oral hygiene status.
Bleeding and plaque score.
Comprehensive with previous:
Therefore, a patient to be ready for re-evaluation must have
had all local etiologic factors eliminated, hopeless teeth extracted
and achieved a satisfactory level of oral hygiene:

Assess plaque control.

Assess tissues response to initial treatment.

Plan further treatment that should take the form of a definitive

treatment plan and may include maintenance care or
periodontal surgery.

Phase III:

Surgical Therapy (see Appendix F)

Phase IV:

Supportive Periodontal Therapy

At this stage, further restorative treatment will likely be

planned.

This program is individualized for the patient.

A hypothetical preliminary treatment plan may be as follows:

1.

Emergency treatment: if indicated e.g. endo #34 or extraction 48.

2.

Phase I Initial Treatment

The order in which different aspects of treatment is carried out will
depend on the clinical findings of each case. Whether it is mainly a caries
case or primarily a periodontal cases or a variant in between these two:
a.

Case presentation and patient motivation.

b.

OHI: You should always what aids the patient is using before
giving him/her advise as to what to use. Mention what toothbrush and
brushing technique is used by the patient.

16

NOTE:

If the patient present with good hygiene bucally and lingually and an
acceptable hygiene interdentally, limit your instructions to interdental
cleaning. You must indicate and list all oral hygiene and teaching aids
you will prescribe to your patient. E.g. Butler 311 with modified Bass
technique, dental floss and proximal brush in molar areas.

c.

Extraction: indicate the tooth number.

d.

Complete endodontic treatment of 45.

e.

Excavation of caries, 46, 35 and removal of overhang 37.

f.

Scaling, root planning and prophylaxis.

g.

Occlusal adjustment.

h.

Orthodontic consultation.

Phase II Re-evaluation
Re-evaluation: 4-6 weeks after initial therapy.
At the time of initial treatment planning for areas having 6 mm or
more pockets, it might be necessary to treat them surgically. Identify all such
areas as needing periodontal surgery (this part is actually decided at the time
of Re-evaluation). After-re-evaluation you must specify the areas that need
surgery and the suggested procedure, e.g.:
a.

Gingivectomy, tooth #45-47

b.

Flap, tooth #13-16

c.

Crown lengthening for tooth #27

PII and B.I at acceptable levels.

a.
4.

Fixed bridge #23 to 26 pocket depth now minimal.

Phase III Corrective/Surgical Phase

Surgery

Prosthesis
a. Full thickness mucoperiosteal flap #13 to 17 with possible ostectomy,
M16.

17

5.

Phase IV Recall or Supportive Periodontal Therapy

Plaque Control Data
If and when you are ready to defend your analysis of the case and
treatment plan are satisfied that the patient is ready for further treatment,
arrange an examination kit on the bracket table, and then call for an
instructor.
When the preliminary treatment plan is approved, enter the appropriate
data on the Perio 1 and Perio 2 Forms, have these signed by the instructor and
then present the treatment to the patient.

Case Presentation
The importance of developing an ability to present the treatment plan to the
patient cannot be over emphasized for a number of reasons the main one being the
obtaining of informed consent from the patient for the treatment you are considering
doing for the patient. In addition, be enthusiastic about the treatment planned as being
of benefit to the patient and always seek to establish in the mind of the patient that
periodontal care is a primary treatment goal that for the long term success of all dental
treatment must be accomplished first in priority.
Include the following in your case presentation:
1.

Discuss what you did in the examination procedure and explain your findings.

2.

Explain to the patient the etiology of his/her role in the treatment.

3.

Discuss the sequential treatment plan step by step and indicate how much time
and how many visits it may take to complete the Phase I therapy.

Phase II Re-Evaluation
In the initial therapy, measures are taken to eliminate or bring as close to zero as
possible the etiologic factors for periodontal disease i.e. The BACTERIAL PLAQUE.
If the initial therapy is well done, only minimal amount of bacteria remain on the teeth
and the body is capable of dealing with the bacterial. The inflammatory reaction in the
periodontium will gradually diminish and the periodontal tissues will eventually return
to a healthy states. This will be a permanent result as long as bacterial masses are not
18

allowed to accumulate in the dentogingival region. The healing process will however
continue during a period of several months which a rebuilding of ground substances and
supporting collagen fibers in the gingiva takes place. The most superficial parts of the
periodontium, the gingiva, thereby regains a firm consistency and a pale pink color.
In our evaluation of the effects of initial therapy, we should therefore leave the
patient without intervention for a period of 6 weeks.
Re-evaluation appointment must, therefore, be scheduled at least 4-6 weeks after
the completion of Phase 1 Therapy.

On the occasion of re-evaluation, the following are evaluated:

1.

The ability of the patient to keep his teeth clean during a prolonged period
without professional help.

This is assessed by registration of (1) tissue

appearance, (2) bleeding index, (3) plaque index (with disclosing solution).
2.

The capacity of the tissues of the periodontium to heal. This is assessed through
measuring pocket depth and bleeding on probing index.

3.

This is also an evaluation of the skill of the therapist to inform, motivate and
encourage the patients as well as give accurate and reasonable advice to the
patients about the cleaning of all surfaces of the teeth. It is also a test of the
dentist's skill to perform thorough scaling and root planning.
The information that is obtained must be analyzed before further
decisions are taken.

Re-evaluation is done to:

a.

Determine the benefits of the treatment rendered so far.

b.

Decide on the status of "questionable" teeth; and to

c.

Determine if any further treatment is indicated, e.g. surgery or prescribe the

desired maintenance therapy routine.

19

Steps for Re-Evaluation Procedure

The actual re-evaluation procedure must be performed in accordance with the
following guidelines:
1.

Do a visual examination of the gingival tissue (presence or absence of gingival

inflammation). Take note of the gingival appearance for your own record, but
do not write anything in the gingival description section yet.

2.

Inspect the mouth for visible hard and soft deposits.

3.

Obtain first the Bleeding Index.

4.

Call your instructor and show him your findings.

5.

Take the plaque index.

6.

Then if the patient is:

a.

Free of visible deposits

b.

The Bleeding Index is 15%

c.

The Plaque Index is 20%

This means that the patient is ready and you can proceed to the next step.
7.

Call an instructor to confirm your findings before proceeding.

8.

At this stage, you should be able to inform the instructor that the patient is ready
(or not) for re-evaluation procedure. If you are correct, the instructor will give
you the "go ahead" to complete the re-evaluation.

9.

If the patient is not ready, record your findings on the patient's chart. Re-instruct
your patient in OHI, re-scale and polish the teeth as needed and re-schedule the
patient after a week or two. The patient must leave your cubicle with a mouth
that is completely free of plaque.
You must be able to determine and explain to the instructor why the
patient is not ready for re-evaluation and what are you planning to do for
correcting this situation.
If you did not follow the step the instructor have the right to dismiss the
patient.

Phase III:

After re-evaluation, patient may need advanced treatment either

periodontal surgery or prosthesis etc.

20

Phase IV:

Recall/Maintenance (Supportive Therapy)

Recall visits should be depending on the Periodontal Status and
clinicians judgment. Patients with high motivation and no systemic
conditions should be asked to come every 6 months. Patients with
moderate or severe periodontal disease, needs more frequent recall visits.
It may be adjusted 3-4 months or even earlier in high risk patients.
On each recall visit. The following should be emphasized.
1. Evaluation of the current oral health status.
2. Necessary maintenance treatment.
3. See if recurrence of disease or any other dental treatment needed.
4. Provide necessary periodontal scaling and root planning.
5. Motivation

EVALUATION OF A STUDENTS CLINICAL PERFORMANCE

Final Clinical Grade
All of the students' cumulative clinics experiences will be compiled, tabulated
and averaged. This numerical score is then converted to a letter grade according to the
criteria listed in the University grading and marking system.
Minimal Clinical Requirements
I.

Philosophy and rationale of Teaching Clinical Periodontics in the Division of

Periodontics
The clinical teaching program is based on the premise that all clinical
procedures are new to the students when the course is begun. During the
students progress through the program, certain clinical techniques will be
practiced and eventually mastered.

The degree of mastery that a student

demonstrates will influence his/her final course grade.

The student should progress toward gaining mastery of the basic
periodontal skills. However, different degrees of speed in the learning of clinical
skills are recognized and reasonable allowance is made for these variations.
Emphasis is placed on quality. However, it must be recognized that experience
is necessary to attain quality without sacrificing efficiency.

21

The final two years of the student's clinical training are viewed by the
Division of Periodontics as a continuum of experience. Clinical components
form an essential part of all courses offered by the Division, but in grading, PDS
311 and 411 carry a heavy didactic weight.

Rationale for Student Evaluation for Clinical Courses

The essential objective is to prepare the student to reach a satisfactory level of
clinical proficiency. Unless regular feedback is given to the student, there is a risk of
creating unnecessary student anxiety regarding his level of achievement (e.g. grades);
which may have negative effect on learning. We had attempted to minimize the anxiety
by using the evaluation system in a more positive and constructive way.
A properly designed evaluation procedure will aid the student by recognizing
goals to be reached at specific points in the course. A well constructed and administered
evaluation process will also provide the student with appropriate feedback for self
evaluation and an opportunity to correct misconceptions or misinterpretations and to
improve the clinical skills.
This chapter also contains specific clinical objectives and a brief description of
each procedure, which forms the criteria for acceptable performance and the resulting
clinical evaluation.

Rationale of Course Requirements

The course requirements are based on the need for experience or practice of new
skills in order that they can be mastered. The first exposure to the clinics, in PDS 311,
should be considered as a learning opportunity. The students will not be graded in
technique. This is to encourage students to seek as much faculty aid and advice as they
feel necessary to accomplish maximum learning.
Once a procedure has been practiced and learnt, the student must be evaluated to
qualify for the next higher course. When the student repeatedly demonstrates and
maintains a high level of performance, it is interpreted as mastery of the clinical skill.
The required number of evaluations for the various procedures as well as the evaluation
methods is outlined elsewhere in this document.

22

Student evaluation is based on the following:

A.

Preparation
i.

The student must be prepared for all clinical procedures.

ii.

Be punctual

iii.

Have all necessary instruments available, sterilized and sharpened.

iv.

Have the evaluation form properly complete and ready for appraisal.

v.

Have entered the details of the procedure performed on the patient in the
daily treatment record, for the instructor's signature.
Empathy toward patient, professional appearance and behavior and

conscientious patient managements are important and included in this evaluation

category.
B.

Knowledge
The student should demonstrate his/her understanding of the rationale,
objective and indications for the planned procedure. Students are expected to
review material pertaining to the planned procedure prior to coming to the clinic
and will be expected to discuss all procedures and basic concepts pertaining to
the procedure with the instructor.

C.

Clinical Technique or Performance

The performance will be evaluated as follows:
E.

Excellent (95%)
Will be awarded when the student performs at a satisfactory level
and does so independently. The work needs no improvement and no
faculty guidance or assistance.

VG.

Very Good (90%)

G.

Good (85%)
Will be awarded when the student is able to perform at a
satisfactory level with little guidance and no assistance. The procedures
needed minimal improvement.

S.

Satisfactory (75%)
Will be give when the student needed considerable guidance or
instruction to complete the procedure satisfactorily.

The procedure

needs considerable faculty assistance.

23

U.

Unsatisfactory (40%)
Will be given when the procedure could not be completed
satisfactorily by the student, or the patient was exposed to unnecessary
risk or had been inflicted unwarranted injury.

O.

Zero
This grade will be given when the performance and the
professionalism of the student is unacceptable and the patient or the
student has to be dismissed.
A student found ignorant in "knowledge" and is not prepared to perform

a procedure or has inflicted serious injury to the patient, he/she may be

dismissed from the clinic and will be given a zero "0" grade for that clinic.
3.

Subjective Evaluation
While every attempt is made to insure that the clinical evaluations and
grading system is objective, it must be recognized that it may be difficult
sometimes to design a perfect system.
As such, there must be a high value placed on the individual and
cumulative judgement and experience of the Division of Periodontics faculty.
Therefore, each students' grade will be reviewed by the faculty at the end of the
grading period. Grading policy and evaluative procedures may vary from year
to year and will be presented to the student at the beginning of each academic
calendar year.
D.

Grades
This is filled only by the faculty. A grade may or may not be
given at the end of the appointment at the discretion of the faculty. If the
grade for a procedure has been left blank, it means that the faculty did
not feel there was sufficient opportunity to evaluate the treatment done.
This will not affect the student's final grade. A grade however, is given
for all procedures checked as complete.

24

25

26

Radiographic Interpretation (a brief summary)

Appendix B:

Examine the C.M.S radiographs in an orderly sequence so that you do not miss
any significant findings. Start with tooth #18 and work your way clockwise to tooth
#48. Assess, identify and record the following:
1.

Plaque Retention Factors

Assess for visible calculus deposits, caries at or near the gingival margin
and defective restorations (overhanging margins, poor contour and open
margins.

2.

Loss of Crestal Density

Examine for continuity of the crestal lamina dura. When there is active
destructive inflammation present, the crestal bone will undergo resorption and
will appear less dense than normal on the radiographs. This most often appears
more obvious on the bitewing films because of the x-ray orientation. Loss of
crestal density is very important as an indicator of periodontitis while with
clinical examination only, it is difficult to differentiate between gingivitis and
periodontitis. Where isolated areas show lack of continuity, record with tooth
number. Where 2-3 interproximal areas in a sextant are positive, record it by the
sextant number of the involved teeth.

3.

Resorption Patterns
Observe the general pattern of bone resorption. Note whether it is
horizontal, vertical or a mixture with significant amounts of both. Always
generalize to report your findings by quadrant or by arch.

4.

Average Distance from Alveolar Crest to the CEJ

Estimate the average distance between the CEJ and intact bony quadrant
by quadrant, and indicate the bone loss as follows: Any significant exceptions
may be noted separately. It is necessary to consider the percent of bone loss that
exists radiographically when making the diagnosis.
Measure the distance between the CEJ and the alveolar crest and
estimate the percent (%) bone loss. A guide line follows:

27

1.

0% Bone Loss

bone level 1.5 mm apical to the CEJ with no signs

of loss of crestal density loss it suggest normal
bone level.

2.

20% Bone Loss

bone level will be between 2-4 mm apical to

the CEJ, it suggests slight bone loss.

3.

20%-50% Bone Loss bone level more than 4 mm but <6 mm apical to
the CEJ, it suggests Moderate bone loss.

4.

50% Bone Loss

bone level >6 mm apical to the CEJ it suggest

severe bone loss.

Note: Bone loss may exhibit different severity in different areas of the mouth. This
must be taken into consideration while making individual tooth diagnosis.
5.

Vertical Defects
Note the location, type (angular or true vertical) and extent of the defects.
You will find that when you correlate the clinical findings with the radiographic
findings, it will be easier to interpret vertical defects more accurately.

6.

Furcation Involvement
Note the location and extent of any apparent furcation involvements.
Simply record the tooth number of teeth with furcation involvement. Later try to
correlate this information with the clinical data.

7.

Widened PDL Space

Record any areas with obvious widening of the PDL space.

8.

Abnormal Root Form

Record any root abnormalities seen radiographically, e.g. Dilaceration,
periapical lesions, short roots (poor crown to root ratio).

9.

Other Significant Findings

Any other factors which may be of significance such as periapical
pathology, cyst, poor crown to the root ratio, impacted teeth, etc. may be
recorded in this space.

28

Appendix C:

Initial Preparation Phase (Phase I Therapy)

Initial therapy or phase I is the first step in the sequence of procedures that
constitute periodontal treatment. The objective of initial therapy is the reduction or
elimination of gingival inflammation. This is achieved by complete removal of all
factors responsible for gingival inflammation such as plaque, calculus, correction of
defective restorations, obturation of carious lesions, etc.
The long term success of periodontal treatment is principally dependant on
maintaining the results achieved with phase I therapy. In addition, initial therapy
provides an opportunity for the therapist to evaluate tissue response as well as the
patient's attitude toward periodontal care, both of which are crucial to the prognosis of a
periodontal condition.
Based on the concept that microbial dental deposits (plaque) produce the
primary pathogens of gingival inflammation, the specific aim of phase I therapy is to
facilitate the daily removal of such accretions from the teeth by eliminating rough and
irregular contours from the tooth surfaces and then establishing a suitable plaque control
regimen.

Advantages of Initial Preparation Phase

1.

Removal of all etiologic factors may eliminate the need for periodontal surgery.

2.

Oral hygiene techniques can be instituted and the patient's willingness and ability
to accomplish plaque control are evaluated.

3.

It permits the dentist to evaluate the patient's tissue response to the removal of
local factors and subsequent healing.

4.

Creates a local environment favorable to good oral and periodontal health.

5.

Surgery can be performed with greater ease, because bleeding will be reduces
during surgery and tissue tags can be avoided.

6.

Permits the dentist to establish rapport with the patient.

29

Initial preparation involves the following procedures:

1.

Patient Education
Since dental plaque and calculus formation associated with inadequate
oral hygiene are by far the most common causes of periodontal diseases, it seems
natural to start the therapy by eliminating these active irritants. The concept of
plaque control as well as the rationale for other aspects of the treatment plan
should be understood by the patient before the active treatment is initiated. It is
very important of the success of the treatment plan.

2.

Preliminary Scaling
The next step should be gross scaling and polishing of the teeth, followed
by specific instruction in oral hygiene.

3.

Deep Caries
Carious lesions should be excavated and temporary restorations placed.
Caries in the vicinity of the gingiva interferes with plaque removal and
consequently with gingival health, even in absence of adjacent calculus or
defective restorations. Any teeth needing endodontic therapy should also be
treated at this time since further periodontal treatment would be meaningless if
endodontic treatment cannot be completed successfully.

4.

Hopeless Teeth
If some teeth have been diagnosed as "hopeless" and they are not in a
strategic or vital position for temporary maintenance of occlusal relations, such
teeth should be extracted at this time. Partially impacted third molars with
communication to the oral cavity, or teeth with advanced periodontal disease or
deep caries without functional or esthetics value, should also be extracted.

5.

Temporary Splinting
Although temporary splinting for hyper mobile teeth have not proved to
be useful in promoting periodontal healing during therapy, their use, however,
may expedite such treatment procedures as scaling, occlusal therapy, and
surgical periodontal therapy.

6.

Thorough Scaling and Root Planning

Fine scaling and root planning are necessary to eliminate irritation from
subgingival calculus and contaminated cementum.
30

7.

Recontouring of Defective Restorations

With

few

exceptions

rough,

overcontoured,

overhanging,

or

subgingivally located restorations and orthodontic appliances may be associated

with pronounced accumulation of plaque and periodontal inflammation. Like
calculus, such restorations or appliances interfere with efficient plaque control
and must be corrected or removed to allow for reduction or elimination of
gingival inflammation. Correction of faulty restorations is as important as the
removal of calculus and should therefore be completed at the same time.
Adequate plaque control by the patient on teeth with restorations is feasible only
if the restorations are well contoured and their surface is smooth.

31

Appendix D:

Introduction and use of the Oral Hygiene Indices

Periodontal disease is caused by bacteria or bacterial products from the dental

plaque, and by their affects on the periodontal tissues. It is possible that the pathogenic
influence is mainly caused by a few species of bacteria in the plaque. Other indigenous
organisms may have little significance in the etiology of periodontal disease. So far,
however, there is no routine method available that can selectively eliminate the
pathogenic microorganisms from the plaque. Our treatment efforts, therefore, have to be
directed against the dental plaque itself.
In cause-directed periodontal disease treatment, removal of plaque and all
plaque-retaining factors along with prevention of new plaque formation is without
comparison, the most important part of our therapy.
Removal of the supragingival plaque is the responsibility of the patient during
the active treatment phase as well as during the subsequent life-long maintenance phase.
Motivating and training the patient to achieve an acceptable level of oral hygiene is the
dentist's responsibility and is one of the most difficult tasks in periodontal therapy. The
HYGIENE FORM has been introduced as an aid both to the student and to the patient in
achieving this goal. It will only fulfill its intentions when its being used according to the
following directions.

Gingival/Plaque Index
1.

Dental Indices
The Gingival index (G.I.) by Le and Silness (1963) should be used .
The criteria are as follows:
0=

healthy gingiva

1=

redness with slight edema

2=

redness with edema and bleeding upon probing or touching the

gingiva.

3=

Severe inflammation, edema and spontaneous bleeding.

P1.I.% record the percent of plaque covered surfaces in the mouth. This
means that you divide the number of plaque covered surfaces with the total
number of surfaces and multiply that with 100. Exclude occlusal surfaces. Use
Oral Hygiene Form No. 2 for average plaque score (%) in mouth.
32

2.

Registration of Plaque
First of all, fill in the Hygiene status No., the patient's name and date.
Then x-out the missing teeth so that the chart coincides with the actual number
of teeth in the mouth (in original form and in the duplicate) by black or blue ink.
Please note that all four surfaces of each tooth are to be examined for
plaque: the facial, lingual and proximal surfaces. Hence, the total number of
surfaces is equal to the number of teeth present multiplied by four.
The plaque is then registered following disclosure by staining solution or
tablets. Always use the disclosing agent in accordance with instructions given
by the manufacturer.

Tablets are usually to be chewed and swashed

continuously for one minute, then the patient may rinse once. Disclosing
solutions are to be applied directly a with cotton pallet. Wait one minute and let
the patient rinse once.
Inspect all tooth surfaces (proximal surfaces must be inspected from both
the lingual and the facial sides). Mark the plaque-covered surfaces in red on the
tooth diagram. If you are in doubt whether plaque is present or not, use the side
of the probe. soft material adhering to the probe indicates plaque. Fill-in the
number of plaque-covered surfaces on the right-hand side of the form, and
calculate the plaque percentage (as mentioned above).

Always write the

instructions (demonstrations) given to the patient that day in the lower right-hand
part of the form.
3.

Registration of Bleeding
Bleeding on probing should be noted by a short red dot () outside the
probe surface area. If bleeding is found in two neighboring proximal areas, be
aware that the two dots () must be separate and distinct.
Bleeding on probing is registered within 30 seconds following the
insertion of the probe in the periodontal pockets in exactly the same way as
during probing for periodontal pockets. It may therefore be convenient to probe
three teeth and then go back to register the bleeding areas before continuing with
the pocket depth measurements on the remaining teeth.

33

The bleeding percentage is calculated in the same manner as the plaque

percentage, except that the number of tooth surfaces equals the number of teeth
present multiplied by 6 (surfaces).
After further explaining to the patient what you found in his/her mouth,
you can now proceed to demonstrate to him/her the correct technique to remove
the plaque.
4.

Oral Hygiene Instruction

A satisfactory level of plaque control by the patient is essential for
periodontal therapy to be effective. To achieve this, it is necessary to motivate
the patient and instruct the patient in the methods to be utilized. Unfortunately,
this aspect of patient management is often not given the emphasis it deserves. In
such instances, patients seldom reach their full ability to practice proper oral
hygiene measures by the time of the re-evaluation appointment, and treatment
becomes delayed.
Patients should understand that most of what we do, e.g. surgery, etc. is
not in itself a "cure", but rather a mean to facilitate daily plaque control. Many
patients are products of the era before plaque was "in vogue", and consider what
the dentist does every six months to be sufficient to control disease. Convey the
lack of truth behind this information to the patient on a level he/she can
understand.
OHI re-enforcement should be given at the beginning of each visit,
before any plaque is removed by scaling or polishing. By setting aside time for
OHI, at the start of each visit, you convey to the patient the importance of his/her
participation in the therapy and also have enough time to do an adequate job.
Instruction requires active participation by the patient. Showing a patient
where plaque has been left and telling the patient to brush and/or floss better will
not be effective unless you work with the patient with the brush and/or floss in
his hand.
The OHI regimen must be suitable for the need of a given patient. For
example, patients with crowded teeth, bridges or exposed furcations usually
require a customized regimen with devices which specifically enable them to
34

reach problem areas. Also, patients with physical or mental impairment will
often require a modification of OHI regimen, as well as a modification of our
expectations concerning their level of performance.
Despite our most conscientious efforts at OHI, there are a number of
patients who will not be motivated to maintain a satisfactory daily level of
plaque control. Not all patients have the same values as we do. It is important,
therefore, to document your activities with respect to OHI, and the patient's level
of performance that the treatment plan can be modified accordingly.

The

patients in this category are difficult to detect but usually are those who brush
and floss well only on the day of the appointment and thus, present with
persistent, generalized inflammation and little or no plaque. Role of miswak and
its effective method of use should be highlighted to patient with the message for
cleanliness.

Diagnosis of Patients Failure in the Performance of Oral Hygiene Procedures

a.

The practitioner may fail to motivate the patient to become a "co-therapist".

b.

The practitioner may assume a level of knowledge which the patient does not
posses and therefore provides incomplete or insufficient instruction.

c.

Failure to recognize that the patient's reported behavior and actual behavior may
differ.

d.

e.

The practitioner may fail to establish a line of communication due to:

Failure to establish a mutual confidence

Failure to establish a credibility.

Failure to evaluate the adequacy of previous instructions:

Positive approach is more effective than institution of fear.

Praise efforts rather than demean poor plaque control.

Patient must be shown areas of plaque retention.

f.

Failure to reinforce previous instructions at each appointment.

g.

Failure to re-evaluate and re-educate as necessary following periodontal surgery:

Exposure of more clinical crown introduced new problems of

management.

Good plaque control is absolutely essential for post-surgical success.

35

Oral Hygiene Instructions (Chairside Procedures)

First Appointment
Oral hygiene instructions should be given immediately after motivation but
BEFORE beginning scaling, root planning and polishing.
1.

Show the patient evidence of dental disease in his/her own mouth. With the use
of a hand mirror show:

2.

a.

caries (evidence of existing disease).

b.

restorations (evidence of past caries).

c.

gingival inflammation (alteration in color and/or consistency).

d.

gingival bleeding (evidence of active disease).

e.

periodontal pockets (the result of disease).

Explain that the bacteria on the teeth are the main cause of the above diseases
and point out that they (bacteria) are usually invisible to the naked eye.

3.

Ask the patient to rinse for at least one minute with disclosing solution.

4.

While the patient is rinsing, explain that the solution contains a harmless
vegetable dye which stains only that part of the tooth which is "dirty" or has
bacteria on it.

5.

After patient rinses a couple of times with clear water, determine the Plaque
Index (PlI) and record this in the treatment record.

6.

Show relationship of red dye to areas of disease. Re-emphasize the point that the
red dye represents bacteria.

7.

Ask the patient to show what tooth brushing technique he/she is currently using.
If the patient did not bring the toothbrush, open a new toothbrush pack, moisten
the bristles and ask the patient to show you his/her brushing technique.

8.

Re-examine the mouth and point out areas which were missed.

9.

Correct the technique where indicated. Make sure that the patient shows you the
correct technique in his/her mouth.

10.

Be sure to emphasize that the main objective of using the brush is to "brush the
red off" or remove the bacteria.

11.

Remind the patient to bring the toothbrush for each subsequent session.

36

Second Appointment
This is the suggested procedure when seeing your patient for the first time
following the introduction of oral hygiene instructions. Careful attention must be given
to the sequence outlined below:
1.

2.

Review the patient's record for any notations regarding:

a.

past performance

b.

what was dispensed (e.g. Butler 311 toothbrush, Proxa brush).

c.

any special instruction given (e.g. bridge cleaning).

d.

problem areas (furcations)

Greet the patient in your usual friendly manner and ask how he/she managed
with the use of the disclosing tablets. If he replies that they have not been used,
determine the reason. It is important to do this because somewhere along the
line you failed to convince the patient of the importance of visualizing the
plaque. It may be that they find something objectionable about the taste or the
coloration of the dye in the tablet. Nevertheless, it is important to determine why
they were not used and an effort should be made to correct this.

3.

If the patient replied that they worked well but that several areas were difficult to
reach, ask the patient to show you where these areas are. Ask the patient when
they last brushed their teeth. This is important because the amount of debris or
plaque on the teeth may give you an idea of how efficiently the patient is
cleansing his teeth. For example, if the patient states that they brushed their
teeth several hours before the dental appointment and the disclosing stain reveals
extensive dental plaque, not only in covering the tooth but also in bulk and/or
thickness, this would indicate that the patient is not properly performing oral
hygiene.

4.

Ask the patient to present their toothbrush. If they say they forgot it, do not
supply them with another but re-emphasize the point that it is necessary for the
instructional session for them to bring their toothbrush. They may buy a new
toothbrush from the pharmacy.

37

5.

Examine the patient's mouth for any deposits, materia alba or food debris. If any
of these are present, it should be pointed out to the patient and emphasize that the
accumulation of these materials is the result of improper cleansing.

The

presence of visible plaque and/or materia alba and food debris is indicative of a
poor response to oral hygiene training.
6.

Areas that previously exhibited inflammation or bleeding should be reviewed.

Patients should be shown any improvement.

7.

Ask the patient to use disclosing dye and determine:

a.

the presence of plaque.

b.

distribution of plaque.

c.

thickness of plaque (thicker plaque indicates "older plaque").

Perform and record the Plaque Index in the patient chart in the

"Record of Treatment".
8.

The patient should first be complimented on any improvement in his oral

hygiene and then attention must be directed to areas which were missed. At this
time, areas which were cited by the patient as difficult to clean should be
observed and patient should be aided with his own toothbrush in properly
cleaning those areas. If there is some improvement in brushing technique, then
dental floss should be suggested and demonstrated at this time for efficient
interproximal cleansing.
Note:
The above procedure should be followed on all subsequent appointments
until patients demonstrate ability and willingness to perform proper oral hygiene.
Then it should be performed on an intermittent bases for reinforcement. During
these follow-up appointments, it is important to determine whether the problems
is due to lack of motivation or lack of skill. If it is lack of skill, an electric
toothbrush might be suggested. If it is lack of motivation, then you have failed
to motivate your patient.
You must record your findings, recommendation and any oral hygiene
devices which you dispensed to the patient in the "Record of Treatment" section
of the patient's file. It is not enough to only write "OHI given".

38

9.

Interproximal cleaning: In addition to dental floss, several other interdental

cleaning aids are available. Given below is a guide to select proper interdental
oral hygiene aids:
a.

Type I Embrasure - use dental floss or Super floss.

b.

Type II Embrasure - slight to moderate recession. Use proximal brush

(Butler Proxa Brush).

c.

Type III Embrasure - extensive recession, loss of papillae. Use proxa

brush or end-tufted brush.
In short, use the largest suitable device for cleaning the
interproximal space.

10.

Review the OHI lecture notes given in 211 PDS for more details.

Recommended Schedule for Home Use of Disclosing Tables

Rx: 12 Disc. tabs. (Red-cote X-pose)
Use in the evening after last meal as follows:
1.

Chew tablets and swish for one minutes.

2.

Look in the mirror and find stained (red) areas on teeth.

3.

Use toothbrush, with toothpaste and dental floss (or suitable interdental cleaning
aid) to remove the red bacterial plaque.

4.

After brushing, chew another tablet and see if any other areas were missed.

5.

Use toothbrush and other aids again to remove this stain.

Teeth must be

thoroughly cleaned.
6.

After 3 to 4 days, change the procedure as follows.

7.

Clean the teeth thoroughly first without using disclosing tablet.

8.

When you are satisfied that your teeth are clean, then chew a disclosing tablet.

9.

Look for and thoroughly remove any plaque remaining.

10.

After that, use the tablets once a week, to check yourself (always use after tooth
cleaning).

39

Appendix E:

Procedures for Scaling, Root Planing and Polishing

Now that you have completed your session of introduction to Oral Hygiene
Instruction, and coronal scaling (where indicated) you are ready to begin scaling, root
planning and polishing.
The instruments should be arranged in the order that they will be used. (left to
right). In addition to routine examination instruments, the scaling kit contains the
following scaler and curette:
Towner U15/30

(scaler for anterior teeth)

Taylor 2/3

(scaler, for posterior teeth)

Columbia 4L/4R

(universal curette-posterior teeth)

Gracey 3/4, 9/10, 11/12 & 13/14

(area specific curette)

Before beginning debridement (i.e. scaling and root planing), check with a
faculty member and tell him/her how much you intend to accomplish during this session
and how you intend to mange the case overall. The faculty will then either agree with
your plan or suggest alterations in your approach. (e.g. sextant by sextant handling vs
quadrant by quadrant treatment).

Remember that:
1.

Patients with subgingival calculus always require more than one appointment to
complete the procedure. 4-6 appointments may be needed.

2.

Avoid long appointments. It is better to have three, one hour session than one
three hour session. Progressive resolution of inflammation due to scaling and
root planing, combined with oral hygiene efforts of the patient, result in greater
visibility of calculus (shrinkage) and less bleeding.

3.

One must try to be systematic. Do not instrument all areas of the mouth in the
first session (unless you are doing GROSS scaling). You may do coronal (gross)
scaling and polishing and then thoroughly scale and root plan individual
sextants/quadrants. This will depend on the amount of supragingival calculus
and on the complexity of the case. Local anesthesia should not be used unless
permission is given by an instructor.

40

4.

Although individual sextants/quadrants/arches may be evaluated during a

clinical session, the scaling, root planning and polishing procedure is NOT
considered complete until the entire mouth had been evaluated by the instructor.
However, if for some unforseen circumtance, the patient fails to return for
further appointments after one or more scaling appointments, you will still get
credit for each segment/quadrant scaled.
An instructor with grade qualitatively while checking a sextant/quadrant.

5.

Subgingival scaling and root planning is a very difficult procedure. Mastery of

the skills in this procedure requires continual practice, experience and expert
guidance.

You are encouraged to seek assistance at any time during the

procedure but especially when you are encountering difficulties or have any
questions. It is better to seek help when you experience a problem rather than
wait until the end of the clinic session or waiting until the instructor is checking
and grading the procedure.
6.

An Oral Hygiene evaluation MUST BE PERFORMED AT THE

BEGINNING OF EACH SCALING APPOINTMENT.

The Pl.I. as

calculated on the Hygiene form is recorded on the "Treatment Record" along

with a brief narrative describing the patient's performance.

41

Appendix F:

Surgical Treatment

The didactic information is covered in the course PDS 411 (Advanced

Periodontal Therapy). Following are guide lines to provide an overview of periodontal
surgery and for familiarity with the surgical treatment planning objectives.
The objective of periodontal therapy is the maintenance and/or recreation of a
dentition free of disease that is functional and esthetics. The major objective is the
attainment of an intact, secure gingival attachments to the teeth. In health, the gingival
attachment consists of a sulcus bounded on its lateral wall by sulcular epithelium, at its
base by epithelial attachment (junctional epithelium), and on its medial wall by the
tooth. The normal lining of the sulcus is non-keratinized, stratified squamous epithelium
with an absence of rete pegs. The epithelium may be considered as an infection barrier.
The gingival attachment depends on the gingival fiber apparatus for adherence of the
gingiva to the tooth. In disease, however, the inflammatory process causes destruction
of the gingival fibers and disruption of the epithelium. Adherence to the tooth is lost and
pocket formation becomes a major symptom. Histologically, the sulcular wall of the
gingiva consists of a wound.
The therapeutic objective, therefore, is the excision of the gingival wound and
production of a surgical wound, which, when the inflammatory state subsides results in
healing and re-adaptation of the gingival tissues to the tooth. The
prerequisites for surgical intervention are complete cleansing of the teeth, calculus
removal and adequate ability of the patient to keep the dentition free of plaque.
The word SURGERY has been defined as the "act and art of treating diseases or
injuries by manual operation". If we use this broad definition, nearly all periodontal
treatment from hard or soft tissue curettage falls under the meaning of the term
"periodontal surgery". In periodontics the term "periodontal surgery" is applied only to
specific surgical manipulations of the periodontal soft tissues and bone and not to
debridement and root planing. These latter procedures, however, play the decisive role
in the success or failure of the surgical procedure and/or therapy.

42

1.

Objectives of periodontal surgery

Traditionally, all periodontal therapy has been aimed at pocket
elimination. Pocket elimination represents on objective of periodontal surgery.
Elimination of the periodontal pocket consists of reducing the depth of the
pockets to that of a physiologic sulcus. Pocket elimination is a critical factor in
restoring periodontal health and arresting the destruction of the supporting
periodontal tissues. The main objective for reducing the depth of the pocket to
that of a normal sulcus (1-3 mm) is to facilitate access by the patient to keep the
area free of plaque. The presence of a pocket creates areas which are impossible
for the patient to keep clean. Deeper pockets, therefore, usually need surgical
eradication (correction) because of the difficulty in removing plaque near the
pocket base by means of oral physiotherapy measures. Waerhaug states that "the
deeper the pocket, the shorter the distance from the plaque to the base of the
pocket". In shallow pockets of about 3 mm the distance between the plaque and
the base of the pocket may be 1 mm or more. In pockets 6 mm the distance
may be as little as 0.2 mm, making removal with a scaler or curette difficult and
removal with a toothbrush, dental floss and interdental cleaners nearly
impossible.

It is, therefore, safe to say that the main purpose for doing

periodontal surgery is to afford both the therapist and the patient better
accessibility to plaque removal.
Probably the most important criterion used over time in determining
whether periodontal surgery is necessary is the depth of the periodontal pocket.
Other than pocket depths there are also clinically recognized physical
characteristics of the gingival tissue, such as color, size and consistency, which
must be considered.

While these are highly subjective in nature they are

considered very important in evaluating state of the gingival tissue. Changes in

these characteristics can lead to the conclusion that inflammatory activity is
present. For example, a change in consistency from firm resilient to soft or
spongy could be an indication of inflammatory condition. Hemorrhage from the
pocket upon provocation is one of the most objective signs of inflammatory
activity. This indicates crevicular vascularity and a decrease in mechanical
strength of the crevicular epithelium.

Some recent studies have also

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demonstrated a high correlation between the volume of GCF flow and severity
of inflammation. GCF can be used, therefore, as an indicator of early as well as
advanced gingival disease.

Clinical Signs of Periodontal Disease Activity

A priority listing of the signs of periodontal disease is:
a.

Propensity of hemorrhage

b.

Pocket depth

c.

Crevicular fluid

d.

Color, size, shape, consistency of the gingiva

The major purpose of the foregoing discussion section is to suggest that

periodontal health should be used as a criteria used disease elimination and control as a
goal, rather than pocket elimination by itself. However, once the need for surgical
therapy has been established, various techniques can be utilized. This will be briefly
discussed in the following section.
The objectives of periodontal surgery can thus be summarized in the following
list:
a.

Elimination of periodontal pockets by removing soft tissue and/or recontouring

it.

b.

Elimination of pockets by removing osseous tissue and/or recontouring it.

c.

Correct mucogingival deficiencies and deformities.

d.

Correct gingival contour that interferes with oral hygiene.

e.

Prepare for restorative dentistry (e.g. crown lengthening).

f.

Establish drainage from gingival or periodontal abscess turn an acute periodontal

problem into a more treatable state.

g.

Improve esthetics appearance for tissue overgrowth or recession.

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Timing of Periodontal Surgery

Except for treatment (drainage) of acute periodontal abscess, all periodontal
surgery should be postponed until one month after completion of the "Initial Therapy
Phase" of periodontal treatment (also known as Initial Preparation). Initial therapy
phase represents one of the most essential phases of therapy. The primary goal of initial
therapy is to reduce or eliminate the local factors responsible for the inflammatory
periodontal disease. In this way the clinical signs of inflammatory disease can be
removed and/or reduced, and the case can be better evaluated for other techniques of
periodontal therapy.

Importance of Initial Therapy

Scaling, root planning and good home care hopefully will result in shrinkage of
the gingival tissue, followed by reattachment (or adaptation) of junctional epithelium
which may restore a physiologic gingival crevice in areas that had been considered for
surgery. Therefore, the need for periodontal surgery may be eliminated and/or reduced.
Observing the patient during the hygienic phase gives an indication of what can
be expected by way of patient cooperation in oral hygiene in the future.

Such

information is important in selecting the type of periodontal surgery that will yield the
best results. It must be emphasized that periodontal surgery may do more harm than
good if adequate cooperation and plaque control cannot be established.
Technically, it is easier to perform accurate surgery when the initial incisions can
be made in fibrotic gingival tissues than in gingival tissues that are soft, edematous, and
hemorrhagic. Surgical management of the tissue including precise suturing is facilitated
by its firmness. The chances for harmful sequel such as loss of attachment associated
with periodontal surgery, are reduced when the surgery is done on fibrous, firm, gingival
tissues and teeth that are plaque-free. Performing periodontal surgery on teeth that have
been scaled and root planed and are devoid of plaque, will create a local environment
that is favorable for tissue regeneration.

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Contraindication to Periodontal Surgery

As a general principle, periodontal surgery is contraindicated for persons who
have any systemic illness in which surgery may endanger their health.
1.

Bleeding disorders
Periodontal surgery involves a traumatic disruption of the tissues and
necessarily causes some bleeding. Any hemorrhagic disorder of severe nature,
such as hemophilia, thrombocytopenic purpura and so forth usually constitutes a
contraindication to periodontal surgery, unless bleeding can be controlled.

2.

Lower resistance to infection

Periodontal surgery is contraindicated for patients, with severely
impaired defense mechanisms against bacterial infection such as seen in
neutropenia. Uncontrolled diabetes may also interfere with normal antibacterial
response to surgery.

3.

Specific considerations
Patients with a short-life expectancy are candidates for palliative
periodontal procedures rather that periodontal surgery.

4.

Poor oral hygiene

Periodontal surgery is definitely contraindicated for persons who will not
keep their teeth clean during initial therapy.

Types of Periodontal Surgical Procedures

The following is an example of periodontal surgical procedures classified into
two groups:
A.

Pocket Elimination Surgery

1.

Gingival Curettage

2.

Gingivectomy/Gingivoplasty

3.

Various types of Flap Operations

4.

Mucogingival Flap (unrepositioned)

Mucogingival Flap (apically repositioned)

Osseous Surgery

Bone Grafts

Ostectomy/Osteoplasty
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B.

Non-Pocket Elimination Surgery

1.

Mucogingival Surgery

Free Gingival Graft

Pedicle Grafts

Bone Denudation procedures

Theoretical Methods for Pocket Elimination

a.

Shrinkage

b.

Resection

c.

Reattachment

d.

Apical positioning

In cases of infrabony defects, the osseous defect itself must be eliminated in

order for pocket elimination to be successful. This can be accomplished by:
a.

Obtaining reattachment to the tooth by formation of new bone "fillingin" of the defect (induction).

b.

Removing the walls of the bony defect (ostectomy/osteoplasty)

c.

Combination of the above procedures (a) and (b).

Residual pocket depths and probable correct periodontal therapy

Pocket depth in mm

Tissue State

Therapy

3 mm
4mm
4-5 mm
Periodontitis

Inflamed
Edematous
Fibrous

Sc & Rp
Sc & Rp
Scaling & gingivectomy

4 mm
5 mm
5-8 mm

edematous
horizontal bone loss
infrabony pockets

Sc & Rp and/or Curettage

Root planing/gingivectomy
Sc & Rp & flap surgery

Gingivitis

c:Perio Clinical Manual

/betchay.updated September 9, 2003

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