Volume 71 • Number 5 • May 2000 (Supplement

)

JOURNAL OF
CONTENTS
Parameters of Care

Periodontology

Foreword ...............................................................i Overview ...............................................................ii Parameter on Comprehensive Periodontal Examination......................................................847 Parameter on Periodontal Maintenance ...............849 Parameter on Plaque-Induced Gingivitis ..............851 Parameter on Chronic Periodontitis With Slight to Moderate Loss of Periodontal Support ................853 Parameter on Chronic Periodontitis With Advanced Loss of Periodontal Support...............................856 Parameter on “Refractory” Periodontitis.............859 Parameter on Mucogingival Conditions ...............861 Parameter on Acute Periodontal Diseases ..........863 Parameter on Aggressive Periodontitis ...............867 Parameter on Placement and Management of the Dental Implant ..................................................870 Parameter on Occlusal Traumatism in Patients With Chronic Periodontitis .........................................873 Parameter on Periodontitis Associated With Systemic Conditions..........................................876 Parameter on Systemic Conditions Affected by Periodontal Diseases .........................................880

Foreword
The Parameters of Care were developed by the Ad Hoc Committee on the Parameters of Care and have been approved by the Board of Trustees of the American Academy of Periodontology. This publication has been edited to reflect decisions by the Board of Trustees in approving the term “periodontal maintenance” in lieu of “supportive periodontal therapy” (January 2000) and a new classification of periodontal diseases, as published in the Annals of Periodontology, December 1999; Volume 4, number 1 (April 2000). Individual copies of this supplement may be purchased by contacting the Product Services Department, American Academy of Periodontology, 737 North Michigan Avenue, Suite 800, Chicago, Illinois 60611-2690; voice: 312/787-5518; fax: 312/787-3670; e-mail: orders@perio.org. This material is also accessible through the Academy’s Web site, www.perio.org, under the Resources and Products Section. Members involved in the development of these Parameters are: Donald A. Adams; Erwin P. Barrington (Chair); Jack Caton, Jr.; Robert J. Genco; Stephen F. Goodman; Carole N. Hildebrand; Marjorie K. Jeffcoat; Fraya Karsh; Sanford B. King; Brain L. Mealey; Roland M. Meffert; James T. Mellonig; Myron Nevins; Steven Offenbacher; Gary M. Reiser; Louis F. Rose; Paul R. Rosen; Cheryl L. Townsend (Chair); and S. Jerome Zackin.

i

Overview
In response to increasing concerns on the part of health care providers, third-party payers, and consumers about the quality, cost, and access to dental care, the American Academy of Periodontology has developed practice parameters on the diagnosis and treatment of periodontal diseases. These parameters are strategies to assist dentists in making clinical decisions from a range of reasonable treatment options to achieve a desired outcome. Practice parameters are designed to help the profession provide appropriate dental services while containing costs, without sacrificing quality. These parameters are constantly updated and are partially based on methodology utilized by participants in the American Academy of Periodontology 1996 World Workshop in Periodontics (Annals of Periodontology, Volume 1, 1996) to assess the evidentiary status of periodontal and implant treatment. The major goal is to improve treatment decisions by increasing the strength of the inference that practitioners can derive from the base of knowledge contained within the literature. There are several types of periodontal diseases, with many treatment options. The Academy has developed a series of parameters to address a full range of clinical conditions. Although the parameters vary in their specificity and research base, they incorporate the best available knowledge on the diagnosis, prevention, and treatment of periodontal diseases. Each parameter should be considered in its entirety. It should be recognized that adherence to any parameter will not obviate all complications or post-care problems in periodontal therapy. A parameter should not be deemed inclusive of all methods of care or exclusive of treatment appropriately directed to obtain the same results. It should also be noted that these parameters summarize patient evaluation and treatment procedures which have been presented in more detail in the medical and dental literature. It is important to emphasize that the final judgment regarding the care for any given patient must be determined by the dentist. The fact that dental treatment varies from a practice parameter does not of itself establish that a dentist has not met the required standard of care. Ultimately, it is the dentist who must determine the appropriate course of treatment to provide a reasonable outcome for the patient. It is the dentist, together with the patient, who has the final responsibility for making decisions about therapeutic options.

ii

Parameters of Care Supplement
Parameter on Comprehensive Periodontal Examination*
The American Academy of Periodontology has developed the following parameter on comprehensive periodontal examination for periodontal diseases. Appropriate screening procedures may be performed to determine the need for a comprehensive periodontal evaluation. Periodontal Screening and Recording (PSR), a screening procedure endorsed by the American Dental Association and the American Academy of Periodontology, may be utilized. J Periodontol 2000;71:847-848. KEY WORDS Periodontal diseases/diagnosis; dental history; medical history; patient care planning.

PATIENT EVALUATION/EXAMINATION Evaluation of the patient’s periodontal status requires obtaining a relevant medical and dental history and conducting a thorough clinical and radiographic examination with evaluation of extraoral and intraoral structures. All relevant findings should be documented. When an examination is performed for limited purposes, such as for a specifically focused problem or an emergency, records appropriate for the condition should be made and retained. 1. A medical history should be taken and evaluated to identify predisposing conditions that may affect treatment, patient management, and outcomes. Such conditions include, but are not limited to, diabetes, hypertension, pregnancy, smoking, substance abuse and medications, or other existing conditions that impact traditional dental therapy. When there is a condition that in the judgment of the dentist requires further evaluation, consultation with an appropriate health care provider should be obtained. 2. A dental history, including the chief complaint or reason for the visit, should be taken and evaluated. Information about past dental and periodontal care and records, including radiographs of previous treatment, may be useful. 3. Extraoral structures should be examined and evaluated. The temporomandibular apparatus and associated structures may also be evaluated. 4. Intraoral tissues and structures, including the oral mucosa, muscles of mastication, lips, floor of mouth, tongue, salivary glands, palate, and the oropharynx, should be examined and evaluated. 5. The teeth and their replacements should be examined and evaluated. The examination should include observation of missing teeth, condition of
* Approved by the Board of Trustees, American Academy of Periodontology, May 1998.

restorations, caries, tooth mobility, tooth position, occlusal and interdental relationships, signs of parafunctional habits, and, when applicable, pulpal status. 6. Radiographs that are current, based on the diagnostic needs of the patient, should be utilized for proper evaluation and interpretation of the status of the periodontium and dental implants. Radiographs of diagnostic quality are necessary for these purposes. Radiographic abnormalities should be noted. 7. The presence and distribution of plaque and calculus should be determined. 8. Periodontal soft tissues, including peri-implant tissues, should be examined. The presence and types of exudates should be determined. 9. Probing depths, location of the gingival margin (clinical attachment levels), and the presence of bleeding on probing should be evaluated. 10. Mucogingival relationships should be evaluated to identify deficiencies of keratinized tissue, abnormal frenulum insertions, and other tissue abnormalities such as clinically significant gingival recession. 11. The presence, location, and extent of furcation invasions should be determined. 12. In addition to conventional methods of evaluation; i.e., visual inspection, probing, and radiographic examinations, the patient’s periodontal condition may warrant the use of additional diagnostic aids. These include, but are not limited to, diagnostic casts, microbial and other biologic assessments, radiographic imaging, or other appropriate medical laboratory tests. 13. All relevant clinical findings should be documented in the patient’s record. 14. Referral to other health care providers should be made and documented when warranted. 15. Based on the results of the examination, a diagnosis and proposed treatment plan should be

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Philadelphia: WB Saunders Company: 1990:491-495. Gaffar A. Dental/medical history. Am J Public Health 1963. Dent Clin North Am 1982. The medical history. Louis: The CV Mosby Company. Dent Clin North Am 1986. Vol. Oral hygiene and periodontal disease. and Management of Temporomandibular Disorders. 7.Supplement presented to the patient. 1981:13. Current Procedural Terminology for Periodontics and Insurance Reporting Manual. 8. 22. 1995. 7th ed. 11. 18. J Am Dent Assoc 1990. Helldén L. 1990. Current status of bleeding in the diagnosis of periodontal diseases.26:3-11. Advances in Periodontology. The historical profile. Radiographs and the responsible dentist. Patients should be informed of the disease process. MD: Center for Devices and Radiological Health. J Periodontol 1985. Periodontal diseases: Diagnosis. 1983:57-63. Loyens S. Theilade E. History. Diagnosis. Boozer C. 1987. Caton J. Corn H. 6. Relative distribution of bacteria at clinically healthy and periodontally diseased sites in humans. 20. 15. The American Academy of Periodontology. 25. 1989. The American Academy of Periodontology. potential complications. 2d ed. Philadelphia: Lea & Febiger. 1990. Consequences of no treatment should be explained to the patient. Kornman K. Proceedings of the World Workshop in Clinical Periodontics. St. Dental Identification. Bottomley WK. 1989. 19.13:249-257. Consenus Report: Periodontal diseases: Epidemiology and diagnosis. J Clin Periodontol 1986. Ann Periodontol 1996. 1992. 1990:194.30:357-368. 17. 4. 14. 12.121:460-464. Ash MM. Chicago: The American Academy of Periodontology. Miles DA. 1. Streeper SN. History and clinical examination. Goldman H. Burch JG. Listgarten MA. Philadelphia: JB Lippincott Company. Rockville.1:37-215. Newman M. Mandel I. Louis: The CV Mosby Company.5:115-132. 26. DHHS publication no. Part 1. SELECTED RESOURCES 1. 13. Occlusal examination. Kerr DA. Wilson T. 28. Polson A. Atlas of Adult Orthodontics. Barrington E. Ann Periodontol 1996. 7th ed. eds. Internal Medicine for Dentistry. Romriell GE. Patient health status evaluation procedures for the dental profession. (Spec.36:177-187. 848 Parameter on Comprehensive Periodontal Examination Volume 71 • Number 5 (Supplement) . and Management of Temporomandibular Disorders. Armitage GC. 7th ed. Contemporary Periodontics.1:216-222. 27. In: Clark’s Clinical Dentistry. 2. Joseph LP. Millard HD. Diagnosis. 88-8273. Lovas JGL. Schiff T. Gen Dent 1989. In: Burkett’s Oral Medicine. Genco R.21:47-67. 1983:180-189. Borglum-Jensen SB. St. Clark JW. 21. Kay D. Marks M. J Periodontol 1965. the expected results and their responsibilities in treatment. Diagnosing periodontal diseases. Mertz CA. therapeutic alternatives. Chicago: Quintessence Publishing. St Louis: The CV Mosby Company. Fox C. Dent Clin North Am 1977. 3. Carranza F. Calculus revisited: A review. 5. In: The President’s Conference on the Examination. Clinical Dentistry. 2nd ed. Terezhalmy GT. Greene JC. 16. White SC. 1988. St. Vol. Goaz PW. Nevins M. Food and Drug Administration. Clinical examination. Glickman’s Clinical Periodontology. 1983:51-56. Experimental gingivitis in man. Chicago: American Dental Association. Louis: The CV Mosby Company.37:201-206. 23.53:913-922. J Oral Med Spec No:5-7. 10. Issue)56:1-3. Philadelphia: Harper & Row. Cohen D. Lynch M. Chicago: The American Academy of Periodontology. In: Rose LF. Oral Radiology: Principles and Interpretation. J Clin Periodontol 1978. 24. Löe H. Chicago: American Dental Association. In: The President’s Conference on the Examination.1-22. Philadelphia: JB Lippincott Company. The Selection of Patients for X-Ray Examination: Dental Radiographic Examinations. Oral Diagnosis. 1977. 1. Lush DT. 9.

Probing depths. Patients should be informed of the disease process.Parameters of Care Supplement Parameter on Periodontal Maintenance* The American Academy of Periodontology has developed the following parameter on Periodontal Maintenance. It is distinct from. removal of microbial flora from sulcular or pocket areas. G. Periodontal maintenance is an integral part of periodontal therapy for patients with a history of inflammatory periodontal diseases. expected results. B. Other signs and symptoms of disease activity. American Academy of Periodontology. prosthetic. Occlusal examination and tooth mobility. Other signs and symptoms of disease activity. scaling and root planing where indicated. dental examination. The patient may move from active therapy to periodontal maintenance and back into active care if the disease recurs. Probing depths. Review and Update of Medical and Dental History Clinical Examination (to be compared with previous baseline measurements) 1. Periodontal examination and recording of results: A. General levels of plaque and calculus. Examination of dental implants and peri-implant tissues and recording of results: A. To minimize the recurrence and progression of periodontal disease in patients who have been previously treated for gingivitis and periodontitis. Bleeding on probing. Evaluation of furcation invasion. and their responsibility in treatment. periodontal diseases/therapy. Extraoral examination and recording of results 2. THERAPEUTIC GOALS 1. Consequences of no treatment should be explained. Evaluation of implant stability. B. patients should then be able to make informed decisions regarding their periodontal therapy. and the judgment of the clinician. 3. Given this information. 4. Exudation. therapeutic alternatives. Dental examination and recording of results: A. Gingival recession. Bleeding on probing. P eriodontal maintenance is started after completion of active periodontal therapy and continues at varying intervals for the life of the dentition or its implant replacements. J Periodontol 2000. D. extraoral and intraoral soft tissue examination. Other tooth-related problems. These procedures are performed at selected intervals to assist the periodontal patient in maintaining oral health. in a timely manner. radiographic review. Examination of prosthesis/abutment components. periodontal examination. periodontal diseases/prevention and control. Caries assessment. review of the patient’s plaque control effectiveness. E. J Periodontol • May 2000 (Supplement) 849 . potential complications. D. disease progression. May 1998. * Approved by the Board of Trustees. KEY WORDS Health education. history. subject to previous examination. F. C. C. Failure to comply with a periodontal maintenance program may result in recurrence or progression of the disease process. Periodontal maintenance procedures are supervised by the dentist and include an update of the medical and dental histories. other diseases or conditions found within the oral cavity. Occlusal examination. 2. Tooth mobility/fremitus.71:849-850. but integrated with. and polishing the teeth. E. B. This is the phase of periodontal therapy during which periodontal diseases and conditions are monitored and etiologic factors are reduced or eliminated. 3. To reduce the incidence of tooth loss by monitoring the dentition and any prosthetic replacements of the natural teeth. active therapy. Periodontal maintenance is an extension of active periodontal therapy. TREATMENT CONSIDERATIONS The following items may be included in an periodontal maintenance visit. To increase the probability of locating and treating. C. F. dental. H. Restorative. D.

Advances In Periodontics. The judgement of the clinician. Consensus report on prevention. Assessment of personal oral hygiene status. Wasserman B. may help determine the need for.4(2):55-71. Long-term maintenance of patients treated for advanced periodontal disease. Duckworth DM. A long-term survey of tooth loss in 600 treated periodontal patients. 11.2:80-86. Brumfield FW.Supplement Radiographic Examination Radiographs should be current and should be based on the diagnostic needs of the patient and should permit proper evaluation and interpretation of the status of the periodontium and dental implants. J Clin Periodontol 1981. Periodontal treatment without maintenance. J Periodontol 1986. Becker W. 14. Radiographic abnormalities should be noted. Tooth loss in maintenance patients in a private periodontal practice. 16. Kornman KS.11:504-514. Lindhe J.49:225-237. 15.69. OUTCOMES ASSESSMENT 1. 2. Based on evaluation of clinical findings and assessment of disease status.10:148-156. Malik AK. 850 Parameter on Periodontal Maintenance Volume 71 • Number 5 (Supplement) ..53:539-549. Consultation with other health care practitioners who will be providing additional therapy or participating in the periodontal maintenance program. J Periodontol 1987. The desired outcome for patients on periodontal maintenance should result in maintenance of the periodontal health status attained as a result of active therapy. Nyman S. Becker BE. Behavior modification: A. 10. Beck FM. Nyman S. Removal of subgingival and supragingival plaque and calculus 2. 17.58:706-714. 8. Schallhorn RG. Rosling B. J Clin Periodontol 1984. Significance of frequency of professional tooth cleaning for healing following periodontal surgery. The American Academy of Periodontology. The American Academy of Periodontology. Mendoza AR. 12. 9. Radiographs of diagnostic quality are necessary for these purposes. Becker W.1:241244. 1989. patients may demonstrate recurrence or progression of periodontal disease. Chicago: Quintessence Publishing. Lindhe J. 19. Wilson TG: Compliance. J Periodontol 1978. In these patients additional therapy may be warranted. Antimicrobial agents as necessary 4. Nyman S.g. Despite adequate periodontal maintenance and patient compliance. the frequency of. Wilson TG. Effect of professional tooth cleaning on healing after periodontal surgery. Lindhe J. 18. Wilson TG. Nixon KC. Compliance with supportive periodontal therapy. Compliance with suggested periodontal maintenance intervals C. Assessment of disease status by reviewing the clinical and radiographic examination findings compared with baseline. periodontal maintenance frequency may be modified or the patient may be returned to active treatment. Supportive Periodontal Therapy (Position Paper). J Periodontol 1987. Chicago: The American Academy of Periodontology.103:227-231. A review of the literature with possible applications to periodontics. Planning 1. Oral hygiene reinstruction B. J Periodontol 1984. EB. Surgical treatment of recurrent disease Communication 1. McFall WT Jr. Berg LE. 4. In: Proceedings of the World Workshop in Clinical Periodontics. 3. Glover ME. Schoen JA. 2. as well as the degree of disease activity. Bone loss following periodontal therapy in subjects without frequent periodontal maintenance. Periodontal maintenance therapy. 2. Assessment 1. The long-term evaluation of periodontal maintenance in 95 patients. Ann Periodontol 1996. Lindhe J. Hirschfeld L. 7. 45% failure rate after 5 years. For most patients with a history of periodontitis. Counseling on control of risk factors. J Periodontol 1998. Treatment 1. A retrospective study in 44 patients. Ann Periodontol 1996. J Am Dent Assoc 1981. Br Dent J 1981. 1:250-255. Prevention. J Periodontol 1982.IX-24. 5. DeVore CH. Newcomb GM. 2. J Clin Periodontol 1975. Hancock. Int J Periodontics Restorative Dent 1984.55:505-509. Axelsson P. Inadequate periodontal maintenance or noncompliance may result in recurrence or progression of the disease process. e. The significance of maintenance care in the treatment of periodontal disease. 2. J Clin Periodontol 1983. Becker BE.150:222-224. Horton JE. 1992. Westfeld E.8:281-294. Informing the patient of current status and alterations in treatment if indicated. 13. visits at 3-month intervals have been found to be effective in maintaining the established gingival health. Socransky S. and the number of radiographs. Newman MG. Treatment of chronic periodontitis. cessation of smoking 3. J Periodontol 1991. Berg L. Snider LE.57:354-359. Hicks MJ. 6. Dorsett D. Tooth loss in 100 treated patients with periodontal disease. 62:731-736. Kerr NW. SELECTED RESOURCES 1.58:231-235. 3. A long-term study.502-506.

with possible development of gingival defects and progression to periodontitis. gingival craters. Clinical Features Gingivitis may be characterized by the presence of any of the following clinical signs: redness and edema of the gingival tissue. pregnancy. These may include diabetes. and their responsibility in treatment. Consequences of no treatment should be explained. presence of calculus and/or plaque. Antimicrobial and antiplaque agents or devices may be used to augment the oral hygiene efforts of patients who are partially effective with traditional mechanical methods. THERAPEUTIC GOALS The therapeutic goal is to establish gingival health through the elimination of the etiologic factors. etc. and other plaque-retentive factors. changes in contour and consistency. caries. 3.g. Given this information. expected results. ill-fitting fixed or removable partial dentures. 2. Debridement of tooth surfaces to remove supraand subgingival plaque and calculus.71:851-852. Plaque-induced gingivitis is the most common form of the periodontal diseases. If the therapy performed does not resolve the periodontal condition. patients should then be able to make informed decisions regarding their periodontal therapy. etc. plaque. substance abuse. stress. and certain periodontal bacteria. disease progression. HIV infection. Correction of plaque-retentive factors such as over-contoured crowns. J Periodontol 2000. open contacts. Patients should be informed of the disease process. OUTCOMES ASSESSMENT 1. An appropriate initial interval for follow up care and prophylaxis should be determined by the clinician. narrow embrasure spaces. A treatment plan for active therapy should be developed that may include the following: 1. and no radiographic evidence of crestal bone loss. and medications. periodontal attachment loss/ prevention and control. J Periodontol • May 2000 (Supplement) 851 . redness.. and reduction of clinically-detectible plaque to a level compatible with gingival health. Following the completion of active therapy. calculus. American Academy of Periodontology. * Approved by the Board of Trustees. potential complications. Patient education and customized oral hygiene instruction. the patient’s condition should be evaluated to determine the course of future treatment. therapeutic alternatives. bleeding upon provocation. surgical correction of gingival deformities that hinder the patient’s ability to perform adequate plaque control may be indicated. KEY WORDS Dental plaque/adverse effects.) with possible development of gingival defects such as gingival clefts.. 5. e. TREATMENT CONSIDERATIONS Contributing systemic risk factors may affect treatment and therapeutic outcomes for plaque-induced gingivitis. genetic predisposition. 4. In selected cases. 2. swelling. open and/or overhanging margins. gingivitis/pathogenesis. smoking. May 1998. No treatment may result in continuation of clinical signs of disease. affecting a significant portion of the population in susceptible individuals. 6. systemic diseases and conditions (immunosuppression). there may be: continuation of clinical signs of disease (bleeding on probing. and tooth malposition. stability of clinical attachment levels.Parameters of Care Supplement Parameter on Plaque-Induced Gingivitis* The American Academy of Periodontology has developed the following parameter on plaque-induced gingivitis in the absence of clinical attachment loss. aging. Satisfactory response to therapy should result in significant reduction of clinical signs of gingival inflammation. nutrition. CLINICAL DIAGNOSIS Definition Plaque-induced gingivitis is defined as inflammation of the gingiva in the absence of clinical attachment loss. gender.

Atlas of Adult Orthodontics. Advances in Periodontology. 6. Listgarten MA. 4. Periodontal diseases: Diagnosis. medical/dental consultation. Armitage GC. 1993. Jensen SB. Factors which may contribute to the periodontal condition not resolving include lack of effectiveness and/or patient non-compliance in controlling plaque. 1989. Chicago: Quintessence. In the management of patients where the periodontal condition does not respond. The American Academy of Periodontology. Philadelphia: Lea & Febiger. Decision-Making in Periodontology. and mental and/or physical disability. Experimental gingivitis in man. 1989. underlying systemic disease. 14.Supplement and possible progression to periodontitis with associated attachment loss. Corn H. WB. Prevention.115:591-595. J Periodontol 1998.36:177-187.121:460-464. J Clin Periodontol 1978. 1992.1:216-222. 12.69:396-399. 13. and continuous monitoring and evaluation to determine further treatment needs. 11. 15. Becker W. Kornman K. Proceedings of the World Workshop in Clinical Periodontics. (Spec. microbial assessment. Current status of bleeding in the diagnosis of periodontal diseases. Issue)56:1-3. additional or alternative methods and devices for plaque removal. Berg L. 4.1:223249. Hall.1:37-215. Stovsky D. 5. Relative distribution of bacteria at clinically healthy and periodontally diseased sites in human. Newman M. 7. St Louis: The CV Mosby Company.50: 234-244. 2. Chicago: The American Academy of Periodontology. Hellden L. J Periodontol 1985. Greenwell H. restorations which do not permit sufficient control of local factors. J Am Dent Assoc 1987. Löe H. Theilade E.5:115-132. 10. Becker B. Untreated periodontal disease: a longitudinal study. patient noncompliance with prophylaxis intervals. 8. Wilson T. J Am Dent Assoc 1990.and/or subgingival calculus. SELECTED RESOURCES 1. 1:250-255. Ann Periodontol 1996. Consensus report: Prevention. The American Academy of Periodontology. Guidelines for Periodontal Therapy (Position Paper). increasing the frequency of prophylaxis. 3. Barrington E. Diagnosing periodontal diseases. Ann Periodontol 1996. presence of supra. J Periodontol 1965. Caton J. Polson A. Bissada N. treatment may include additional sessions of oral hygiene instruction and education. Consensus Report: Periodontal diseases: Epidemiology and diagnosis. 852 Parameter on Plaque-Induced Gingivitis Volume 71 • Number 5 (Supplement) . 9. Ann Periodontol 1996. 2d ed. Marks M. Hancock EB. Ann Periodontol 1996. additional tooth debridement. 3. Periodontics in general practice: Perspectives on nonsurgical therapy. Nevins M. J Periodontol 1979.

but may have periods of rapid progression. it can occur over a wide range of ages. Clinical Features Although chronic periodontitis is the most common form of destructive periodontal disease in adults. and function with appropriate esthetics. or more generalized. Other factors include the clinician’s ability to remove subgingival deposits. periodontitis/complications. Consequences of no treatment should be explained. and patient’s ability to control plaque. The disease is characterized by loss of clinical attachment due to destruction of the periodontal ligament and loss of the adjacent supporting bone. American Academy of Periodontology. TREATMENT CONSIDERATIONS Clinical judgment is an integral part of the decisionmaking process. periodontal attachment loss/prevention and control. CLINICAL DIAGNOSIS Definition Chronic periodontitis is defined as inflammation of the gingiva extending into the adjacent attachment apparatus. Treatment considerations for patients with slight to moderate loss of periodontal support are described below. Patient-related factors include systemic health. may be attempted.71:853-855. therapeutic preferences. Given this information. Patients should be informed of the disease process. periodontitis/diagnosis. Slight to moderate destruction is generally characterized by periodontal probing depths up to 6 mm with clinical attachment loss of up to 4 mm. expected results. potential complications. tooth loss/prevention and control. Chronic periodontitis with slight to mod* Approved by the Board of Trustees. Clinical features may include combinations of the following signs and symptoms: edema. Radiographic evidence of bone loss and increased tooth mobility may be present. gingival bleeding upon probing. A patient may simultaneously have areas of health and chronic periodontitis with slight. J Periodontol • May 2000 (Supplement) 853 . Chronic periodontitis with slight to moderate destruction is characterized by a loss of up to one-third of the supporting periodontal tissues. THERAPEUTIC GOALS The goals of periodontal therapy are to alter or eliminate the microbial etiology and contributing risk factors for periodontitis. age. Many factors affect the decisions for the appropriate therapy(ies) and the expected therapeutic results. In addition. erate loss of periodontal supporting tissues may be localized. Failure to appropriately treat chronic periodontitis can result in progressive loss of periodontal supporting tissues. where indicated. It usually has slow to moderate rates of progression. patient care planning. thereby arresting the progression of the disease and preserving the dentition in a state of health. involving one area of a tooth’s attachment. and advanced destruction. and/or suppuration. It can occur in both the primary and secondary dentition. J Periodontol 2000. patients should then be able to make informed decisions regarding their periodontal therapy. and to prevent the recurrence of periodontitis. loss of clinical attachment should not exceed Class I (incipient). erythema. moderate. comfort. KEY WORDS Disease progression. regeneration of the periodontal attachment apparatus. therapeutic alternatives. if the furcation is involved. May 1998. involving several teeth or the entire dentition. compliance. restorative and prosthetic demands. and the presence and treatment of teeth with more advanced chronic periodontitis. and their responsibility in treatment. and could result in tooth loss.Parameters of Care Supplement Parameter on Chronic Periodontitis With Slight to Moderate Loss of Periodontal Support* The American Academy of Periodontology has developed the following parameter on the treatment of chronic periodontitis with slight to moderate loss of periodontal supporting tissues. In molars. an adverse change in prognosis.

pharmacotherapeutics. Contributing systemic risk factors may affect treatment and therapeutic outcomes for chronic periodontitis.1:567-580. Ann Periodontol 1996. Stabilization or gain of clinical attachment.Supplement Initial Therapy 1. Non-surgical pocket therapy: Pharmacotherapeutics. Local factors contributing to chronic periodontitis should be eliminated. certain periodontal bacteria. periodontal maintenance should be scheduled at appropriate intervals (see Parameter on Periodontal Maintenance. pregnancy. alteration. A. F. Drisko CH. Restoration of open contacts which have resulted in food impaction. and dental occlu- Parameter on Chronic Periodontitis With Slight to Moderate Loss of Periodontal Support Volume 71 • Number 5 (Supplement) . D. Removal or reshaping of restorative overhangs and over-contoured crowns. 3. or controlled. 9. B. Odontoplasty. These may include diabetes. These findings may be compared to initial documentation to assist in determining the outcome of initial therapy as well as the need for and the type of further treatment. Elimination. Bone replacement grafts. In patients where the periodontal condition does not resolve. To accomplish this. B. Guided tissue regeneration. Ann Periodontol 1996. 854 Periodontal Surgery A variety of surgical treatment modalities may be appropriate in managing the patient. Persistent clinically detectable plaque levels not compatible with gingival health. 4. 8. the following procedures may be considered: A. Gher ME. Not all patients or sites will respond equally or acceptably. E. Additional therapy may be warranted on a site specific basis. or control of risk factors which may contribute to chronic periodontitis should be attempted. 6.and subgingival scaling and root planing should be performed to remove microbial plaque and calculus. lack of effectiveness or non-compliance with plaque control. Refinement therapy to achieve therapeutic objectives. or therapist’s decision. Non-surgical pocket therapy: Mechanical. patient desires. Gingival augmentation therapy. C. 2. Gingivectomy. Instruction. Persistent or increasing probing depths. HIV infection. pages 849-850). Lack of stability of clinical attachment.. and evaluation of the patient’s plaque control should be performed. OUTCOMES ASSESSMENT 1. Reduction of probing depths. control of diabetes. 2. 2. 1. 5. substance abuse. D. e. 7. and medications. Treatment of occlusal trauma.1:491-566. 3. Ann Periodontol 1996. Supra. systemic diseases and conditions (immunosuppression). Resective therapy: A. 3. 3. A periodontal examination and re-evaluation may be performed with the relevant clinical findings documented in the patient’s record. 3. B. B. Other Treatments 1. Inflammation of the gingival tissues. Antimicrobial agents or devices may be used as adjuncts. gender. Areas where the periodontal condition does not resolve may occur and be characterized by: A. Consensus report on non-surgical pocket therapy: Mechanical. Restoration of carious lesions. SELECTED RESOURCES 1. Tooth movement. G. C. periodontal surgery should be considered to resolve the disease process and/or correct anatomic defects. B. cessation of smoking. smoking. D. appropriate treatment to control the disease may be deferred or declined. Correction of ill-fitting prosthetic appliances. aging. The desired outcome of periodontal therapy in patients with chronic periodontitis with slight to moderate loss of periodontal support should result in: A. 4. Flaps with or without osseous surgery. additional therapy may be required. 2.1:443-490. 2. C. reinforcement. Treatment of residual risk factors should be considered. stress. Reduction of clinically detectable plaque to a level compatible with gingival health. genetic predisposition. Cobb CM. Significant reduction of clinical signs of gingival inflammation. An appropriate initial interval for periodontal maintenance should be determined by the clinician (Periodontal Maintenance Parameter. If the results of initial therapy resolve the periodontal condition. Combined regenerative techniques. Regenerative therapy: A. Non\-surgical pocket therapy: Dental occlusion. nutrition.g. B. If the results of initial therapy do not resolve the periodontal condition. Consultation with the patient’s physician may be indicated. pages 849-850). Evaluation of the initial therapy’s outcomes should be performed after an appropriate interval for resolution of inflammation and tissue repair. For reasons of health. C.

27. Palcanis KG. Westfelt E. Current status of bleeding in the diagnosis of periodontal diseases. J Periodontol 1979. Caton JG. 11. I. Reynolds HS. Charles CH. Genco RJ. J Periodontol 1985. Buckley LA. Harper DS. Mashimo P. 23. Zambon JLJ. J Periodont Res 1980. Burgett FG.1:589-617. Hovliaras CA. 15. Surgical pocket therapy. Crowley MJ. 2:83-97. Long-term effect of surgical/nonsurgical treatment of periodontal disease. J Periodontol 1994. The role of local factors in the etiology of periodontal diseases. Kaldahl WB. Ann Periodontol 1996. Periodontol 2000 1993. J Periodontol 1994. Johnson GK. Ramfjord S. 19. Ann Periodontol 1996. Effect of a chemotherapeutic agent delivered by an oral irrigation device on plaque.50:495-509. Ciancio SG.19:381-387. 1989. Hull PS. Patil KD. Mather ML. Periodontal therapy in humans. Microbiological and clinical effects of a single course of periodontal scaling and root planing. Corn H. Kalkwarf KL. Short-term microbiological and clinical effects of subgingival irrigation with an antimicrobial mouth rinse. Walsh TF. Fine JB. Ann Periodontol 1996. Armitage GC. Barrington EP. Effects of scaling and root planing on the composition of the human subgingival microbial flora. gingivitis. Wang HL. Slots J.65:30-36. Marks M. (Spec.2:98-116. J Clin Periodontol 1992. 22.13: 1098. Burgett FG. Löe H. Knowles J. Socransky S. The role of systemic conditions and disorders in periodontal disease. An overview of periodontal surgical procedures. Shiloah J. Compendium Contin Educ Dent 1992. Caffesse RG. Gordon JM. Momsquès T. 10. Consensus report on surgical pocket therapy. The influence of molar furcation involvement and mobility on future clinical periodontal attachment loss.19:245-248. Nissle RR. 26. Treatment of Gingivitis and Periodontitis (Position Paper). Clinical effects of pulsed oral irrigation with 0. Haffajee A.21:91-97. J Clin Periodontol 1994. J Periodontol 1993. J Periodontol 1989. Schick R. Phillips RW.68:1246-1253. Issue)56:1-3.1:618-620. J Clin Periodontol 1977. 14.65:25-29. Ah MKB. Philadelphia: Lea & Febiger.Parameters of Care Supplement sion. Listgarten MA.60:310-315. Morrison EC. 17. Polson AM. 6. Rosling B.11:448458.1:581-588. 8. Glenwright HD. Nyman S. Nyman S. 20. Periodontol 1981.64:835-843. 5. Shyr Y. 18. The American Academy of Periodontology. A randomized trial of occlusal adjustment in the treatment of periodontitis patients.2% chlorhexidine digluconate in patients with adult periodontitis. 13. Charbeneau TD. Supragingival and subgingival irrigation: Practical application in the treatment of periodontal diseases. Ramfjord SP. 25. Hovious LA. J Clin Periodontol 1984. J. Nissle R. Results of periodontal treatment related to pocket depth and attachment levels. 9. Eight years. A longitudinal study of untreated periodontal disease. The effect of smoking on the response to periodontal therapy. Burgett FG.4:1-6. Lindhe J. Morrison E. and of adjunctive tetracycline therapy. Development of a classification system for periodontal diseases and conditions. and subgingival microflora. J Periodontol 1997. Atlas of Adult Orthodontics. Periodontol 2000 1993. Löe H. J Clin Periodontol 1992. 21. Ann Periodontol 1999.52:518-528.4: 240-249. Lindhe J. J Periodontol • May 2000 (Supplement) 855 . Kornman KS. Greenstein G. 11:523-530. 24. J Clin Periodontol 1984. Periodontal surgery in plaque-infected dentitions.50:225-233. Ramfjord S. Levine MJ. Genco RJ.15:144-151. 7. 16. 12. J Periodontol 1979. The role of subgingival irrigation in the treatment of periodontitis.

erythema. In addition. Increased tooth mobility may be present. May 1998. or more generalized. patient care planning. * Approved by the Board of Trustees. J Periodontol 2000. regeneration of the periodontal attachment apparatus. an adverse change in prognosis. age. Patients should be informed of the disease process. Treatment considerations for patients with advanced loss of periodontal support are described below. tooth loss/prevention and control. Chronic periodontitis with advanced loss of periodontal supporting tissues may be localized. involving several teeth or the entire dentition. Many factors affect the decisions for appropriate therapy(ies) and the expected therapeutic results. Patient-related factors include systemic health. where indicated. thereby arresting the progression of disease and preserving the dentition in a state of health. Initial Therapy 1. moderate. involving one area of a tooth’s attachment. Radiographic evidence of bone loss is apparent. compliance. periodontitis/complications. if present. and/or suppuration. KEY WORDS Disease progression. patients should then be able to make informed decisions regarding their periodontal therapy. Loss of clinical attachment.Supplement Parameter on Chronic Periodontitis With Advanced Loss of Periodontal Support* The American Academy of Periodontology has developed the following parameter on the treatment of chronic periodontitis with advanced loss of periodontal supporting tissues. expected results. Clinical Features Clinical features may include combinations of the following signs and symptoms: edema. in the furcation. Contributing systemic risk factors may affect treatment and therapeutic outcomes for chronic periodontitis. Chronic periodontitis with advanced loss of periodontal support is characterized by a loss of greater than onethird of the supporting periodontal tissues. comfort. A patient may simultaneously have areas of health and chronic periodontitis with slight. and function with appropriate esthetics. and the presence and treatment of teeth with more advanced chronic periodontitis. and patient’s ability to control plaque. gingival bleeding upon probing. Given this information. potential complications. cer- 856 Volume 71 • Number 5 (Supplement) . therapeutic alternatives. These may include diabetes. and their responsibility in treatment. The disease is characterized by loss of clinical attachment due to destruction of the periodontal ligament and loss of the adjacent supporting bone. TREATMENT CONSIDERATIONS Clinical judgment is an integral part of the decisionmaking process. and advanced destruction. periodontal attachment loss/prevention and control. therapeutic preferences. Consequences of no treatment should be explained. CLINICAL DIAGNOSIS Definition Chronic periodontitis is defined as inflammation of the gingiva and the adjacent attachment apparatus. Other factors include the clinician’s ability to remove subgingival deposits. and to prevent the recurrence of periodontitis. may be attempted. Advanced destruction is generally characterized by periodontal probing depths greater than 6 mm with attachment loss greater than 4 mm. prosthetic demands. smoking. American Academy of Periodontology. Failure to appropriately treat chronic periodontitis can result in progressive loss of periodontal supporting tissues. will exceed Class I (incipient).71:856-858. periodontitis/diagnosis. THERAPEUTIC GOALS The goals of periodontal therapy are to alter or eliminate the microbial etiology and contributing risk factors for periodontitis. and could result in tooth loss.

5. Instruction. Problem focused surgical therapy.and subgingival scaling and root planing should be performed to remove microbial plaque and calculus. Consultation with the patient’s physician may be indicated. 3. B. 4. Correction of ill-fitting prosthetic appliances. Combined regenerative techniques. Progress toward the reduction of clinically detectable plaque to a level compatible with gingival health. initial therapy may become the end point. control of diabetes.g. Stabilization or gain of clinical attachment. Regenerative therapy: A. possibly including antibiotic-sensitivity testing. genetic predisposition. D. Flaps with or without osseous surgery. Refinement therapy to achieve therapeutic objectives. 6. E. C. nutrition. B. substance abuse. Tooth movement. C. 1. Restoration of open contacts which have resulted in food impaction. Compromised Therapy In certain cases. to reduce gingival recession. pregnancy. periodontal surgery should be considered. Extraction of hopeless teeth. F. D. Guided tissue regeneration. patient desires. Significant reduction of clinical signs of gingival inflammation. E. Radiographic resolution of osseous lesions. Subgingival microbial samples may be collected from selected sites for analysis. 2. Treatment of occlusal trauma. Additional therapy may be warranted on a site specific basis. Supra. etc. H. C. This should include timely periodontal maintenance. because of the severity and extent of disease and the age and health of the patient. To accomplish this. G. treatment that is not intended to attain optimal results may be indicated. HIV infection. Local factors contributing to chronic periodontitis should be eliminated or controlled. Reduction of probing depths. appropriate treatment to control the disease may be deferred or declined. C. Odontoplasty. additional therapy may be required. cessation of smoking. Areas where the periodontal condition does not resolve may occur and be characterized by: A. B. A variety of surgical treatment modalities may be appropriate in managing the patient. C. 2. systemic diseases and conditions (immunosuppression). For reasons of health. This approach may be considered to enhance effective root debridement. Inflammation of the gingival tissues. to possibly enhance regenerative therapy. gender. 3. In patients where the periodontal condition does not resolve. Gingival augmentation therapy 2. e. Persistent or increasing probing depths. Progress toward occlusal stability. Not all patients or sites will respond equally or acceptably. stress. A. the following procedures may be considered: A. aging. An appropriate initial interval for periodontal maintenance should be determined by the clinician (see on Periodontal Maintenance Parameter. B. reinforcement. Restoration of carious lesions. B. and medications. or control of risk factors which may contribute to adult periodontitis should be attempted. or therapist’s decision. Persistent clinically detectable plaque levels not compatible with gingival health. 3. Treatment of residual risk factors should be considered. The desired outcome of periodontal therapy in patients with chronic periodontitis with advanced loss of periodontal support should include: A. Removal or reshaping of restorative overhangs and over-contoured crowns. Lack of stability of clinical attachment. 2.. In these cases. Gingivectomy. and evaluation of the patient’s plaque control should be performed. B. Antimicrobial agents or devices may be used as adjuncts. Elimination. on patients who demonstrate effective plaque control and favorable compliance in their prior dental care.Parameters of Care Supplement tain periodontal bacteria. J Periodontol • May 2000 (Supplement) 857 . pages 849-850). Other Treatments 1. Root resective therapy. Periodontal Surgery In patients with chronic periodontitis with advanced loss of periodontal support. Bone replacement grafts. 3. Resective therapy: A. F. D. 4. lack of effectiveness or non-compliance with plaque control. alteration. OUTCOMES ASSESSMENT 1.

J Clin Periodontol 1990.50:225-233. 2:83-97. Consensus report on non-surgical pocket therapy: Mechanical. J Periodontol 1998. Non-surgical pocket therapy: Dental occlusion. 14. Drisko CH. Ann Periodontol 1996.10:433442. Philadelphia: Lea & Febiger. A role for antibiotics in the treatment of refractory periodontitis. Contemporary Periodontics. J Periodontol 1981.69:396-399. Ann Periodontol 1996. The influence of molar furcation involvement and mobility on future clinical periodontal attachment loss. Goldman H. Barrington E. An indicator of periodontal stability. Progression of periodontal disease in adult subjects in the absence of periodontal therapy. Chicago: Quintessence Publishing. Löe H. Roberts WE. The role of local factors in the etiology of periodontal diseases. Wang HL.52:518-528. Becker B. St. Treatment of Gingivitis and Periodontitis (Position Paper). Becker W. 13. 1989.68:1246-1253.1:581-588. Ann Periodontol 1996. Haffajee AD. Socransky S. J Periodontol 1990. 10. Chicago: The American Academy of Periodontology. Joss A.1:618-620.61:543-552. 1994.17:714-721.1:491-566. 15. Wilson T. Berg L. 12. 19. The American Academy of Periodontology. Genco R. Louis: The CV Mosby Company. Clinical management of periodontal diseases. Decision Making in Dental Treatment Planning. St. Burgett FG. 8. Hall WB. Cobb CM. J Periodontol 1979. 18.):772-781. Lang N.1:589-617. Atlas of Adult Orthodontics. Guidelines for Periodontal Therapy (Position Paper). Magnusson I. Periodontol 2000 1993. 7. Labarre EE. Ranney R. 17. 5. Knowles J.2:13-25. J Am Dent Assoc 1990. Löe H. Nevins M. 1989. 1990.65:25-29. Non-surgical pocket therapy: Mechanical. 21. Lindhe J. Proceedings of the World Workshop in Clinical Periodontics. Classification of periodontal diseases. Caton J. 4. Greenstein G. Morrison E. The American Academy of Periodontology. An overview of periodontal surgical procedures. 858 Parameter on Chronic Periodontitis With Advanced Loss of Periodontal Support Volume 71 • Number 5 (Supplement) . J Periodontol 1994. Gher ME. Surgical pocket therapy. 2. 16. Absence of bleeding on probing. J Clin Periodontol 1983. J Periodontol 1997. J Periodontol 1979. Ramfjord S. Clark WB. Ann Periodontol 1996. Adler R. Palcanis KG. Eight years. Walker CB. Nyman S. Periodontol 2000 1993. 3. Louis: The CV Mosby Company. Kornman K. J Periodontol 1993. 20. 23. Untreated periodontal disease: A longitudinal study. Burgett FG. Periodontal disease activity: A critical assessment. Gordon JM. Diagnosing periodontal diseases. 24. Ramfjord S. Periodontol 2000 1993. Cohen D. Schick R.2:128-139. 22. and dental occlusion. The American Academy of Periodontology.64(Suppl. Ann Periodontol 1996.Supplement SELECTED RESOURCES 1. 9. Nissle R. Shyr Y. 25. Results of periodontal treatment related to pocket depth and attachment level.121:460-464.1:567-580.50:234-244.1:443-490. Corn H. pharmacotherapeutics. Barrington EP. Lang N. 11. Newman M. Marks M. Non-surgical pocket therapy: Pharmacotherapeutics. 6. 1992. Consensus report on surgical pocket therapy. Kornman K. Ann Periodontol 1996. Advances in Periodontology.

No treatment is very likely to result in further progression of the disease and eventual tooth loss. “Refractory” periodontitis is usually diagnosed after the conclusion of conventional active therapy. e. certain blood dyscrasias. periodontitis/complications. These diseases may occur in situations where conventional therapy has failed to eliminate microbial reservoirs of infection. be non-responsive to treatment. Elimination or correction of defective restorations and other local factors that might interfere with oral hygiene efforts or act as retention sites for periodontal pathogens. Use of local and/or systemic antimicrobial agents. Clinical Features The primary feature of “refractory” periodontitis is the occurrence of additional clinical attachment loss after repeated attempts to control the infection with conventional periodontal therapy. immunosuppressive disorders. Thorough scaling and root planing to remove microbial deposits and eliminate anatomical root features that might act as reservoirs for microbial infection. J Periodontol • Mary 2000 (Supplement) 859 . 8. Consequences of no treatment should be explained. 4. 2. of the following: 1. Such conventional therapy frequently includes most. The term refers to destructive periodontal diseases in patients who. but not necessarily all. CLINICAL DIAGNOSIS Definition “Refractory periodontitis” is not a single disease entity. patient care planning. patients should then be able to make informed decisions regarding their periodontal therapy. KEY WORDS Disease progression. therapeutic alternatives. refractory chronic periodontitis and refractory aggressive periodontitis. foreign body impaction. retrograde pulpal diseases.g. Have recurrence of progressive periodontitis after many years of successful periodontal maintenance. Occlusal therapy. 6. and their responsibility in treatment. Periodontal maintenance and re-evaluation. Extraction of severely involved teeth. This diagnosis is not appropriate for patients who: 1. 3.71:859-860. Have received incomplete or inadequate conventional therapy. The diagnosis of “refractory” periodontitis should only be made in patients who satisfactorily comply with recommended oral hygiene procedures and follow a rigorous program of periodontal maintenance. Patients should be informed of the disease process. The “refractory’’ designation can be applied to all forms of destructive periodontal disease that appear to * Approved by the Board of Trustees.Parameters of Care Supplement Parameter on “Refractory” Periodontitis* The American Academy of Periodontology has developed the following parameter on the treatment of “refractory’’ periodontitis. Have identifiable systemic conditions that may increase their susceptibility to periodontal infections such as diabetes mellitus. or has resulted in the emergence or superinfection of opportunistic pathogens. In such cases a reasonable treatment objective is to slow the progression of the disease. THERAPEUTIC GOALS The goal of therapy for “refractory” periodontitis is to arrest or slow the progression of the disease. 5. periodontitis/therapy. 7. Have localized areas of rapid attachment loss which are related to factors such as: root fracture.. American Academy of Periodontology. and pregnancy. 2. control may not be possible in all instances. behavior modification. Patient education and training in personal oral hygiene. potential complications. They may also occur as the result of a complexity of unknown factors which may compromise the host’s response to conventional periodontal therapy. despite well-executed therapeutic and patient efforts to stop the progression of disease. expected results. Given this information. when longitudinally monitored. 4. Due to the complexity and many unknown factors. May 1998. or various root anomalies. Surgical therapy. demonstrate additional attachment loss at one or more sites. J Periodontol 2000. 3.

Marks RG. conventional periodontal therapies may be used. Effects of a combination therapy to eliminate Porphyromonas gingivalis in refractory periodontitis.61:686-691. J Periodontol 1994. pages 849-850). Syed SA. In: Proceedings of the World Workshop in Clinical Periodontics. Socransky S. OUTCOMES ASSESSMENT 1. Tooth loss in maintenance patients in a private periodontal practice. Rosling B.1:581-588. the following steps may be taken: 1. J Periodontol 1988. Hamp S-E. J Periodontol 1982. Telsey B.11:321-330.1:491-566. Magnusson I. Effect of combined systemic antimicrobial therapy and mechanical plaque control in patients with recurrent periodontal disease. Collection of subgingival microbial samples from selected sites for analyses. Genco RJ. 5. 21. 4:240-249. Non-surgical pocket therapy: Pharmacotherapeutics. 5. a reasonable treatment objective is to slow the progression of the disease. The effect of long-term lowdose tetracycline therapy on the subgingival microflora in refractory adult periodontitis.. Metronidizole in periodontitis. 22. gins T. J Periodontol 1986. 6. Drisko. Glover ME. Arnold RR. In conjunction with the administration of an antimicrobial regimen. The effect of clindamycin on the microbiota associated with refractory periodontitis. 13. New views on periodontal microbiota in special patient categories. Pertuiset JH. Walker CB. McArthur WP. 25. Kornman KS.64:155-161. Loesche WJ. Walker C. Effect of non-surgical periodontal therapy combined with adjunctive antibiotics in subjects with refractory periodontal disease. Young V. 2. Socransky SS. The American Academy of Periodontology. control may not be possible in all instances. Wilson TG. 14. Morrison EC.58:231-235. 4. Mandel ID.14:52-55. Tooth loss in 100 treated patients with periodontal disease. Oshrain HI. Kerry GA. an aid for patients refractory to periodontal therapy. Host responses in patients with generalized refractory periodontitis. I. J Clin Periodontol 1991. A long-term study. Hirschfeld L. Ellison SA. Intensified periodontal maintenance program which may include shorter intervals between appointments with microbiologic testing if indicated (Parameter on Periodontal Maintenance. 6. et al. Haffajee AD. Taubman MA.4:1-6. Clark WB. J Periodontol 1982.55:325-335. Kornman KS. 18. Fine DH. Slots J. possibly including antibiotic-sensitivity testing. 7. Lofthus J. Hig19. J Clin Periodontol 1994. Chicago: American Academy of Periodontology. 860 Parameter on ‘‘Refractory’’ Periodontitis Volume 71 • Number 5 (Supplement) . 8.Supplement TREATMENT CONSIDERATIONS Once the diagnosis of “refractory” periodontitis has been made. I. Schoen JA. Rosling BG: Relationship between some subgingival bacteria and periodontal pocket depth and gain or loss of periodontal attachment after treatment of adult periodontitis. Due to the complexity and many unknown factors of “refractory” periodontitis. J Periodontol 1984. Periodontal surgery in plaque-infected dentitions. Clinical and bacteriological results after 15 to 30 weeks.18: 291-299. Dzink JL. Ann Periodontol 1996. 11. Armitage GC. smoking). Saglie FR. Marks RG. J Periodontol 1987. 26. Stoll J. J Periodontol 1987. 3. A long-term survey of tooth loss in 600 treated periodontal patients. Offenbacher S. microbiological and immunological characteristics of subjects with refractory periodontal disease. Maruniak J. 1989:I/23-I/31. Nyman S. Holt SC. Magnusson I. 3. Recurrent periodontal disease and bacterial presence in the gingiva. J Periodontol 1990:61:692-698. Ebersole JL. microbiological and immunological features of subjects with refractory periodontal diseases. J Clin Periodontol 1988. J Periodontol 1978. Efficacy of clindamycin hydrocloride in refractory periodontitis: 24month results. The desired outcome for patients with “refractory” periodontitis includes arresting or controlling the disease. Telsey B. 20. J Clin Periodontol 1984. J Periodontol 1993. Walker C. Oshrain HI. Clinical results. Walker CB. J Periodontol 1990. Dorsett D. Bacterial invasion in root cemetum and radicular dentin of periodontally diseased teeth in humans: A reservoir of periodontopathic bacteria. Gordon J.16:647-653. Loesche WJ. Adriaens PA. 2. Low SB. 18:411-420. 4. Johansson L-Å. Consensus report on non-surgical pocket therapy: Mechanical. J Clin Periodontol 1985. Wasserman B. SELECTED RESOURCES 1.53: 604-610. De Boever JA. C. Karl EH. J Clin Periodontol 1977. J Clin Periodontol 1987. Malik AK. J Clin Periodontol 1991. Ann Periodontol 1999. Neutrophil chemotaxis in refractory cases of periodontitis. 2. 10.59:222-230. McFall WT Jr.64:998-1007. Clark WB.21:98-106.49:225-237.12:540-552. pharmacotherapeutics. 15. Clinical. In such cases. 12. Development of a classification system for periodontal diseases and conditions. Low SB. Microbial identification and antibiotic sensitivity testing. Lindhe J. Periodontal diagnosis and diagnostic aids: Consensus report. and dental occlusion. 57:325-327.53:539-549. Lundström Å. Rezende M. J Periodontol 1993. Slots J. Gordon J. Reevaluation with microbiological testing as indicated. Ann Periodontol 1996.g. Selection and administration of an appropriate antibiotic regimen. A simplified laboratory procedure to select an appropriate antibiotic for treatment of refractory periodontitis. J Clin Periodontol 1989. Identification and attempt to control risk factors (e.15:390-398. 17. Sanz M. Microbial composition and pattern of antibiotic resistance in subgingival microbial samples from patients with refractory periodontitis. 9. Hovliaras C. Collins JG. Emrich LJ.65:8-16. 23. Rams RE. 16. Hernichel-Gorbach E.58:553-558. Listgarten MA. Lai CH. 24. Clinical.

2. and their responsibility in treatment.Parameters of Care Supplement Parameter on Mucogingival Conditions* The American Academy of Periodontology has developed the following parameter on the identification and treatment of mucogingival conditions. The problem-focused examination should also include appropriate screening techniques to evaluate for periodontal or other oral diseases. A medical history should be taken and evaluated to identify predisposing conditions that may affect treatment or patient management. TREATMENT CONSIDERATIONS 1. KEY WORDS Gingival diseases/etiology. and probing depths extending beyond the MGJ. and/or amount of soft tissue and underlying bone. Examination Mucogingival conditions may be detected during a comprehensive or problem-focused periodontal examination. therapeutic alternatives. appropriate radiographs may be utilized as part of the examination. disease progression. gingival augmentation. In order to monitor changes of mucogingival conditions. Anatomical variations that may complicate the management of these conditions include tooth position. The goals of mucogingival therapy are to help maintain the dentition or its replacements in health with good function and esthetics. gingiva/anatomy and histology. 7. Patients should be informed of the disease process. Mucogingival relationships should be evaluated to identify deficiencies of keratinized tissue. Given this information. 3. position. Features of a problem-focused examination that apply to mucogingival conditions: 1. May 1998. The consequences of this option may range from no change in the condition to progression of the defect. and may include restoring anatomic form and function. and other tissue abnormalities. CLINICAL DIAGNOSIS Definition Mucogingival conditions are deviations from the normal anatomic relationship between the gingival margin and the mucogingival junction (MGJ). Several mucogingival conditions may occur concurrently.71:861-862. potential complications. dental. While radiographs do not detect mucogingival problems. Variations in ridge anatomy may be associated with mucogingival conditions. absence or reduction of keratinized tissue. 5. A further goal is to reduce the risk of progressive recession. abnormal frenulum insertions. baseline findings should be recorded. J Periodontol 2000. J Periodontol • May 2000 (Supplement) 861 . 4. Relevant findings from probing and visual exam- inations of the periodontium and the intraoral soft tissues should be collected and recorded. health education. Etiologic factors that may have an impact on the results of therapy should be evaluated. pocket reduction. This may be accomplished with a variety of procedures including root coverage. Consequences of no treatment should be explained. as well as control of etiologic factors. * Approved by the Board of Trustees. patient care planning. patients should then be able to make informed decisions regarding their periodontal therapy. and ridge reconstruction. Variations in ridge configuration should also be evaluated. THERAPEUTIC GOALS Mucogingival therapy is defined as non-surgical and/or surgical correction of defects in morphology. frenulum insertions and vestibular depth. risk factors. American Academy of Periodontology. A dental history including the chief complaint should be taken and evaluated. expected results. Clinical Features Common mucogingival conditions are recession. 6. necessitating the consideration of combining or sequencing surgical techniques.

C. Wennström JL. Satisfactory esthetics. and/or antimicrobial agents. H. G. A. Marks M. 1989. Depending on the mucogingival conditions. Smukler H. Dent Clin North Am 1993.12:667-675. 16. Lateral sliding flaps with and without citric acid.58: 696-700. Exposure of unerupted teeth. Ridge defects that may need correction prior to prosthetic rehabilitation can be treated by a variety of tissue grafting techniques and/or guided tissue regeneration. Frenectomy. Int J Periodontics Restorative Dent 1987. J Periodontol 1987. Stein MD.1:702-706. Papilla regeneration. Bissada N. Morrison E. Int J Periodontics Restorative Dent 1987. Behrents R. Not all patients or sites will respond equally or acceptably. 11. Bird WC. D. Odontoplasty. F. additional therapy may be required.5(2):913. 13. Additional therapy may be warranted on a site specific basis. Philadelphia: Lea & Febiger. 4. K. Laterally positioned mucoperiosteal pedicle grafts in the treatment of denuded roots.7(6):43-57. A classification of marginal tissue recession. localized alveolar ridge defects. Alspach S. 5. C. Langer L. Coatoam G. Caffesse R. In patients where the condition did not resolve. J. The rationale for mucogingival therapy in the child and adolescent. Corn H. Vestibular depth alteration. J Clin Periodontol 1986. Atlas of Adult Orthodontics. Control of inflammation through plaque control. A 10-year longitudinal study of untreated mucogingival defects. The subepithelial connective tissue graft for treatment of gingival recession. J Periodontol 1992. 12. 4. B. 14. J Periodontol 1972.1:671-701. Dorfman HS. 9. 6.37:243-264. Areas where the condition did not resolve may be characterized by: A. Mucogingival therapy. I. scaling and root planing. A 5-year longitudinal study. 862 Parameter on Mucogingival Conditions Volume 71 • Number 5 (Supplement) . Wennström. Persistence of clinical signs of inflammation. Langer B. and esthetic considerations of the patient. Tooth movement. Return to function in health and comfort. Ann Periodontol 1996. A clinical and statistical study.43:623-627. Int J Periodontics Restorative Dent 1985. E. Significance of the width of keratinized gingiva on the periodontal status of teeth with submarginal restorations. availability of donor tissue. Persistence of the mucogingival problem. 3. Surgical procedures to reduce probing depths. A longitudinal evaluation of varying widths of attached gingiva. Lack of association between width of attached gingiva and development of soft tissue recession. The selection of surgical procedures may depend on the configuration of the defect. Semilunar coronally repositioned flap. J Periodontol 1976. Miller PD Jr. B. D.63:71-72. J Periodontol 1981. Root coverage. Less than satisfactory esthetics. the following treatments may be indicated: A.13:182-185. Dent Clin North Am 1993. Correction of the mucogingival condition. B. Ann Periodontol 1996. 3. Maynard JG Jr. B. Treatment options for altering vestibular depth may include gingival augmentation and/or vestibuloplasty. SELECTED RESOURCES 1. JL. Green K. Bissada NF. 15. Burgett F. Consensus report on mucogingival therapy. J Clin Periodontol 1987. 7.52:307-313. 2. The relationship between the width of keratinized gingiva and gingival health. C.7(1):37-51.Supplement 2. Stetler KJ. The desired outcome of periodontal therapy for patients with mucogingival conditions should result in: A. Crown lengthening. Cessation of further recession. E. 2. Preventive and reconstructive concepts in therapy. Tarnow DP. The width of keratinized gingiva during orthodontic treatment: Its significance and impact on periodontal status. Ridge augmentation. Palcanis KG. J Clin Periodontol 1985.47:590-595. Extraction site grafts to prevent ridge collapse. Tissues free of clinical signs of inflammation. 10. Lang NP. Freeman AL. 3. Seibert JS. Treatment of moderate. 8. OUTCOMES ASSESSMENT 1. Kennedy JE.37:265-280. Löe H. Gingival augmentation therapy.14:181-184. Salkin LM.

J Periodontol • May 2000 (Supplement) 863 . Combined periodontal-endodontic lesions. Outcomes Assessment 1. patients should then be able to make informed decisions regarding their periodontal therapy. 2. KEY WORDS Disease progression. Treatment Considerations Treatment considerations include drainage to relieve the acute symptoms and mitigation of the etiology. PERIODONTAL ABSCESS Clinical Diagnosis Definition: A localized purulent infection within the tissues adjacent to the periodontal pocket that may lead to the destruction of periodontal ligament and alveolar bone. potential complications. CLINICAL DIAGNOSIS Definition Acute periodontal diseases are clinical conditions of rapid onset that involve the periodontium or associated structures and may be characterized by pain or discomfort and infection. additional therapy may be required. a purulent exudate. In patients where the gingival condition does not resolve. health education. expected results. 3. Necrotizing periodontal diseases. Areas where the gingival condition does not resolve may be characterized by recurrence of the abscess or change to a chronic condition. Factors which may contribute to the nonresolution of this condition may include the failure to remove the cause of irritation. with a red. Periodontal abscess. Therapeutic Goals The goal of therapy for a gingival abscess is the elimination of the acute signs and symptoms as soon as possible. 6. Herpetic gingivostomatitis. Clinical features may include combinations of the following signs and symptoms: a smooth. Clinical features. Gingival abscess. American Academy of Periodontology. 3. Clinical features may include combinations of the following signs and symptoms: a localized area of swelling in the marginal gingiva or interdental papillae. shiny swelling of the gingiva. 4. smooth. Consequences of no treatment should be explained. Clinical Features Acute periodontal infections include: 1. with possible systemic manifestations. Clinical features. an adverse change in prognosis. and their responsibility in treatment.71:863-866. or inaccurate diagnosis. 2. They may or may not be related to gingivitis or periodontitis. patient care planning. Given this information. shiny surface. Pericoronal abscess (pericoronitis). periodontal disease/therapy. and could result in tooth loss. 4. A purulent exudate may be present. therapeutic alternatives. 5. The desired outcome of therapy in patients with a gingival abscess should be the resolution of the signs and symptoms of the disease and the restoration of gingival health and function.Parameters of Care Supplement Parameter On Acute Periodontal Diseases* The American Academy of Periodontology has developed the following parameter on the treatment of acute periodontal diseases. * Approved by the Board of Trustees. J Periodontol 2000. They may be localized or generalized. May 1998. risk factors. with the area of swelling tender to touch. Failure to treat acute periodontal diseases appropriately can result in progressive loss of periodontal supporting tissues. A localized purulent infection that involves the marginal gingiva or interdental papilla. GINGIVAL ABSCESS Clinical Diagnosis Definition. dental. incomplete debridement. Patients should be informed about the disease process. The lesion may be painful and appear pointed. pain.

appropriate fluid intake. 2. A periodontal abscess may be associated with endodontic pathosis. and ulceration of the gingiva and/or oral mucosa. patient non-compliance. Resolution of the acute phase may result in partial regaining of attachment that had been lost. A comprehensive periodontal evaluation should follow resolution of the acute condition. 3. fever. as necessary. Therapeutic Goals The goal of therapy for a periodontal abscess is elimination of the acute signs and symptoms as soon as possible. 4. Treatment Considerations Treatment considerations include irrigation and debridement of the necrotic areas and tooth surfaces. Factors which may contribute to non-resolution of the condition may include failure to remove the causes of irritation. Clinical Features Clinical features may include combinations of the following signs and symptoms: generalized pain in the gingiva and oral mucous membranes. vesiculation. The desired outcome of therapy in patients with a periodontal abscess is the resolution of signs and symptoms. and administration of antimicrobials and management of patient comfort. These conditions may have a tendency to recur and frequent periodontal maintenance visits and meticulous oral hygiene may be necessary. HERPETIC GINGIVOSTOMATITIS Clinical Diagnosis Definition. Necrotizing ulcerative gingivitis (NUG) is an acute infection of the gingiva. A comprehensive periodontal evaluation should follow resolution of the acute condition. and/or underlying systemic conditions. Treatment Considerations Treatment considerations include establishing drainage by debriding the pocket and removing plaque. The desired outcome of therapy in patients with necrotizing periodontal diseases should be the resolution of signs and symptoms and the restoration of gingival health and function. In patients where the condition does not resolve. bright red marginal gingiva which bleed on slight manipulation. Areas where the acute condition does not resolve may be characterized by recurrence of the abscess and/or continued loss of periodontal attachment. inflammation. Therapeutic Goals The goal of therapy for necrotizing periodontal diseases is the prompt elimination of the acute signs and symptoms. 4. In some circumstances extraction of the tooth may be necessary. Therapeutic Goals The goal of therapy for herpetic gingivostomatitis is the relief of pain to facilitate maintenance of nutrition. In patients with NUG.. A surgical procedure for access for debridement may be considered. Volume 71 • Number 5 (Supplement) . The tooth may be sensitive to percussion and may be mobile. additional therapy and/or medical/dental consultation may be indicated. Areas where the gingival condition does not resolve may occur and be characterized by recurrence and/or progressive destruction of the gingiva and periodontal attachment. and malaise. concomitant endodontic pathosis). NECROTIZING PERIODONTAL DISEASES Clinical Diagnosis Definition. Herpetic gingivostomatitis is a viral infection (herpes simplex) of the oral mucosa. it has been referred to as necrotizing ulcerative periodontitis (NUP). and other irritants and/or incising the abscess. Rapid loss of periodontal attachment may occur. calculus. 3. or the presence of underlying systemic disease. Both NUG and NUP may be asso864 Parameter on Acute Periodontal Diseases ciated with HIV/AIDS and other diseases where the immune system is compromised. Where NUG has progressed to include attachment loss. Outcomes Assessment 1. and poor nutrition. incomplete debridement. Patient counseling should include instruction on proper nutrition. hydration. In patients where the condition does not resolve. incomplete diagnosis (e.Supplement and/or increase in probing depth. oral hygiene instructions and the use of oral rinses. NUG may include combinations of the following signs and symptoms: necrosis and ulceration of the tips of the interdental papillae or gingival margin. Outcomes Assessment 1. Factors which may contribute to non-resolution include the failure to remove the causes of irritation. incomplete debridement. 2. additional evaluation and therapy may be required. Clinical Features. inaccurate diagnosis. and basic oral hygiene.g. The mouth may have a malodor and systemic manifestations may be present. and painful. there may be increased levels of personal stress. limited occlusal adjustment. Other treatments may include irrigation of the pocket. pain control. lymphadenopathy. and smoking cessation. oral care. including appropriate antibiotic therapy. and management of systemic manifestations. heavy smoking.

The use of antiviral medications may be considered. with the area of swelling tender to the touch. including the causes of irritation. additional therapy may be indicated. Therapeutic Goals The goal of therapy for a pericoronal abscess is the elimination of the acute signs and symptoms as soon as possible. Other treatments may include endodontic therapy. and malaise. Therapeutic Goals The goal of therapy for combined periodontal/endodontic lesions (abscesses) is the elimination of the signs. The infections may arise primarily from pulpal inflammatory disease expressed itself through the periodontal ligament or the alveolar bone to the oral cavity. trismus. Treatment Considerations Treatment considerations include debridement and irrigation of the undersurface of the pericoronal flap. 2. Clinical features. and management of patient comfort. swollen. Clinical features may include signs and symptoms of the following: localized red. COMBINED PERIODONTAL/ENDODONTIC LESIONS (ABSCESSES) Clinical Diagnosis Definition. Outcomes Assessment 1. Patients should be instructed in home care. shiny swelling of the gingiva or mucosa. topical anesthetic rinses). In some circumstances. Outcomes Assessment 1. 3. Patient counseling should include instruction in proper nutrition. A surgical procedure for access for debridement may be considered. oral care. The desired outcome of therapy in patients with a periodontal/endodontic lesion is the resolution of the signs and symptoms. Areas where the condition does not resolve may be characterized by recurrence of the acute symptoms and/or spread of infection to surrounding tissues. a comprehensive periodontal and endodontic examination should follow resolution of the acute condition. Factors which may contribute to non-resolution may include the failure to remove the causes of irritation or incomplete debridement.Parameters of Care Supplement Treatment Considerations Treatment considerations include gentle debridement and the relief of pain (e. the administration of antimicrobials. Combined periodontal/endodontic lesions are localized. The desired outcome in patients with herpetic gingivostomatitis should be the resolution of signs and symptoms. A localized purulent infection within the tissue surrounding the crown of a partially or fully erupted tooth. pain. The patient should be informed that the disease is contagious at certain stages. Treatment Considerations Treatment considerations include establishing drainage by debriding the pocket and/or by incising the abscess. In other circumstances. lymphadenopathy. irrigation of the pocket. Also evident may be a purulent exudate. A fistulous track may be present. Clinical features may include combinations of the following signs and symptoms: smooth. appropriate fluid intake. 4. trauma from the opposing tooth may be an aggravating factor. an endodontic consultation may be required. and reassurance that the condition is self-limiting. In some cases of pericoronal abscess.g. fever. use of antimicrobials and tissue recontouring. they may arise as a sequela of a fractured tooth. limited occlusal adjustment. 2. circumscribed areas of infection originating in the periodontal and/or pulpal tissues. 2. In addition.. They also may arise primarily from a periodontal pocket communicating through accessory canals of the tooth and or apical communication and secondarily infect the pulp. symptoms and etiology as soon as possible. In patients where the condition does not resolve. medical consultation may be indicated. In any case. The tooth may be sensitive to percussion and mobile. Facial swelling and/or cellulitis may be present. PERICORONAL ABSCESS (PERICORONITIS) Clinical Diagnosis Definition. The desired outcome of therapy in patients with a pericoronal abscess should be the resolution of signs and symptoms of inflammation and infection and the restoration of tissue health and function. Outcomes Assessment 1. lesions that are painful to touch. If the condition does not resolve. or extraction of the involved and/or opposing tooth. Clinical features. Rapid loss of the periodontal attachment and periradicular tissues may occur. Areas where the acute condition does not resolve may be characterized by recurrence of an J Periodontol • May 2000 (Supplement) 865 . and/or a purulent exudate. extraction of the tooth may be necessary.

2nd ed. 1990. Hoag P. Johnson R. Acute necrotizing ulcerative gingivitis. Louis: The C. or the presence of underlying systemic disease. 3.66:990-998. Perspectives on soft tissue management for the prevention and treatment of periodontal diseases. Bissada NF. Necrotizing ulcerative gingivitis. 6. DeHaven H. and stomatitis: Clinical staging and predisposing factors. Cohen ME. Johnson BD. Compendium Continuing Educ Dent 1995. etiology. Kareha MJ. Therapeutic considerations in the management of a periodontal abscess with an intrabony defect. incomplete diagnosis. Philadelphia: Lea & Febiger. Engel D. 4. J Clin Periodontol 1981. 4th ed. Yuodelis R.8:375386. 5. Bissada NF. J Periodontol 1986. incomplete debridement. Schluger S. 2. Page R. A review of diagnosis.16:418-431. Horning GM. Factors which contribute to non-resolution of the condition may include failure to remove the causes of infection. 4. 866 Parameter on Acute Periodontal Diseases Volume 71 • Number 5 (Supplement) . St. Manouchehr-Pour M. Resolution of the acute phase by management of the multiple etiologic factors may result in partial restoration of the clinical attachment that has been lost. In patients where the condition does not resolve. and treatment. Periodontal disease in juvenile and adult diabetics: A review of the literature.V. Pawlak A. Periodontal Diseases.57:141-150. J Periodontol 1995. additional evaluation and therapy is required.Supplement abscess and/or continued loss of periodontal attachment and periradicular tissues. 107:766-770. periodontitis. SELECTED RESOURCES 1. Mosby Company. Rosenberg ES. 1990. J Am Dent Assoc 1983. 3. Essentials of Periodontics. 7.

The disease is frequently associated with the periodontal pathogen Actinobacillus actinomycetemcomitans and neutrophil function abnormalities. health education. Generalized aggressive periodontitis usually affects people under 30 years of age. immune defects. potential complications. However. thereby arresting the progression of disease and preserving the dentition in comfort. control of disease may not be possible in all instances. and appropriate esthetics and to prevent the recurrence of disease. Therapeutic Goals The goals of periodontal therapy are to alter or eliminate the microbial etiology and contributing risk factors for periodontitis. in most cases. Given this information. Localized aggressive periodontitis usually has a circumpubertal onset with periodontal damage being localized to permanent first molars and incisors. These methods should include oral hygiene instruction and reinforcement and evaluation of the patient’s plaque control. Clinical Features Some secondary features of aggressive periodontisis that are generally. A poor serum antibody response to infecting agents is frequently detected. otherwise appear healthy. It tends to have a familial aggregation and there is a rapid rate of disease progression. but not universally. Patients should be informed of the disease process.Parameters of Care Supplement Parameter on Aggressive Periodontitis* The American Academy of Periodontology has developed the following parameter on the treatment of aggressive periodontitis. This may have an adverse effect upon prognosis and could result in tooth loss. J Periodontol 2000. supra. and the microbial flora. pages 859-860). There is generalized interproximal attachment loss affecting at least 3 permanent teeth other than * Approved by the Board of Trustees. the first molars and incisors. dental. KEY WORDS Disease progression. therapeutic alternatives. and their responsibility in treatment.71:867-869. atypical patterns of affected teeth are possible. may be attempted. CLINICAL DIAGNOSIS Definition Aggressive periodontitis encompasses distinct types of periodontitis that affect people who. function. Due to the complexity of the aggressive periodontal diseases with regard to systemic factors. where indicated. patients (or their parents or guardians. regeneration of the periodontal attachment apparatus. expected results. as appropriate) should then be able to make informed decisions regarding their periodontal therapy.and subgin- J Periodontol • May 2000 (Supplement) 867 . a reasonable treatment objective is to slow the progression of the disease (Parameter on “Refractory” Periodontitis. Attachment loss occurs in pronounced episodic periods of destruction. treatment methods for the aggressive periodontal diseases may be similar to those used for chronic periodontitis (Parameter on Chronic Periodontitis With Advanced Loss of Periodontal Support. risk factors. The disease is frequently associated with the periodontal pathogens Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis and neutrophil function abnormalites. but patients may be older. May 1998. In such cases. periodontal diseases/therapy. pages 856-858). Aggressive periodontitis occurs in localized and generalized forms. Failure to treat aggressive periodontitis appropriately can result in progressive and often rapid loss of periodontal supporting tissues. In addition. Consequences of no treatment should be explained. American Academy of Periodontology. A robust serum antibody response to infecting agents is frequently detected. present are: 1) amounts of microbial deposits are inconsistent with the severity of periodontal tissue destruction and 2) the progression of attachment and bone loss may be self-arresting. patient care planning. Treatment Considerations In general.

3. Increasing tooth mobility. Progress toward occlusal stability. Due to the potential familial nature of aggressive diseases. 5. Localized juvenile periodontitis and generalized severe periodontitis: Clinical findings. 8. Progressive loss of clinical attachment. Yukna RA. Persistent gingival inflammation.1:1-36. Areas where the periodontal condition does not resolve may occur and be characterized by the presence of: 1. J Periodontol 1992. 5. 12:465-476. Defective polymorphonuclear leukocyte function in human periodontal disease. A general medical evaluation may determine if systemic disease is present in children and young adults who exhibit severe periodontitis. Consensus report on periodontal diseases: Epidemiology and diagnosis. No female preponderance in juvenile periodontitis after correction for ascertainment bias. Periodontal therapy in young adults with severe generalized periodontitis. Slots J. Mellott CA. In very young patients. as determined by the clinician (see Parameter on Periodontal Maintenance. Genco RJ.Supplement gival scaling and root planing to remove microbial plaque and calculus. McLey LL. eruption of permanent teeth should be monitored to detect possible attachment loss. Schenkein HA. Destructive periodontal disease in healthy children. 14. 868 2. 17. Mellott CA.64:760-771. Kaugars CC. 3rd ed. J Periodontol 1993.265: 445-447. Persistent clinically detectable plaque levels not compatible with periodontal health. 15. Kalkwarf KL. particularly if aggressive periodontitis appears to be resistant to therapy. Diehl SR. Zambon. Stabilization or gain of clinical attachment. Radiographic evidence of resolution of osseous lesions. Sepe WW. Proceedings of the World Workshop in Clinical Periodontics Chicago: The American Academy of Periodontology. 90) 1993. Gunsolley JC. in the early stages of disease. Outcomes Assessment The desired outcomes of periodontal therapy in patients with aggressive periodontitis should include: 1. Modification of environmental risk factors should be considered. Ann Periodontol 1996. pages 849-850). Gunsolley JG. SELECTED RESOURCES 1. Consensus report on periodontal diseases: Pathogenesis and microbial factors.1:216-222. 11. J Periodontol 1991. Rosling BG. J Periodontol 1994.65: 268-273. Clinical. and periodontal maintenance. 16. 5. Tate AL. Nature 1977. 4. Evans GH. van Oss CJ. 9. Kaugars CC. Genco RJ. 3.62:745-749. Reduction of probing depths. Ann Periodontol 1996. occlusal therapy as necessary. Alternative antimicrobial agents or delivery systems may be considered. Brooks CN. the use of tetracyclines may be contraindicated due to the possibility of staining of teeth. Periodontal diseases: Microbial factors. 6. Actinobacillus actinomycetemcomitans and localized juvenile periodontitis. In addition to the parameters for chronic periodontitis. Ann Periodontol 1996.90:1-46. Consultation with the patient’s physician may be indicated to coordinate medical care in conjunction with periodontal therapy. Swed Dent J (Suppl. Chicago: The American Academy of Periodontology. 65:274-279. Cianciola LJ. periodontal surgery as necessary. the following should be considered for patients who have aggressive periodontitis: 1. 3. Significant reduction of clinical signs of gingival inflammation. 4. PN. Brooks CN. The American Academy of Periodontology. Zambon JC. Palcanis KG. Glossary of Periodontal Terms.63: 761-765. Periodontal diseases: Epidemiology. McKenna J. 60:491-497.1:897-925. 4.11:181-192. 13. J Periodontol 1989. Gordon JM. Gunsolley JC. Wright JT. control of other local factors. microbiologic and histologic studies. 1989. 2. 2. 2.1:926932. Christersson LA. Initial periodontal therapy alone is often ineffective. Microbiological and clinical effects of surgical treatment of localized juvenile periodontitis. Ann Periodontol 1996. Mayer ET. Brooks CN. Hart TC. Microbiological identification and antibiotic sensitivity testing may be considered. Ranney RR. Walker CB. Cogen RB. Burmeister JA. The long-term outcome may depend upon patient compliance and delivery of periodontal maintenance at appropriate intervals. 3. Progress toward the reduction of clinically detectable plaque to a level compatible with periodontal health. J Periodontol 1994. Mabry TW. J Clin Periodontol 1984. 6. Persistent or increasing probing depths. J Clin Periodontol 1985. Marazita ML. Best AM. 7. Zambon JJ. 12. Patters MR. lesions may be treated with adjunctive antimicrobial therapy combined with scaling and root planing with or without surgical therapy. Neutropenias and neutrophil Parameter on Aggressive Periodontitis Volume 71 • Number 5 (Supplement) . 10. Maintenance therapy in young adults with severe generalized periodontitis. JJ. Caine FA. The American Academy of Periodontology. 1992. If primary teeth are affected. Papapanou. However. Christersson LA. evaluation and counseling of family members may be indicated. Current status of systemic antibiotic usage in destructive periodontal disease. 4. Effect of various graft materials with tetracycline in localized juvenile periodontitis.

J Clin Periodontol 1986. Defective neutrophil and monocyte motility in patients with early onset periodontitis.63: 52-57.62:608-616.63:806-811. Saxén L.A follow-up study. Ann Periodontol 1999. Liljenberg B. Results after 5 years. Lindhe J. 19. Löe H. 26.Parameters of Care Supplement 18. Mullally. J Periodontol 1983. Maderazo EG. 31. Mandell RL.16:124-127. and differential diagnosis.32:5-19. J Periodontol 1992. Tijhof CJ. J Periodontol 1991. Polson AM. 34. Geissler F. A retrospective radiographic study of alveolar bone loss in the primary dentition in patients with localized juvenile periodontitis. Wennström J. Novak MJ. 22. 30. Crossner C-G. J Periodontol 1994. Page RC. L. Early-onset periodontitis in the United States of America. J Clin Periodontol 1984. Periodontol Abstr J Western Soc Periodontol 1984. Microbiological and clinical results of metronidazole plus amoxicillin therapy in Actinobacillus actinomycetemcomitans-associated periodontitis. et al. J Periodontol 1985. Altman L. Tetracycline therapy in patients with early juvenile periodontitis.4:53. Van Winkelhoff AJ. Sandholm. et al. Definition of a clinical disease entity. 24. Treatment of juvenile periodontitis without antibiotics. Stolman J. 21. Treatment of localized juvenile periodontitis. J Clin Periodontol 1986. Sjödin B. 25. Sims TJ. J Periodontol 1988. Kornman KS. Consensus Report: Aggressive periodontitis. de Graaff J. Healing following surgical and non-surgical treatment of juvenile periodontitis. Cigarette smoking and periodontal destruction in young adults. Slots J. 29.56:443-446. Watanabe K. Altman LC. Page RC. Lavine WS. Son S. Socransky SS. Kari K. Lindhe J. Adair SM. Robertson PB. I. Microbiological and clinical effects of surgery plus doxycycline on juvenile periodontitis.13:869-882. Wennström A. 23.59:366-372. J Clin Periodontol 1983. Brown LJ. Baab DA.47: 169-175. J Periodontol • May 2000 (Supplement) 869 . Linden GJ. Impaired neutrophil chemotaxis in patients with juvenile and rapidly progressing periodontitis. 32.59:373-379.10:465486. dysfunction in children: Relationship to periodontal diseases. Kim DK. Bowen T. Suppression of the periodontopathic microflora in localized juvenile periodontitis by systemic tetracycline. 33. J Periodont Res 1990. J Clin Periodontol 1989. Rosling BG. Östlund P. J Periodontol 1992.25:31-48. 27. Unell L. Asikainen S. J Periodont Res 1979. Clinical and microbiological evaluation of therapy for juvenile periodontitis. A 5-year longitudinal study. Prepubertal periodontitis. Infect Immun 1985. 20. BH.13:714-719.54:257-271. J Periodontol 1988.11:399-410. Prepubertal periodontitis: A review of diagnostic criteria. 65:718-723. Kim KJ. pathogenesis.14:10-19. Chung CP. Longitudinal monitoring for disease progression of localized juvenile periodontitis. 28.

4. Design of planned restoration. patients should then be able to make informed decisions regarding their implant therapy. patient care planning. Appropriate educational materials are an essential part of gaining informed consent. Dental implants are used to replace single or multiple teeth or to serve as an abutment(s) for fixed or removable prostheses with the goal of restoring masticatory function and/or esthetics. 3. Number and location of missing teeth. 2. Dental implants are a recognized form of tooth replacement and as such should be presented as an alternative for the replacement of missing teeth. alcoholism. to insure implant health. A systematic and coordinated plan delineating the responsibilities of each member of the team should be developed and followed. high American Society of Anesthesiology (ASA) score. 870 Volume 71 • Number 5 (Supplement) . smoking. THERAPEUTIC GOAL The therapeutic goal of implant therapy is to support restorations that replace a tooth or missing teeth so as to provide patient comfort. J Periodontol 2000. The various habits and conditions which may place the patient at higher risk for implant failure. Surgical considerations for patients requiring implant placement should include evaluation of: anatomy and location of vital structures. A comprehensive treatment plan should be developed in consultation with all parties involved. Given this information. Imaging techniques. 5.71:870-872. 4. Patient motivation/ability to provide home care. Oral health status. dental implants/therapeutic use. IMPLANT PLACEMENT Prosthetic considerations for patients requiring implant placement should include evaluation of: 1. location. Surgical template. informed consent. Diagnostic casts.g. and their responsibility in treatment. 5. 2. function. type. including non-replacement. close monitoring and professional care by the dental team and good personal home care are imperative. mounted or mountable.Supplement Parameter on Placement and Management of the Dental Implant* The American Academy of Periodontology has developed the following parameter on the placement and management of dental implants. Patients should be informed about all therapeutic alternatives. and esthetics. American Academy of Periodontology. * Approved by the Board of Trustees. expected results. bone quality.. Periodontal and restorative status of the remaining dentition. The patient should also be informed that. May 1998. 3. bruxism. 6. potential complications. 3. periodontal disease. and radiation therapy. and angulation of the implants and abutments: 1. type. Interarch distance. 2. Medical and psychological status. DEFINITION A dental implant is a biomedical device usually composed of an inert metal or metallic alloy that is placed on or within the osseous tissues. The following diagnostic aids may be utilized in presurgical considerations to assist in determining the number. Patient expectations of therapy outcome. KEY WORDS Dental implants/adverse effects. PRETREATMENT CONSIDERATIONS The periodontist and other members of the dental team often share the responsibility of evaluating the patient for implants. Treatment considerations for implant patients should include an evaluation of: 1. and soft tissues. and location of implants to be placed. The implant restoration consists of components that attach the prosthesis to the implant. e. quantity and contour. Existing and proposed occlusal scheme. Number.

OUTCOMES ASSESSMENT The desired outcome of successful implant therapy is maintenance of a stable. Worthington P. 7. Variations from the desired outcome of implant placement include: 1. A 15year study of osseointegrated implants in the treatment of the edentulous jaw. 3. J Clin Periodontol 1993. Buser D. Persistent uncontrolled inflammation/infection. Increased probing depths. The excessive loss of Brånemark fixtures in type IV bone: a 5-year analysis. A microbiological and histological study. Jaffin RA. Fractured or loosened components. J Clin Periodontol 1986. Routine evaluation may reveal the need for procedures to correct the following: 1. 2. 1-year results of a prospective study with 100 ITI hollow-cylinder and hollow-screw implants. Prosthesis instability. Fixture mobility. 3. Implant stability. 2. Zarb GA. Int J Oral Maxillofac Implants 1986. 8.Parameters of Care Supplement The surgical technique is based on the pretreatment evaluation and on the type of implant to be utilized. 8. functional. 4. Persistent pain and/or loss of function. Eriksson AR. Oral hygiene assessment. Int J Oral Maxillofac Implants 1992. An experimental study in the dog. Rockler B. Lang NP. Lekholm U. An unfavorable response to corrective procedures may warrant adjustment of the prostheses and/or removal of the implants. 3. 3. Persistent peri-implant radiolucency. Radiographic appearances of implant and periimplant structures. Weber HP. 2. Presence of exudate or bleeding on probing. The condition of the soft tissues at tooth and fixture abutments supporting fixed bridges. 6.20:623-627. Int J Oral Surg 1981. Neuropathy/paresthesia. J Periodont Res 1989. Clinical appearance of peri-implant tissues. Adell R. A staged approach has been used to place endosseous implants. Van Dyke TE. A 3year longitudinal prospective study. 2. 10. 6.24:96-105. 7. Considerations in the evaluation of the implant are: 1. Brennan WA. Lekholm U. Probing depths. Quantity. surrounding tissues and oral hygiene are vital to the long-term success of the dental implant. Inability to restore the implant. Occlusal traumatism. 4. 7. Albrektsson T. SELECTED RESOURCES 1. 8. Brånemark P-l. esthetically acceptable tooth replacement for the patient. Rockler B.13:558-562. Appropriate postoperative instructions. McCollum J. Post-placement procedures: The following considerations should be reviewed prior to the restorative phase: 1. Berman CL. Overall CM. The long-term efficacy of currently used dental implants: a review and proposed criteria of success. Ericsson I. stability of prostheses and implants. 4. Implants can be placed at the time of tooth extraction as well. Ellen RP.15:39-52. 4. IMPLANT MANAGEMENT Periodic evaluation of implants. Mechanical failures of both the implant components and prosthetic superstructures have been associated with occlusal overload. Clin Oral Implants Res 1990. Clinical parameters of evaluation during implant maintenance. Excessive/progressive loss of hard and soft tissues. Patient comfort and function. Appropriate surgical protocol. and health of soft and hard tissues. Appropriate restorative procedures may be initiated upon satisfactory completion of the above considerations. involving both structural components and tissue considerations. Presence of plaque/calculus. quality. pages 849-850). Modification of maintenance interval (see Parameter on Periodontal Maintenance. 3. Int J Oral Maxillofac Surg 1986. Implant mobility or loss. 7. Pain. 5. Adell R.7:220-227. 2. Marginal tissue reactions at osseointegrated titanium fixtures (I). Mills M. Surgical template utilization. 5. Inflammation/infection. Aseptic technique.62:2-4. Zarb GA. Occlusal status. Microbiota and crevicular fluid collagenase activity in the osseointegrated dental implant sulcus: a comparison of sites in edentulous and partially edentulous patients. Lekholm V. 3. Rapley JW. et al. Slots J. Bauman GR. 6. 6. MANAGEMENT OF IMPLANT -RELATED COMPLICATIONS The etiology of implant complications can be multifactorial.10:387416.1:11-25. Tissue integration of nonsubmerged implants. 5. The following also should be considered: 1. J Periodontol 1991. 2. Implant fracture. Hallmon WH. J Periodontol • May 2000 (Supplement) 871 .1:33-40. 5. 4. Progressive bone loss. 9. Lindhe J. 4. Adell R. Lindhe J. O’Neal RB. Apse P. Ericksson I. 8. Implant position and abutment selection. Probing depth at implants and teeth.

Hjorting-Hansen. Quirynen M.Supplement 11. Fritz. Rosenberg ES. 1:796-815. Slots J. Criteria for success of osseointegrated endosseous implants. Ann Periodontol 1996. Zarb GA. Implant therapy II. J Periodontol 1992.1:792-795. Implant therapy I. 872 Parameter on Placement and Management of the Dental Implant Volume 71 • Number 5 (Supplement) . Microbial differences in 2 clinically distinct types of failures of osseointegrated implants. Torosian JP. Plaque-induced marginal tissue reactions of osseointegrated oral implants: A review of the literature. Ann Periodontol 1996.2:109-114. J Prosthetic Dent 1989. Treatment of failing dental implants. Holmstrup P.1:8-12. 12.2:135144. Horner JA. Consensus Report: Implant therapy I. Listgarten MA. 15. Smith DE. 17. DL. Mombelli A. ME. Clin Oral Implants Res 1992. Ann Periodontol 1996. 19. The effect of titanium abutment implant surface irregularities on plaque accumulation in vivo. Mericske-Stern R. 1:707-791. 16. 20. Lang NP.816-818. 14.63:802-805. The distribution of bacterial morphotypes around natural teeth and titanium implants ad modum Brånemark. Clin Oral Implants Res 1991. Microbiological features of stable osseointegrated implants used as abutments for overdentures. 13. Curr Opin Dent 1992. Cochran. Ann Periodontol 1996. Consensus report: Implant therapy II. Clin Oral Implants Res 1990.3:149-161. Schou S. 18.1:1-7. Clin Oral Implants Res 1990. 62:567-572. Meffert RM.

The presence and degree of tooth mobility should be determined. American Academy of Periodontology. Therefore. Occlusal therapy is generally addressed following.Parameters of Care Supplement Parameter on Occlusal Traumatism in Patients With Chronic Periodontitis* The American Academy of Periodontology has developed the following parameter on occlusal traumatism in patients with chronic periodontitis. 3. patients should then be able to make informed decisions regarding their periodontal therapy. Failure to treat occlusal traumatism appropriately in patients with chronic periodontitis may result in progressive loss of bone and an adverse change in prognosis. and their responsibility in treatment. The lesion of trauma from occlusion may occur in conjunction with. traumatic/complications. Presence of wear facets beyond expected levels for the patient’s age and diet consistency. expected results. the effects of occlusal traumatism may be magnified because the resistance to the forces has changed. J Periodontol 2000. Use of supplementary J Periodontol • May 2000 (Supplement) 873 . Occlusal traumatism affects the supporting structures of the tooth or teeth. Fremitus. Given this information. dental occlusion. 8. therapeutic alternatives. Chipped enamel or crown/root fractures. dental occlusion. procedures to resolve the inflammatory lesions. Tooth mobility: Increasing displacement may be of greater concern since a stable pattern of mobility may indicate adaptation. Consequences of no treatment should be explained. Tooth migration. 7. or in conjunction with. Tooth pain or discomfort on chewing or percussion. 6. differential diagnoses may be established.71:873-875. Occlusal therapy is an integral part of periodontal therapy. 2. radiolucencies in the furcation or at the apex of a tooth that is vital. Although trauma from occlusion and inflammatory periodontal disease may occur concurrently. Patients should be informed about the occlusal problem. These clinical signs and symptoms may be indicative of other pathoses. Just as with mobility. and a functional evaluation of the occlusion should be performed. or root resorption. Radiographic changes such as widening of the periodontal ligament space. * Approved by the Board of Trustees. disruption of the lamina dura. potential complications. Tenderness of the muscles of mastication or other signs or symptoms of temporomandibular dysfunction. traumatic/diagnosis. 4. Occlusal traumatism may occur in an intact periodontium or in a periodontium that has been reduced by inflammatory periodontal disease. and could result in tooth loss. Clinical Features A positive diagnosis of occlusal traumatism can be made if some of the signs and symptoms of an injury can be located in some part of the masticatory system. periodontitis/etiology. periodontium/injury. but are not pathognomonic for the condition: 1. KEY WORDS Disease progression. May 1998. CLINICAL DIAGNOSIS Definition Injury to the periodontium may result from occlusal forces in excess of the reparative/adaptive capacity of the attachment apparatus. The following represent clinical features of such an injury. patient care planning. In the presence of a reduced periodontium. inflammatory periodontal diseases. or independent of. 5. The treatment goals and endpoints for each condition may be independent of each other. stable radiographic findings may indicate adaptation. each condition may be treated separately.

Provide for efficient masticatory function. Premature contacts and occlusal interferences remain. SELECTED RESOURCES 1. 6. treatment is usually first addressed during initial therapy following efforts to reduce or minimize the inflammatory lesion (see Parameters on Chronic Periodontitis. 3. 3rd ed. Treatment considerations for the chronic periodontitis patient with occlusal traumatism may include one or more of the following: 1. 3. Guidelines for periodontal therapy (Position Paper). A mobility pattern which is stable and allows the patient to function in comfort without danger of further damage is an acceptable end point. Elimination or reduction of tooth mobility. and occlusal interferences. This goal is measured by the cessation or stabilization of the presenting signs or symptoms. Evaluation of occlusal symptoms should continue throughout the course of therapy. These results include. OUTCOMES ASSESSMENT The desired outcome of treatment of occlusal traumatism is that the patient should be able to masticate with comfort. and the function of the remaining dentition. pages 853-858). Establishment of an occlusion that is stable. but are not limited to. 2. functional. 2. Tooth migration continues. Parafunctional habits persist. If the existing relationship is altered through treatment. reproducible intercuspal position. If occlusal traumatism does not resolve. Establish or maintain a stable. several therapeutic objectives are suggested: 1.69:396-399. In the absence of clinical signs or symptoms. Orthodontic tooth movement. TREATMENT CONSIDERATIONS Treatment of the symptoms of occlusal traumatism is appropriate during any phase of periodontal therapy. 4. the following: 1. 2. Patient pain and discomfort persist. pulp vitality tests and evaluation of parafunctional habits. 5. Persistence of radiographic changes. occlusal adjustment to obtain a conceptualized ideal occlusal pattern provides little or no benefit to the patient. 6. THERAPEUTIC GOALS The goal of therapy in the treatment of occlusal traumatism is to alleviate the etiologic factors and enable patients to maintain a comfortable and functional dentition. Occlusal reconstruction. 1992. without further damage to the periodontium. Occlusal relationships may be evaluated as part of periodontal maintenance. 2. physiologic. Occlusal adjustment. Occlusal therapy may be accomplished through several different approaches. 6. Temporary. and cheeks. The choice depends on several factors. The American Academy of Periodontology. 4. and esthetically acceptable. the amount of periodontal support of the remaining teeth. 7. 4.. Mobility should either diminish or be absent or may persist if there is reduced periodontal support. Efforts are directed toward elimination or minimization of excessive force or stress placed on a tooth or teeth. such as the characteristics of the forces. 5. the new relationship should be physiologically acceptable to the patient. fremitus. 2. 3. prophylactic occlusal adjustment appears to be contraindicated. Relief of premature contacts.Supplement diagnostic procedures may be helpful. Eliminate or modify parafunctional habits.g. including movement in all directions regardless of the initial point of contact. lips. e. Develop a comfortable occlusion. Therefore. The migration which preceded therapy may also resolve from the alteration of the forces generated by the tongue. Treatment may need to be repeated or revised. the following may occur: 1. the underlying cause of these forces. Management of parafunctional habits. such as widening of the periodontal ligament space and periradicular or furcation radiolucencies associated with occlusal traumatism. Glossary of Periodontal Terms. 3. 6. Extraction of selected teeth. provisional. 4. Further migration of the teeth should not occur. The American Academy of Periodontology. compatible with periodontal health. J Periodontol 1998. 5. Temporomandibular dysfunction may worsen. 5. Except in the case of acute conditions. Radiographic changes diminish or become stable. 874 Parameter on Occlusal Traumatism in Patients With Chronic Periodontitis Volume 71 • Number 5 (Supplement) . 7. Mobility continues to increase. Chicago: The American Academy of Periodontology. In order to achieve this goal. Establish an occlusion with acceptable phonation and esthetics. Relief of pain and improved patient comfort. Provide freedom of movement to and from the intercuspal position. or long-term stabilization of mobile teeth with removable or fixed appliances.

Schluger S.1:567-580. 12. 10. 1992. J Periodontol • May 2000 (Supplement) 875 . Inc.. 11. The American Academy of Periodontology. Philadelphia: Lea & Febiger. D. Philadelphia. 7. Toronto: C. Advances in Periodontics.V. Sydney. 1989. Listgarten M. London. Marks M. Quintessence Publishing Co. Toronto: C. Baltimore. Ramfjord S. Louis. Hong Kong: Quintessence Publishing Co. Page RC. Newman MG. 8th ed. Textbook of Clinical Periodontology. 1989. Saunders Company. Philadelphia. Copenhagen: Munksgaard. 4th ed.. Grant D. Chicago. 1980... Clinical Periodontology. Contemporary Periodontics. 1995. Toronto. Tokyo. 1995. Ann Periodontol 1996. Gher. Sao Paulo. Saunders Company. St. Consensus report on non-surgical pocket therapy: Mechanical. 1990. Berlin. ME. Washington. 6. Philadelphia. Efficacy of Treatment Procedures in Periodontics. pharmacotherapeutics. Philadelphia: W. 1990. Louis. Proceedings of the World Workshop in Clinical Periodontics. Atlas of Adult Orthodontics. Carranza FA Jr. 4. Rio de Janeiro. 1988. Montreal. 2nd ed..1:581-588. Periodontics. Periodontal Diseases. Stern I. 8. London. 14. Ash MM. Non-surgical pocket therapy: Dental occlusion. Kornman KS. Occlusion.B. 13. 9. Goldman H. London: Lea & Febiger. Chicago. Shanley DB. Ann Periodontol 1996. Corn H. 5. Chicago. Genco R. Cohen D. Mosby.V. 1989.C. Inc. and dental occlusion. Wilson TG. Youdelis R. Lindhe J. The American Academy of Periodontology. St. Tokyo: W. Johnson RH. Tokyo. Mosby.B.Parameters of Care Supplement 3.

Supplement Parameter on Periodontitis Associated With Systemic Conditions* The American Academy of Periodontology has developed the following parameter on periodontitis associated with systemic conditions. therapeutic alternatives. systemic diseases. Signs or symptoms of smoking. Patients should also be informed of the periodontal disease process. patients should then be able to make informed decisions regarding their periodontal therapy. History of familial systemic disease. Referral to or consultation with other health care providers should be made and documented when warranted. Patients affected by periodontal disease with concomitant systemic factors should be informed about the significance of the systemic condition(s) to the periodontal disease process. Therapeutic drug use. an adverse change in prognosis. Failure to treat periodontitis appropriately can result in progressive loss of periodontal supporting tissues. American Academy of Periodontology. THERAPEUTIC GOALS The therapeutic goal is to achieve a degree of periodontal health consistent with the patient’s overall health status.71:876-879. The treatment outcome of periodontal therapy in the patient with contributing systemic factors may be directly affected by the control of the systemic condition. Periodontal therapy may be modified based on the current medical status of the patients. mucocutaneous lesions. tooth loss. chemical dependency. The clinician should be aware of systemic conditions and/or drugs that may be contributing factors to periodontal diseases. excessive gingival hemorrhage. potential complications. 2. A comprehensive periodontal evaluation should be performed as described in the Parameter on Comprehensive Periodontal Examination (pages 847-848). or other indica* Approved by the Board of Trustees. B. periodontitis/complications. periodontitis/therapy. Periodontal organisms may be the source of infections elsewhere in the body. Therefore. and their responsibilities in treatment. Patient Evaluation 1. The systemic and psychological status of the patient should be identified to reduce medical risks that may compromise or alter the periodontal treatment. and of steps necessary to evaluate them. 3. G. However. the systemic/psychological status 876 Volume 71 • Number 5 (Supplement) . F. and compromise of the dentition. KEY WORDS Periodontitis/diagnosis. and other addictive habits. Request laboratory tests as appropriate. E. CLINICAL DIAGNOSIS Definition A number of systemic factors have been documented as being capable of affecting the periodontium and/or treatment of periodontal disease. Conditions which are suggestive of systemic disorders should be identified: A. Physical disabilities. Given this information. D. Evidence of psychological/emotional factors. those infections may also affect systemic health. Consequences of no periodontal treatment should be explained. expected results. May 1999. C. disease progression. tors of undetected or poorly-controlled systemic disease. gingival overgrowth. pages 853-858). Signs or symptoms of xerostomia. J Periodontol 2000. TREATMENT CONSIDERATIONS Patients with systemic conditions that contribute to progression of periodontal diseases may be successfully treated using established periodontal treatment techniques (see Parameters on Chronic Periodontitis. Systemic etiologic components may be suspected in patients who exhibit periodontal inflammation or destruction which appears disproportionate to the local irritants. risk factors. 4. History of recent or chronic diseases.

including surgery. Consideration of antimicrobial therapy for emergency periodontal treatment when granulocyte counts are low. Chemotherapy or therapy associated with bone marrow transplantation may also adversely affect the gingiva. HEMATOLOGIC DISORDERS/LEUKEMIA Hemorrhagic gingival enlargement with or without necrosis is a common early manifestation of acute leukemia. Administration of antibiotics and other drugs with caution. METABOLIC CONDITIONS Diabetes Mellitus Patients with undiagnosed or poorly-controlled Type 1 (insulin dependent) diabetes mellitus or Type 2 (non-insulin dependent) diabetes mellitus may be particularly susceptible to periodontal diseases. lichenoid reactions. 5. Avoidance of elective periodontal therapy during periods of exacerbation of the malignancy or during active phases of chemotherapy. or menopause. Periodontal therapy. level of glycemic control. drugs can cause xerostomia. Treatment considerations for patients affected by drug-induced periodontal disease may include: 1. 3. 7. Treatment considerations for patients with periodontitis associated with diabetes should include: 1. Consultation with the patient’s physician as necessary. Pregnancy Hormonal fluctuations in the female patient may alter the status of periodontal health. 2. chronic leukemia. Patients should be informed that gingival enlargement may recur if drug therapy can not be modified or if adequate plaque control is not achieved and maintained. 4. 4. Treatment considerations for pregnant patients with periodontal disease include: 1. Consultation with the patient’s physician as necessary. Patients with chronic leukemia may experience similar but less severe periodontal changes. Such changes may occur during puberty. The most pronounced periodontal changes occur during pregnancy. Drugs such as anticonvulsants. 5. 6. 2. 7. Identification of signs and symptoms of undiagnosed or poorly controlled diabetes mellitus. Considerations for patients with hematologic disorders and periodontal disease should include: 1. Consideration of diagnosis and duration of diabetes. and other hypersensitivity reactions. Modification of the drug regimen prescribed in consultation with the physician if gingival enlargement or other adverse drug reactions or side effects occur. Consideration of adjunctive systemic antibiotics for periodontal procedures if the diabetes is poorly controlled. DRUG-INDUCED DISORDERS Drugs can be a contributing etiologic factor in periodontal diseases. calcium channel blocking agents. Recommendation that diabetic patients take medication as prescribed and maintain an appropriate diet on the day of periodontal therapy. 5. pregnancy. Oral contraceptives may be a contributing factor in alterations of gingival tissues. In addition. for patients with stable. 2. 3. Minimization of sites of periodontal infection by means of appropriate periodontal therapy prior to the treatment of leukemia and/or transplantation. baseline periodontal evaluation prior to initiation or modification of drug therapy. osteoporosis. Consideration of deferral of periodontal surgery until after parturition. 6. most well-controlled diabetic patients can maintain periodontal health and will respond favorably to periodontal therapy. Changes may also be associated with the use of oral contraceptives. and cyclosporin may be associated with gingival enlargement. Preparation to diagnose and manage medical emergencies associated with diabetes. Surgery as necessary to eliminate gingival enlargement. 3. the menstrual cycle. 3. Monitoring for evidence of host-versus-graft disease and of drug-induced gingival overgrowth following bone marrow transplantation. Conversely. Consultation with patient’s physician as necessary. 4. 4. J Periodontol • May 2000 (Supplement) 877 . Performance of periodontal maintenance as needed.Parameters of Care Supplement of the periodontal patient may alter the nature of therapy rendered and may adversely affect treatment outcomes. and medications and treatment history. Consideration of postponement of periodontal treatment during the first trimester. When possible. 6. 2. Coordination of treatment with the patient’s physician. Attempts to reduce stress/anxiety. Performance of emergency periodontal treatment at any time during pregnancy. Use of local anesthesia in preference to general anesthesia or conscious sedation.

Rapid periodontal destruction in adult humans with poorly controlled diabetes. Norderyd OM. Tobacco use as a risk factor. 2. Etiology of periodontal disease. 15. 3.62:116-122. Australian Dent J 1991. Levine RA. Mohammad AR. Uitto V-J. Bergström J. Due to the complexity of systemic factors. 9. 4. Oakhill A. de Moraes N. Persistent clinically detectable plaque levels not compatible with gingival health.13:836-840. et al. Special considerations for immune system disorder patients with periodontal disease include: 1. The relationship between work stress and oral health status. Diabetes Educator 1992. et al. Oliver RC. or have certain autoimmune diseases may be taking immunosuppressing medications. Diabetes Care 1993. Chapple IL. A report of two cases. Ho AW. Implications of diabetes mellitus and periodontal disease. Osteoporosis and periodontal disease: A review. J Periodontol 1994.16:329-334. Controlling associated mucosal diseases and acute periodontal infections.65:260-267. Mendieta C. Consultation and coordination of treatment with patient’s physician as necessary. 19.1:17-28. 18. Preber H. Porter SR.): S678-S683. J Periodontol 1993. 3. Sex steroid hormones and cell dynamics in the periodontium. Offenbacher S. J Periodontol 1991. 12. 6. 5. Novaes AB Jr.20:615622. Mealey BL. Periodontal disease. Significant reduction of clinical signs of gingival inflammation. I. J Calif Dent Assoc 1994.30:877-880. Reduction of probing depths.65:545-550. Shlossman M.64:957-962. additional therapy may be required as well as further evaluation of the patient’s systemic condition. are undergoing cancer treatment. Genco RJ. J Clin Periodontol 1990. Keenan KM. Loë H. Clinical and microbiological investigations of anorexia nervosa. Stabilization or gain of clinical attachment. Pereira AL. 17. J Periodont Res 1993. In such instances. Systemic drugs as a risk factor 878 Parameter on Periodontitis Associated with Systemic Conditions Volume 71 • Number 5 (Supplement) . Luker J. 14. 4. Touyz SW. 16. Enzyme activity in crevicular fluid in relation to metabolic control of diabetes and other periodontal risk factors. 3. The sixth complication of diabetes mellitus. 20. Machtei EE. Assessment of risk of periodontal disease. Mariotti A. J Periodontol 1993. A satisfactory outcome of therapy in patients with systemic disorders may include: 1. Periodontal manifestations of systemic disease and management of patients with systemic disease. Lahtinen A. Scully C. 18:310-315. Manifestations of insulin-dependent diabetes mellitus in the periodontium of young Brazilian patients. SELECTED RESOURCES 1. Administration of systemic or local medications (for example.64:358-362. Hypophosphatasia: Dental aspects and mode of inheritance. J Periodontol 1991. 4. Periodontal disease and NIDDM in Pima Indians.28:523-535. Beumont PJ. Arnold RR. Shlossman M. Marcenes WS. Emrich LJ.62:123-130. Grossi SG. 2. 5. J Periodontol 1994. J Clin Periodontol 1993. OUTCOMES ASSESSMENT The predictability of the outcome may be enhanced through close medical/dental coordination. 2. Persistent inflammation/infection of the gingival tissues. 2. Collins JG. a reasonable treatment objective is to slow the progression of the periodontal disease. Flynn DG. Caton JG. Zambon JJ. Diabetes Care 1990. Liew VP. Novaes AB. Radiographic evidence of progressive bone loss. Periodontal status of women taking postmenopausal estrogen supplementation.22(Mar):69-75. Curr Opin Periodontol 1993. Hallmon WW. Budding LM. Reeve CM. Tervonen T. may have especially severe forms of periodontal disease. 3. J Am Acad Dermatol 1994. Patients infected with human immunodeficiency virus (HIV).36:435-441. Compendium Continuing Educ Dent 1994. antibiotics) only if indicated and administered in a manner that avoids opportunistic infections and adverse drug interactions. Soc Science Med 1992. control of periodontal diseases may not be possible. Periodontal disease in non-insulin dependent diabetes mellitus.18(Suppl. The incidence of necrotizing periodontal diseases may increase in the patient with acquired immunodeficiency syndrome (AIDS). Quinones CR. Brunsvold MA. Williams H. 10. 17:22-28. 21. 11. Jones JD. In patients where the periodontal condition does not resolve.Supplement IMMUNE SYSTEM DISORDERS Some forms of periodontal disease may be more severe in individuals affected with immune system disorders. Rees TD. Shelham A. 13. Patients who have received organ transplants. Oral features of a family with benign familial neutropenia. New clinical diagnostic strategies based on pathogenesis of disease. Lack of stability of clinical attachment. Frisken KW. Risk indicators for attachment loss. 5. Grossi SG. 7. Nelson RG. et al. Assessment of risk for periodontal disease.5:2753. Crit Rev Oral Biol Med 1994. Curr Opin Dent 1991. Persistent or increasing probing depths. Control of acute symptoms. Ainamo J. Reduction of clinically detectable plaque to a level compatible with gingival health.35:1511-1520. Progression of the disease may be characterized by the presence of: 1.18-27. 8. Genco RJ.

Medications as risk factors for periodontal diseases. J Periodontol 1993. Moss ME. Beck J. Bakri MM.67:1076-1084. Skrepcinski FB. Moses O. Machtei EE. Beeley JA. Pihlstrom BL.67:1114-1122. Genco RJ. Seppälä B.19:161162. and anxiety. 67:1070-1075. 35. Current view of risk factors for periodontal diseases. J Periodontol 1993. Alterations in phagocyte function and periodontal infection. et al. Dent Update 1992. 34. Consensus report on periodontal implications: Medically compromised patients. and periodontal status. Periodontal considerations in the patient with HIV. Severe progressive periodontal destruction due to radiation tissue injury. Kaplan BH. Periodontol Implications: Medically compromised patients.64:12251230. Ann Periodontol 1996. 27. Vokonas PS. Taylor GW. Severe periodontitis and risk for poor glycemic control in patients with non-insulin-dependent diabetes mellitus.67:1085-1093. Zubery Y. 23.67(Suppl. Yusof ZW. 42. for periodontal disease initiation and progression. 26. 28. et al. Zambon JJ. Grossi SG.67:1050-1054. 31. Van Dyke TE.13(5):5-8. Ainamo J. Periodontal infection as a possible risk factor for preterm low birth weight.67:1041-1049. Pediatric Dent 1990. J Periodontol 1996. 21:161-165. Roberts MW. bacterial pathogens.16:20-42. 32. Fertik G. Heiss G. 24.67:1055-1059. 38. Zambon JJ. Garcia R. J Periodontol 1996. Agranulocytosis— periodontal manifestations and treatment of the acute phase: A case report. older adults. Speirs RL. Ryder MI. Burt BA.67: 1094-1102. Grossi SG. Becker MP. Katz V. et al.1:256-321. J Periodontol 1996. Meyer MW. Grossi SG. 40. J Periodontol 1996. Cigarette smoking increases the risk for subgingival infection with periodontal pathogens.67:1060-1069. Beck JD. Association between cigarette smoking. et al. Periodontium and oral mucosa. J Periodontol 1996. J Clin Periodontol 1994. Food and oral health: 2. J Periodontol 1996.Parameters of Care Supplement 22. 33. Oral manifestations associated with leukocyte adhesion deficiency: A five-year case study. Scannapieco FA. Clin Prev Dent 1991. Genco RJ. Cummins D. Atkinson JC.1:390-400. Genco RJ. Exploratory casecontrol analysis of psychosocial factors and adult periodontitis.67:1138-1142. Herzberg MC. Effects of oral flora on platelets: Possible consequences in cardiovascular disease.43-51. Wactawski-Wende J.):1103-1113. 37. 41. J Periodontol 1996. Kozlovsky A. 30.64:1253-1258. 25. J Periodontol 1996. Ho AW. J Periodontol 1996. Offenbacher S. et al. Ann Periodontol 1996. The role of osteopenia in oral bone loss and periodontal disease. DeCaro T. J Periodontol • May 2000 (Supplement) 879 . Periodontal disease and cardiovascular disease. J Periodontol 1996. 29. J Periodontol 1996. Daniel MA. J Periodontol 1996.67:1123-1137.12:107-111. 39. Mealey BL. Compendium Contin Educ Dent 1995. Relationships between periodontal disease and bacterial pneumonia. Mylotte JM. Dunford R. Curr Opin Periodontol 1993. Offenbacher S. 36. Ciancio SG. Stoltenberg JL. A site-by-site follow-up study on the effects of controlled versus poorly controlled insulindependent diabetes mellitus. Osborn JB. Reponse to periodontal therapy in diabetics and smokers. Trevisan M.

patients should be informed of the possible effects of periodontal infection on their overall well-being. periodontal diseases/complications. Patient Evaluation 1. The periodontium may serve as a reservoir of bacteria. Preliminary evidence suggests that periodontal infections may also be associated with pulmonary disease and other remote site infections. pages 876-879). progression. TREATMENT CONSIDERATIONS Diabetes Mellitus Periodontitis may adversely affect glycemic control in diabetes. 2.Supplement Parameter on Systemic Conditions Affected by Periodontal Diseases* The American Academy of Periodontology has developed the following parameter on systemic conditions affected by periodontal diseases. While much information is available concerning the potential effects of systemic conditions and diseases on the periodontium. in oral-derived bacteremia and infective endocarditis). Diabetes mellitus. Any consultation should be documented. The concept of periodontal diseases as localized entities affecting only the teeth and supporting apparatus is increasingly being questioned. less is known about the consequences of a diseased periodontium on systemic health. 3. American Academy of Periodontology. bacterial products. medications. Cardiovascular diseases. It may also be associated with an increased 880 Volume 71 • Number 5 (Supplement) . J Periodontol 2000. 3. Periodontal infections may increase the risk for certain conditions by contributing to disease pathogenesis or by serving as a source of infective organisms. periodontal infections may significantly impact systemic health in others. Pregnancy. and inflammatory and immune mediators which can interact with other organ systems remote from the oral cavity. systemic diseases. While these effects may be limited in some individuals. periodontal condition. CLINICAL DIAGNOSIS Definition The role of local infections in generalized disease is well established (for example. and treatment of such diseases (see Parameter on Periodontitis Associated With Systemic Conditions. Other health care providers may be consulted as indicated by the patient’s systemic health status. and may serve as risk indicators for certain systemic diseases or conditions. risk factors. 2. Research and clinical experience indicate that periodontal infections may have an impact on the following diseases or conditions: 1. and to establish periodontal health which may minimize potential negative influences of periodontal infections. * Approved by the Board of Trustees. Periodontal diseases may have widespread systemic effects. and risk factors for systemic diseases. May 1999. KEY WORDS Infection/complications. As part of the approach to establishing and maintaining health.71:880-883. to inform the patient of possible interactions between the patient’s periodontal disease and systemic condition. patients should then be able to make informed decisions regarding their periodontal therapy. and proposed treatment. A comprehensive periodontal evaluation should be performed as described in the Parameter on Comprehensive Periodontal Examination (pages 847-848). periodontium/ physiopathology. THERAPEUTIC GOALS The therapeutic goals are to diagnose periodontal infections which may impact on the patient’s systemic health. Given this information. The medical history should be evaluated for existing systemic diseases or conditions. It is well known that systemic conditions may affect the onset.

status of pregnancy. Watts TLP. 3. Periodontal pathogens may contribute to atherogenic changes and thromboembolic events in the coronary arteries. Reduction of probing depths. Viberti G. 5.91:901-909. For example. especially in patients with severe periodontitis and poorly controlled diabetes. Single-blind studies of the effects of improved periodontal health on metabolic control in Type 1 diabetes mellitus. Education of the patient regarding the possible impact of periodontal infection on glycemic control. medications and treatment history. and the possible interactions between oral and systemic health or disease. SELECTED RESOURCES 1. The American Heart Association guidelines should be followed for patients at risk for infective endocarditis. Consideration of consultation with the patient’s physician to advise of the presence of periodontal infection and proposed treatment. Infective endocarditis. and risk factors for periodontitis which may influence diabetic complications. Chest 1987. may result in improvement in glycemic control. Report of a case. pages 876-879). Periodontal therapy and patient motivation to establish and maintain periodontal health (see Parameter on Periodontitis Associated With Systemic Conditions. While bacteremias may occur in individuals with a healthy periodontium. and risk factors for periodontitis which may influence pregnancy outcomes. Consideration of gestational period. Consideration may be given to the use of systemic antibiotics in conjunction with mechanical therapy (see Parameter on Periodontitis Associated With Systemic Conditions. 7. Collins A. pages 876-879).61:243-247. J Clin Periodontol 1995. Andersen WC. 3. Treatment considerations for patients at risk for or with existing cardiovascular diseases include: 1. Treatment considerations for pregnant patients include: 1. Stabilization or gain of clinical attachment. level of glycemic control. Addressing the risk factors for periodontal disease as they affect the systemic condition. 2. Periodontal therapy and patient motivation to establish and maintain periodontal health. treatment and medications. Periodontal therapy and patient motivation to establish and maintain periodontal health (see Parameter on Periodontitis Associated With Systemic Conditions. pages 876-879). 4. J Periodontol 1990. 2. Bartlett JG. Consideration of diagnosis and duration of diabetes. Aldridge JP. 4. Individuals with periodontal disease may have significantly increased risk of coronary heart disease and related events such as angina pectoris and myocardial infarction. periodontal disease may increase the risk of cerebral ischemia and non-hemorrhagic stroke. 3. Consideration of diagnosis and status of cardiovascular disease. Consideration of consultation with the patient’s physician to advise of the presence of periodontal infection and proposed treatment. 2. 6. Education of the patient regarding the possible impact of periodontal infection on pregnancy outcome. Diagnosis of the patient’s periodontal condition. Consideration of consultation with the patient’s physician to advise of the presence of periodontal infection and proposed treatment. Diagnosis of the patient’s periodontal condition. Anaerobic bacterial infections of the lung.22: 271-275. 4. Similar processes may occur in other arteries. 3. Reduction of clinically detectable plaque and periodontal pathogens to a level compatible with periodontal health. Knowledge of the patient’s medical history and systemic status. 2. Lester V. Education of the patient regarding the possible impact of periodontal infection on the cardiovascular system. 2.Parameters of Care Supplement risk of cardiovascular complications associated with diabetes. Control of acute periodontal infections. 5. 5. 5. Cardiovascular Diseases Coronary artery disease. they may be intensified in patients with periodontitis. Pregnancy Women with periodontitis may have an increased risk for pre-term low birth weight delivery. 4. Reduction of clinical signs of gingival inflammation. Treatment considerations for patients with diabetes mellitus include: 1. and risk factors for periodontitis which may influence coronary artery disease. Diagnosis of the patient’s periodontal condition. Horton HL. J Periodontol • May 2000 (Supplement) 881 . Parietal lobe abscess after routine periodontal recall therapy. Periodontal treatment. 3. OUTCOMES ASSESSMENT The desired outcome of therapy is to prevent adverse systemic consequences of existing periodontal infection via: 1. the periodontal condition. Wilson RF.

Hill MK. Offenbacher S. Ann Periodontol 1998. Scannapieco FA.63:843-848. Meyer MW. Infect Immun 1994. veterans. Poor periodontal health of the pregnant woman as a risk factor for low birth weight.Supplement 4. Treatment of periodontal disease in diabetics reduces glycated hemoglobin.319:972-978. 5. 11. 23. The significance of colonization of the respiratory tract. Pierce AK. Beck JD. Krohn M. Br Med J 1989. Herzberg MC. Johanson WG. DeCaro T. 8. Hill GB. Soskolne WA. 33. Thomas GD.):1103-1113. Collins JG. Mitchell-Lewis DA. Brain abscess from chronic odontogenic cause: report of case. 41. The association between alveolar bone loss and pulmonary function: The VA dental longitudinal study. Vokonas PS. Garcia R. Takahashi K. A review of premature birth and subclinical infection.298:779-781. Dental plaque. Windley HW III. JAMA 1997. Holmes KK. The pathobiology of periodontal diseases may affect systemic diseases: Inversion of a paradigm. Gibbs P. Nishimura F. Cummins D. Takashiba S. Ann Periodontol 1998. 34. 9. et al.1:256-321. Russell CM. 6. Periodontal disease and diabetes mellitus: A two-way relationship. Prevention of bacterial endocarditis. Periodontitis: A risk factor for coronary heart disease? Ann Periodontol 1998. 10. Fertik G. Herzberg MC. 28. Loesche WJ. Hillier SL.67: 1094-1102. Recommendations by the American Heart Association.62:4356-4361. 3:184-196. J Periodontol 1992. Buggle F. Grossi SG.3:257-261. Effects of oral flora on platelets: Possible consequences in cardiovascular disease. Kinane DF. Mason JC. 882 Parameter on Systemic Conditions Affected by Periodontal Diseases Volume 71 • Number 5 (Supplement) . J Periodontol 1996. Hillier SL.277:1794-1801. Wilson W. K):51-53. Eschenbach DA.37:8083. Ann Periodontol 1998. Nosocomial respiratory infections with gram-negative bacilli. Taubert KA. Offenbacher S. Am J Obstet Gynecol 1992. Fasciano R. 3:51-61.103:205-211. et al. Offenbacher S. Periodontal disease as a complication of diabetes mellitus. Periodontal implications: medically compromised patients. Katz V. Garcia R. Grossman N. 38. Lamster IB. Glucose intolerance in acute infections. Valtonen VV. Valtonen VV. Ziegler C. Dominguez BL. Grau AJ. Br Med J 1993. 22. Crit Care Med 1992. Grossi SG. Stewart EM. Williamson DF. Eschenbach MD. Sweet RL. Mattila KJ. Sparrow D. Zambon JJ. J Am Dent Assoc 1988. Mealey BL. Sanford JP. Ann Periodontol 1998. 12. J Oral Med 1982.3:233250. Smith MA. Anda RF. A case-control study of chorioamnionic infection and histologic chorioamnionitis in prematurity. Manwell MA. Meyer MW. Mee EW. Ann Periodontol 1996. Offenbacher S. Chen Y-M.306:688-691. A new causal model of dental diseases associated with endocarditis. Offenbacher S. Infect Immun 1994. Arnold RR. Dental infections as a risk factor for acute myocardial infarction. Drangsholt MT. 35. Cavernous sinus thrombosis and brain abscess initiated and maintained by periodontally involved teeth.225:15-19.67:1123-1137. Kahn HS. New concepts regarding the pathogenesis of periodontal disease in HIV infection. Beck JD. Multiple brain abscesses secondary to dental caries and severe periodontal disease. 7. Scannapieco FA. 39. Arnold RR.3:20-29. 18.S. Periodontal infection as a possible risk factor for preterm low birth weight. et al. Relationships between periodontal disease and bacterial pneumonia. Association between acute cerbrovascular ischemia and chronic and recurrent infection. Ann Periodontol 1998. Sonis ST. Br J Oral Maxillofac Surg 1988. Saal CJ. Genco RJ. Ann Periodontol 1998.28:1724-1729. J Periodontol 1996. Offenbacher S. Mylotte JM. Ann Periodontol 1998. 26. Mylotte JM. Cohen M. Heiss G. Stroke 1997. DeCaro T. Goteiner D. Association between dental health and acute myocardial infarction.20:740745. Kurihara M. The relationship between reduction in periodontal inflammation and diabetes control: A report of 9 cases. et al. Ann Intern Med 1972. Ann Periodontol 1998. J Intern Med 1989. Nieminen MS. Begg MD. Effects of a Porpyhromonas gingivalis infection on inflammatory mediator response and pregnancy outcome in hamsters. Assessing the relationship between dental disease and coronary heart disease in elderly U.3:142-150.3:127-141.3:62-75. Hietaniemi KL. Ann Periodontol 1998. Jared HL. platelets.3:151160.67:1138-1142.117:453-455.129:301311. 15. et al. 17. 14. J Periodontol 1997. Newbold D. Grossi SG. Grbic JT. Dental infections and coronary atherosclerosis.3:108-120. O’Reilly PG. 30. 32. Ann Periodontol 1998. Murayama Y. and cardiovascular diseases. Ann Periodontol 1998.14(Suppl. Valle MS. Effects of Escherichia coli and Porpyhromonas gingivalis lipopolysaccharide on pregnancy outcome in the golden hamster. Mattila KJ. Hayes C. Marks PV.67:1114-1122. 40. Mitchell A. Collins JG. 36. Kiviat N. New Engl J Med 1988. Potential pathogenic mechanisms of periodontitis-associated pregnancy complications. Terpenning MS. 37. Sammalkorpi K. Patel KS. 29. 19. Nieminen MS.77:701-706. Gibbs RS. J Periodontol 1996. Dajani AS. Dental disease and risk of coronary heart disease and mortality. 27. Williams R. Miller LS. Skrepcinski FB. et al.62:4652-4655.67(Suppl. Garcia RI. Dasanayake AP. Atherosclerosis 1993. Response to periodontal therapy in diabetics and smokers. DeStefano F. Page RC. Schork A. Vokonas PS. et al.3:206-212. Periodontal diseases’ contributions to cardiovascular disease: An overview of potential mechanisms. Preterm birth: Associations with genital and possibly oral microflora.3:222232. 25.26:244-247. Cheuk SL. Periodontal disease and cardiovascular disease. Skrepcinski FB. 20. Romero R. Martius J. Colonization of dental plaque by respiratory pathogens in medical intensive care patients. J Am Dent Assoc 1998. J Periodontol 1996. Ann Periodontol 1998. Genco RJ.68:713-719. J Periodontol 1996. Epidemiological and clinical aspects of periodontal diseases in diabetics. 21. 16. 13. 31. Mattila KJ.166:1515-1528. Eur Heart J 1993. 24.

Valtonen VV. Kaste M. Huttunen JK. Syrjänen J. Yki-Järvinen H. Thorstensson H. Br Med J 1988. J Periodontol • May 2000 (Supplement) 883 . J Clin Periodontol 1996. Kaste M. Syrjänen J. 42. Valtonen V. J Periodontol 1996. Mahan CJ. Taylor GW.67:1085-1093. 44. Koivisto VA. Severity.172:776-778. Severe periodontitis and risk for poor glycemic control in patients with non-insulin-dependent diabetes mellitus. 45.296:1156-1160.69:317-323. Williams RC. J Int Med 1989. Burt BA. 47. Dental infections in association with cerebral infarction in young and middle-aged men. Iivanainen M. Iivanainen M. Medical status and complications in relation to periodontal disease experience in insulin-dependent diabetics.Parameters of Care Supplement 3:3-12. 43. Periodontal disease and diabetes in young adults. Peltola J. Preceding infection as an important risk factor for ischaemic brain infarction in young and middle aged patients. 46. Sammalkorpi K. J Clin Endocrinol Metab 1989. Nikkilä EA. et al.23:194-202. Hugoson A. Huttunen JK. duration and mechanism of insulin resistance during acute infections. Becker MP. Kuylensteirna J.225:179-184. JAMA 1960.