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Comprehensive Periodontal Therapy: A Statement by the American Academy of Periodontology*
The American Academy of Periodontology (AAP) periodically publishes reports, statements, and guidelines on a variety of topics relevant to periodontics. These papers are developed by an appointed committee of experts, and the documents are reviewed and approved by the AAP Board of Trustees. he American Academy of Periodontology offers the following statement that sets forth the scope, objective, and procedures that constitute periodontal therapy. This statement is provided to assist all members of the dental team who provide periodontal care and should be considered in its entirety. This statement may also be useful to those who supervise, teach, or regulate the provision of periodontal therapy. SCOPE OF PERIODONTAL THERAPY As a result of advances in knowledge and therapy, the majority of patients can retain their dentition over their lifetime with proper treatment, reasonable plaque/bioﬁlm control, and continuing care. Periodontics is the specialty of dentistry that encompasses prevention, diagnosis, and treatment of diseases of the supporting and surrounding tissues of teeth and dental implants. The scope of the specialty of periodontics alsoencompasses maintenance of the health, function, comfort, and esthetics of all supporting structures and tissues in the mouth. The goals of periodontal therapy are to preserve, improve, and maintain the natural dentition, dental implants, periodontium, and peri-implant tissues in order to achieve health, comfort, esthetics, and function. A healthy periodontium is characterized by the absence of inﬂammation, which may appear clinically as redness, swelling, suppuration, and bleeding on probing. PERIODONTAL EVALUATION A comprehensive assessment of a patient’s current health status, history of disease, and risk characteris*This statement was developed under the direction of the Task Force to Update the Guidelines for Periodontal Therapy and approved by the Board of Trustees of the American Academy of Periodontology in November 2010. DISCLAIMER: This statement represents the views of the Academy regarding periodontal therapy and related procedures. It must be recognized, however, that decisions with respect to the treatment of patients must be made by the individual practitioner in light of the condition and needs of each speciﬁc patient. Such decisions should be made in the best judgment of the practitioner, taking into account all relevant circumstances. NOTE: The Academy updates guidelines and statements on a periodic basis. All previous publications should be considered in light of their historical context with regard to current knowledge and practices.
tics is essential to determine the periodontal diagnosis and prognosis of the dentition and/or the suitability of dental implants. Patients should receive a comprehensive periodontal evaluation and their risk factors should be identiﬁed at least on an annual basis. Such an evaluation includes discussion with the patient regarding his/her chief complaint, medical and dental history review, clinical examination, and radiographic analysis. Microbiologic, genetic, biochemical, or other diagnostic tests may also be useful, on an individual basis, for assessing the periodontal status of selected individuals or sites. The following procedures should be included in a comprehensive periodontal evaluation: 1. Extra- and intraoral examination to detect nonperiodontal oral diseases or conditions. 2. Examination of teeth and dental implants to evaluate the topography of the gingiva and related structures; to measure probing depths, the width of keratinized tissue, gingival recession, and attachment level; to evaluate the health of the subgingival area with measures such as bleeding on probing and suppuration; to assess clinical furcation status; and to detect endodontic–periodontal lesions. 3. Assessment of the presence, degree, and/or distribution of plaque/bioﬁlm, calculus, and gingival inﬂammation. 4. Dental examination including caries assessment, proximal contact relationships, the status of dental restorations and prosthetic appliances, and other tooth- or implant-related problems. 5. An occlusal examination that includes, but may not be limited to, determining the degree of mobility of teeth and dental implants, occlusal patterns and discrepancy, and determination of fremitus. 6. Interpretation of current and comprehensive diagnostic-quality radiographs to visualize each tooth and/or implant in its entirety and assess the quality/ quantity of bone and establish bone loss patterns. 7. Evaluation of potential periodontal–systemic interrelationships. 8. Assessment of the need for and suitability of dental implants. 9. Determination and assessment of patient risk factors such as age, diabetes, smoking, cardiovascular disease, and other systemic conditions associated
and combinations of these procedures for osseous. INFORMED CONSENT AND PATIENT RECORDS Informed consent should be obtained prior to the commencement of therapy. Management of periodontal–systemic interrelationships. PROGNOSIS. . etiology. 12. regenerative procedures. or implants. implant site development. or biochemical assessment or monitoring during the course of periodontal therapy. ESTABLISHING A DIAGNOSIS.Comprehensive Periodontal Therapy Volume 82 • Number 7 with development and/or progression of periodontal disease. and counseling on control of risk factors (e. Osseous procedures include ostectomy and osteoplasty. occlusal adjustment. In some instances. regenerative. Occlusal therapy that may include tooth movement. 3. root biomodiﬁcation. 944 4. resective procedures. or biteguard therapy as a means to establish and maintain occlusal health. use of biologics. meticulous periodontal scaling and root planing. and recommended follow-up are essential and should be maintained according to state law. 5. Patient education. 7. 2. The reasonably foreseeable inherent risks and potential complications associated with the proposed therapy. Combined dental tissue and osseous procedures may be required. but not limited to. 3. orthodontic. Surgical and non-surgical periodontal and implant procedures to be performed. and sinus grafting. Selective extraction of teeth. treatment should include: 1. Dental tissue procedures include root resection. The treatment plan should be used to establish the methods and sequence of delivering appropriate periodontal treatment. Consideration of risk factors including. which play a role in development. Removal of supra. 5. eliminate. thereby arresting or slowing further disease progression. etc. training in oral hygiene. and cosmetic periodontal therapy or dental implant placement. proposed therapy. tooth hemisection. ridge preservation. including failure with the ultimate loss of teeth or dental implants. Information given to the patient should include the following: 1. diabetes and smoking. Resective procedures to reduce or eliminate periodontal pockets and create an acceptable gingival form that facilitates oral hygiene and periodontal maintenance. these procedures may be incorporated into the surgical treatment. Periodontal/oral reconstructive procedures include guided bone regeneration. Consideration of diagnostic testing that may include microbiologic. diagnosis. when appropriate. or crown lengthening. Recommendations for treatment to be performed by other dentists or physicians. furcation. and odontoplasty. 4. or to alter the host response through local or systemic delivery. 6. smoking. and the prognosis with and without the proposed therapy or possible alternatives. ridge augmentation. Complete records of the periodontal examination (including full charting). splinting. ﬁberotomy. periodontally accelerated osteogenic orthodontics. 6. genetic. 3. possible alternative treatment(s). when appropriate. and/or endodontic consultation or treatment. Periodontal plastic surgery for gingival augmentation. 7. gingivoplasty. 8.and subgingival bacterial plaque/bioﬁlm and calculus by comprehensive. Preprosthetic periodontal procedures including exploratory ﬂap surgery. and management of periodontal diseases. The diagnosis. 2. medical status. 10. treatment.) with appropriate referral if needed.g. AND TREATMENT PLAN Clinical ﬁndings together with a diagnosis and prognosis should be used to develop a logical plan of treatment to eliminate or alleviate the signs and symptoms of periodontal diseases. Surgical placement of dental implants and management of peri-implant disease. When indicated. Chemotherapeutic agents may be used as appropriate to reduce. stress. or enhancement of oral esthetics. Periodontal maintenance program including ongoing evaluation and reevaluation for treatment. and gingival recession defects. mucogingival procedures. Periodontal regenerative procedures including bone replacement grafts. which may include non-surgical. 2. or change the quality of microbial pathogens. and various mucogingival ﬂap procedures. progression. frenulectomy. TREATMENT PROCEDURES When indicated. Soft tissue procedures include gingivectomy. The need for periodontal maintenance treatment after active therapy due to the potential for disease recurrence.. Provision for ongoing reevaluation during periodontal or dental implant therapy and throughout the maintenance phase of treatment. Procedures to facilitate orthodontic treatment including tooth exposure. the plan should include: 1. Medical and dental consultation or referral for treatment. correction of recession or soft tissue deformities. prosthetic. roots. Consideration of adjunctive restorative. guided tissue regeneration. 4. surgical. 11. 9.
Albandar JM. or prosthesis considered to be contributing to the periodontal disease process. Burt BA. Mechanical tooth cleaning to disrupt/remove dental plaque. 2. for treatment of carious lesions. 3. 6. or iatrogenic causalities. periodontal maintenance visits should include: 1. 3. and uncorrectable anatomic. 2. or other conditions) and diagnostic-quality radiographs when appropriate. Periodontol 2000 2002. or those who present with other limitations may be unable to undergo recommended procedures required to establish a completely healthy periodontium. This should include professional management of those risk factors associated with development and/or progression of periodontal diseases including. J Dent Res 1987. J Clin Microbiol 2005. Global epidemiology of periodontal diseases: An overview. Finishing procedures. Olsen I. Patients with medical compromises. The patient has been counseled on why and how to perform an effective daily personal oral hygiene program including managing their own personal risk factors associated with development and/or progression of periodontal diseases. the record should document that: 1. Rams TE. and gingival augmentation. restoration. PERIODONTAL MAINTENANCE THERAPY Upon completion of active periodontal therapy. The patient should be kept informed of: 1. A recommendation has been made for the correction of any tooth form. stain. 7. inadequate plaque/bioﬁlm control. Identiﬁcation and treatment of new.. or newly occurring periodontal or peri-implant disease. EVALUATION OF THERAPY Upon completion of planned periodontal therapy. Deﬁning the normal bacterial ﬂora of the oral cavity.70:30-43. those who refuse or delay treatment. Update of medical and dental histories. Changes in the periodontal prognosis and risk factors associated with periodontal diseases. 5. 4. 1988-1994. or refractory areas of periodontal and peri-implant pathoses. other dental or medical specialists. 5. defective restorations. Other oral health problems that may include caries. 13. 4. Dewhirst FE. Kingman A. Albandar JM.70:351]. Changes that would warrant referral to. speciﬁc to individual circumstances. BIBLIOGRAPHY Aas JA. 945 . tooth position. 3. structural. 2.43:5721-5732.66:13-18. Destructive periodontal disease in adults 30 years of age and older in the United States. appropriate therapy to establish the best possible periodontal health is indicated. 5. and non-periodontal mucosal diseases or conditions. pulpal–periodontal problems. with elimination or mitigation of new or persistent risk and etiologic factors with appropriate treatment. All indicated therapeutic procedures have been performed. as well as for the maintenance of dental implants. Status of dental implants.29: 7-10. Evaluation of current extra. Areas of persistent. In those situations. FACTORS MODIFYING RESULTS The results of periodontal therapy may be adversely affected by factors that include systemic diseases. unknown or undeterminable etiologies. 6. pulpal pathoses. J Periodontol 1999. Kingman A. Establishment of an appropriate interval for periodontal maintenance. recurrent.J Periodontol • July 2011 Comprehensive Periodontal Therapy temporary anchorage devices. Albandar JM. which include posttreatment evaluation with review and reinforcement of daily oral hygiene when appropriate. gingival bleeding. and calculus. Paster BJ. occlusal dysfunction. An epidemiological investigation into the relative importance of age and oral hygiene status as determinants of periodontitis. if present. refractory. inability or failure of the patient to follow the suggested treatment or maintenance program. The patient’s response to therapy has been evaluated. Advisability of further periodontal treatment or retreatment of indicated sites.and intraoral periodontal and peri-implant soft tissues as well as dental hard tissues and referral when indicated (e.g. 70:13-29. J Periodontol 1999. 1988-1994 [published correction appears in J Periodontol 1999. An appropriate professional periodontal maintenance program. but not limited to. or consultation with. and treatment objectives have been met. Stokes LN. Assessment of the oral hygiene status with reinstruction when indicated. bioﬁlms. Ongoing assessment of risk factors to identify an individual who may be more highly susceptible to ongoing breakdown of the periodontal or peri-implant tissues. recurrent. adverse environmental inﬂuences such as smoking and stress. Gingival recession. and dental calculus in adults 30 years of age and older in the United States. Abdellatif HM. has been recommended to the patient for long-term control of his/her condition. smoking and diabetes. 4. Local delivery or systemic chemotherapeutic agents may be used as adjunctive treatment for recurrent or refractory disease. Brunelle JA.
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