Assist.Prof.

Alaa Omran

INTRODUCTION :
Periodontal disease are chronic multifactorial inflammatory disease
which affect supporting tissue of the teeth ,they include gingivitis which
affect only soft tissue surrounding the teeth and
Periodontitis which characterized by progressive destruction of the
tooth-supporting apparatus. Its primary features include the loss of
periodontal tissue support manifest through clinical attachment loss
(CAL) and radiographically assessed alveolar bone loss, presence of
periodontal pocketing and gingival bleeding (Papapanou et al.,
2018). If untreated, it may lead to tooth loss, although it is preventable
and treatable in the majority of cases.
EXAMINATION :
Medical history
Most of the health history is obtained at the first visit, and it can be
supplemented by pertinent questioning at subsequent visits. The health
history can be obtained verbally by questioning the patient and
recording his or her responses in the patient chart or by means of a
questionnaire that the patient completes prior to the appointment.
The importance of the health history should be clearly explained,
because patients often omit information that they cannot relate to
their dental problems. The patient should be made aware of the
following: (1) the possible impact of certain systemic diseases,
conditions, behavioral factors, and medications on periodontal disease,
its treatment, and treatment outcomes; (2) the presence of conditions
that may require special precautions or modifications of the treatment
procedure and (3) the possibility that oral infections may have a
powerful influence on the occurrence and severity of a variety of
systemic diseases and conditions .
CARRANZA CLINICAL PERIODONTOLOGY 13 EDIT.
Panoramic radiograph :
The diagnosis of periodontitis is based mainly on clinical
examination . Still, radiographic assessment is a critical component
that confirms the presence of interproximal clinical findings of
periodontal bone levels to estimate the prognosis of periodontally
involved teeth, the treatment plan and the evaluation of the
recurrence or progression of periodontitis In this sense,
radiographic bone loss evaluation becomes particularly important
to the classification of periodontitis based on stages defined by
severity, and grades that reflect this disease progression
Panoramic radiograph is a routine dental care imaging method
that provides a valuable screening opportunity [ This two-
dimensional radiography provides important and additional
information which could potentially guide during periodontal
staging and grading. In particular, a panoramic radiograph is useful
in the measurement of Periodontal Bone Loss (PBL) [], and
intraoral and panoramic radiographic PBL measurements have
been demonstrated to be clinically coincident

J,CLIN ,MED, 2020

Clinical examination :
Pocket Depth and Clinical Attachment Loss

Since chronic periodontal inflammation can lead to a loss of the

supporting periodontium, measuring the loss of this attachment
has been a key criterion for classification of the disease stage and
grade and a strong predictor for future tissue destruction and thus
disease progression . Generally, a periodontal probe is used to
measure both clinical attachment loss (CAL) and pocket depth
(PD) . CAL is defined as the distance from the base of the pocket
(coronal end of junctional epithelium) to the cementoenamel
junction (CEJ) of the tooth (hard tissue reference). In contrast, PD
is the distance from the base of the pocket to the gingival margin
(soft tissue reference). Both CAL and PD have been used as the
defining periodontal disease analysis because each can be used
to record changes in the periodontal condition over time.
However, the PD quantifies the tissue loss without accounting for
gingival margin level changes observed in gingival recession or
overgrowth, and while more time-intensive to measure, CAL is a
considered better diagnostic parameter to quantify the loss of
periodontal attachment. Despite this, PD has been commonly
used and is still recorded by general dentists and periodontists .
The 2017 World Workshop has now standardized that CAL
between teeth (the interdental CAL) determines the periodontal
disease classification .
DIAGNOSTICS, 2021

Bleeding on Probing

Gingivitis and periodontitis weaken the gums (i.e., pocket

ulceration), so bleeding can occur during the probing of disease
sites. For that reason, bleeding on probing (BOP) has been
considered as a sign of periodontal disease and is evaluated as a
numerical indicator called a BOP score The BOP score is assessed
as a proportion of bleeding sites within six tested sites on all
present teeth when stimulated by a standardized probe with a
controlled force (0.2–0.25 N) to the bottom of the pocket. While the
presence of BOP can be a poor predictor of periodontal disease
activity, the absence of BOP is an excellent indicator of periodontal
stability [In the 2017 World Workshop, the BOP score was also
recognized as a basic parameter that set thresholds for the
diagnosis of gingivitis and assures the state of a healthy (BOP
score < 10%) or gingivitis (localized: 10% ≤ BOP score ≤ 30%,
generalized: BOP score > 30%) [This was the first time that gingival
health had been defined, serving as an important benchmark for
future diagnostic and prognostic work. To assess BOP, a binary
readout (presence or absence) is performed, and manual
periodontal probes are most commonly used. To test for BOP,
clinicians use a manual periodontal probe to gently stimulate the
tissue at the base of the periodontal pocket. Once bleeding occurs
at the probing sites, the number of bleeding sites is quantified as a
proportion of the total evaluated sites.

DIAGNOSTICS, 2021

Plaque index

To examine the presence of plaque and calculus, sharp explorers

or manual periodontal probes have been typically used. Like with
BOP, clinicians binarily assess the presence or absence of this
accumulated material .scores recorded on four surfaces ;distal,
mid and mesial points on the facial ) bucall) and (lingual) (palatal)
aspects .score 0 =no plaque , score 1 = plaque present
DIAGNOSTICS, 2021
Tooth mobility :
Tooth mobility is an important physical feature of periodontal
diseases. When periodontal diseases occur, it can cause bone
resorption and damage to the supporting soft tissues. As a result,
the structure that holds the teeth firmly in place is lost, and the
teeth become mobile . Tooth mobility is determined clinically by
putting directional pressure on the tooth and observing its
movement. The Miller index is the most commonly used manual
method in which the tooth is held firmly between two instruments
and moved back and forth . For a more accurate and reproducible
evaluation of the degree of tooth mobility, numerous techniques
have been studied and tested. These include devices of electronic
registration, microperiodontometer , dental holographic
interferometry , laser vibrometer, piezoelectric transducer],
resonance frequency analysis (RFA) , and non-contact vibration
device
Mobility is scored according to the ease and extent of tooth movement
according to the Miller Index46 as follows: • Mobility no. 1: first
distinguishable sign of movement greater than “normal” • Mobility no.
2: movement of the crown up to 1 mm in any direction • Mobility no. 3:
movement of the crown more than 1 mm in any direction or vertical
depression or rotation of the crown in its socket.
DIAGNOSTICS, 2021 , Carranza clinical periodontology 13 edit

Furcation involvement
Attachment loss can result in furcation invasion, the pathologic
resorption of interradicular bone within a furcation of a multirooted
tooth due to periodontal disease. Furcation invasion is detected by
carefully probing the root surface for horizontal concavities where the
roots diverge. Specialized probes, such the Nabers probe, may facilitate
detection of mesial and distal furcation invasion on maxillary molars
where access is limited. The Glickman Classification23 of furcation
invasion is the most commonly used, and it is as follows: • Grade I:
pocket formation into the flute but intact interradicular bone • Grade
II: loss of interradicular bone and pocket formation of varying depths
into the furcation but not completely through to the opposite side of
the tooth • Grade III: through-and-through lesion • Grade IV: same as
grade III with gingival recession, rendering the furcation clinically
visible.
Carranza clinical periodontology 13 edit

clinical pathway for a diagnosis of periodontitis

A proposed algorithm has been used by the EFP to assist clinicians with
this periodontal diagnosis process when examining a new patient
(Tonetti & Sanz, 2019). It consists of four sequential
steps:1. Identifying a patient suspected of having periodontitis2.
Confirming the diagnosis of periodontitis3. Staging the periodontitis
case4. Grading the periodontitis case

Classification of Periodontal and Peri-Implant Diseases and

Conditions (Caton et al., 2018; Chapple et al., 2018; Jepsen et al.,
2018; Papapanou et al., 2018).According to this classification :
A case of clinical periodontal health is defined by the absence of
inflammation [measured as presence of bleeding on probing (BOP) at
less than 10% sites] and the absence of attachment and bone loss
arising from previous periodontitis.• A gingivitis case is defined by the
presence of gingival inflammation, as assessed by BOP at ≥10% sites
and absence of detectable attachment loss due to previous
periodontitis. Localized gingivitis is defined as 10%–30% bleeding sites,
while generalized gingivitis is defined as >30% bleeding sites• A
periodontitis case is defined by the loss of periodontal tissue support,
which is commonly assessed by radiographic bone loss or interproximal
loss of clinical attachment measured by probing. Other meaningful
descriptions of periodontitis include the number and proportions of
teeth with probing pocket depth over certain thresholds (commonly >4
mm with BOP and ≥6 mm), the number of teeth lost due to
periodontitis, the number of teeth with intra-bony lesions and the
number of teeth with furcation lesions.• An individual case of
periodontitis should be further characterized using a matrix that
describes the stage and grade of the dis-ease. Stage is largely
dependent upon the severity of disease at presentation, as well as on
the anticipated complexity of case management, and further includes a
description of extent and distribution of the disease in the dentition.
Grade provides supplemental information about biological features of
the disease including a history-based analysis of the rate of
periodontitis progression; assessment of the risk for further
progression; analysis of possible poor outcomes of treatment; and
assessment of the risk that the disease or its treatment may negatively
affect the general health of the patient. The staging, which is
dependent on the severity of the disease and the anticipated
complexity of case management, should be the basis for the patient's
treatment plan based on the scientific evidence of the different
therapeutic interventions. The grade, however, since it provides
supplemental information on the patient's risk factors and rate of
progression, should be the basis for individual planning of care (Tables
7 and 8) (Papapanou et al., 2018; Tonetti, Greenwell, & Kornman,
2018).
after the completion of periodontal therapy, a stable periodontitis
patient has been defined by gingival health on a reduced periodontium
(bleeding on probing in <10% of the sites; shallow probing depths of 4
mm or less and no 4 mm sites with bleeding on probing). When, after
the completion of periodontal treatment, these criteria are met but
bleeding on probing is present at >10% of sites, then the patient is
diagnosed as a stable periodontitis patient with gingival inflammation.
Sites with persistent probing depths ≥4 mm which exhibit BOP are likely
to be unstable and require further treatment. It should be recognized
that successfully treated and stable periodontitis patients will remain at
increased risk of recurrent periodontitis, and hence if gingival
inflammation is present adequate measures for inflammation control
should be implemented to prevent recurrent periodontitis
journal of clin.periodontology 2020

From : tonetti , greenwell, kornman, 2018.

Journal of clin.periodontology 2020
From : tonetti , greenwell, kornman, 2018.
Journal of clin.periodontology 2020
Determination of prognosis
A prognosis is a prediction of the probable course, duration, and
outcome of a disease based on a general knowledge of the
pathogenesis of the disease and the presence of risk factors for the
disease. It is established after the diagnosis is made and before the
treatment plan is established. The prognosis is based on specific
information about the disease and the manner in which it can be
treated, but it also can be influenced by the clinician’s previous
experience with treatment outcomes (successes and failures) as they
relate to the particular case.
Carranza clinical periodontology 13 edit
Types of prognosis
Good prognosis: Control of etiologic factors and adequate periodontal
support ensure the tooth will be easy to maintain by the patient and
clinician. Fair prognosis: Approximately 25% attachment loss or grade I
furcation invasion (location and depth allow proper maintenance with
good patient compliance). Poor prognosis: 50% attachment loss, grade
II furcation invasion (location and depth make maintenance possible
but difficult). Questionable prognosis: >50% attachment loss, poor
crown-to-root ratio, poor root form, grade II furcation invasion
(location and depth make access difficult) or grade III furcation
invasion; mobility no. 2 or no. 3; root proximity. Hopeless prognosis:
Inadequate attachment to maintain health, comfort, and function.
Carranza clinical periodontology 13 edit
Factors in determining the prognosis
Overall Clinical Factors; Patient age ; Disease severity ;Biofilm control
;Patient compliance ,
Systemic and Environmental Factors; Smoking, Systemic disease or
condition, Genetic factors, Stress, Local Factors ; Biofilm and calculus,
Subgingival restorations,
Anatomic Factors Short, tapered roots, Cervical enamel projections,
Enamel pearls, Bifurcation ridges, Root concavities, Developmental
grooves, Root proximity, Furcation invasion, Tooth mobility, Caries,
Tooth vitality, Root resorption , Prosthetic and Restorative Factors ,
Abutment selection.
Carranza clinical periodontology 13 edit
Treatment plan ;
Is a plan for therapy formulated only after thorough examination has
been completed , diagnosis , and prognosis have been determined and
the needs and desires of the patient have been taken into
consideration.
Treatment plan is the blueprint for case management
Carranza clinical periodontology 13 edit
Sequence for the treatment of periodontitis stages I, II and III Patients
once diagnosed, should be treated according to a pre established
stepwise approach to therapy that, depending on the disease stage,
should be incremental, each including different interventions .An
essential prerequisite to therapy is to inform the patient of the
diagnosis, including causes of the condition, risk factors, treatment
alternatives and expected risks and benefits including the option of no
treatment. This discussion should be followed by agreement on a
personalized care plan. The plan might need to be modified during. the
treatment journey, depending on patient preferences, clinical findings
and changes to overall health.
1. The first step in therapy is aimed at guiding behaviour change by
motivating the patient to undertake successful removal of supragingival
dental biofilm and risk factor control and may include the following
interventions:• Supragingival dental biofilm control• Interventions to
improve the effectiveness of oral hygiene [motivation, instructions (oral
hygiene instructions, OHI)]• Adjunctive therapies for gingival
inflammation• Professional mechanical plaque removal (PMPR), which
includes the professional interventions aimed at removing supragingival
plaque and calculus, as well as possible plaque-retentive factors that
impair oral hygiene practices.• Risk factor control, which includes all
the health behavioural change interventions eliminating/mitigating the
recognized risk factors for periodontitis onset and progression (smoking
cessation, improved metabolic control of diabetes, and per-haps
physical exercise, dietary counselling and weight loss).This first step of
therapy should be implemented in all periodontitis patients,
irrespective of the stage of their disease, and should be re-evaluated
frequently in order to• Continue to build motivation and adherence, or
explore other alternatives to overcome the barriers• Develop skills in
dental biofilm removal and modify as required• Allow for the
appropriate response of the ensuing steps of therapy
2. The second step of therapy (cause-related therapy) is aimed at
controlling (reducing/eliminating) the subgingival biofilm and calculus
(subgingival instrumentation). In addition to this, the following
interventions may be included:• Use of adjunctive physical or chemical
agents• Use of adjunctive host-modulating agents (local or systemic)•
Use of adjunctive subgingival locally delivered antimicrobials• Use of
adjunctive systemic antimicrobials This second step of therapy should
be used for all periodontitis patients, irrespective of their disease stage,
only in teeth with loss of periodontal support and/or periodontal
pocket formation*.*In specific clinical situations, such as in the
presence of deep probing depths, first and second steps of therapy
could be delivered simultaneously (such as for preventing periodontal
abscess development).The individual response to the second step of
therapy should be assessed once the periodontal tissues have healed
(periodontal re-evaluation). If the endpoints of therapy (no periodontal
pockets >4 mm with bleeding on probing or no deep periodontal
pockets [≥6 mm]) have not been achieved, the third step of therapy
should be considered. If the treatment has been successful in achieving
the endpoints of therapy, patients should be placed in a supportive
periodontal care (SPC) program.
3. The third step of therapy is aimed at treating those areas of the
dentition non-responding adequately to the second step of therapy
(presence of pockets ≥4 mm with bleeding on probing or presence of
deep periodontal pockets [≥6 mm]), with the purpose of gaining further
access to subgingival instrumentation, or aiming at regenerating or
resecting those lesions that add complexity in the management of
periodontitis (intra-bony and furcation lesions).It may include the
following interventions:• Repeated subgingival instrumentation with or
without adjunctive therapies• Access flap periodontal surgery•
Resective periodontal surgery• Regenerative periodontal surgery
When there is indication for surgical interventions, these should be
subject to an additional patient consent and specific evaluation of risk
factors or medical contra-indications should be considered .The
individual response to the third step of therapy should be re-assessed
(periodontal re-evaluation) and ideally the endpoints of therapy should
be achieved, and patients should be placed in supportive periodontal
care, although these endpoints of therapy may not be achievable in all
teeth in severe Stage III periodontitis patients.
4. Supportive periodontal care is aimed at maintaining periodontal
stability in all treated periodontitis patients combining preventive and
therapeutic interventions defined in the first and second steps of
therapy, depending on the gingival and periodontal status of the
patient's dentition. This step should be rendered at regular intervals
according to the patient's needs, and in any of these recall visits, any
patient may need re-treatment if recurrent disease is detected, and in
these situations, a proper diagnosis and treatment plan should be
reinstituted. In addition, compliance with the recommended oral
hygiene regimens and healthy lifestyles are part of supportive
periodontal care. In any of the steps of therapy, tooth extraction may
be considered if the affected teeth are considered with a hopeless
prognosis.
JOURNAL OF CLINICAL PERIODONTOLOGY 2020.
Sequence of treatment of stage IV periodontitis
Distinctive features of stage IV
Secondary occlusal trauma/tooth hypermobility attributable to a
reduced periodontal attachment that is attributed to periodontitis.
•Tooth migration, drifting and opening of diastema are associated with
severe attachment loss at the affected teeth
.•Loss of five or more teeth due to periodontitis.
.•Loss of posterior support and/or flaring of anterior teeth due to
periodontitis.
•Loss of masticatory function (masticatory dysfunction) secondary to a
combination of the above.
The above signs and symptoms of functional impairment (masticatory
dysfunction) may also be present as sequelae of multiple tooth loss due
to caries or severe malocclusion in people without significant
periodontal breakdown or even in people with periodontal breakdown
compatible with stages I–II periodontitis, who do not meet the criteria
for stage IV. Hence, differential diagnosis is important .Stage IV
periodontitis not only jeopardizes the survival of individual teeth, but
that of the entire dentition. In these patients, control of periodontitis
(through standard periodontal therapy, i.e., steps I–III plus supportive
periodontal care) is not enough to stabilize the mouth, resolve
masticatory dysfunction and improve quality of life An inter-disciplinary
treatment plan that may include the management of secondary
occlusal trauma, orthodontic tooth movement and/or restorative
dental care following successful periodontal therapy must therefore be
implemented to adequately treat these patients.
Journal of clin.periodontology 2020.
phenotypic variation and identification of clinical case types

Stage IV periodontitis cases may present with great phenotypic

variation based on the individual patterns of their periodontal
breakdown, number of missing teeth, inter-maxillary relationships
and residual alveolar ridge, which will result in different degrees of
functional and aesthetic compromise, as well as different
treatment needs .To provide a simplified workable guideline, four
major stage IV periodontitis phenotypes were recognized by the
organizing commit-tee, leading to specific clinical case types:

•Case type 1: the patient with tooth hypermobility due to

secondary occlusal trauma that can be corrected without tooth
replacement. It is recognized that there is a continuum of severity
and complexity of management between some stage III
periodontitis patients, and case type 1 of periodontitis in stage IV

.•Case type 2: the patient with pathological tooth migration,

characterized by tooth elongation, drifting and flaring, which is
amenable to orthodontic correction

.•Case type 3: partially edentulous patients who can be

prosthetically restored without full-arch rehabilitation

.•Case type 4: partially edentulous patients with a dentition that

need full-arch rehabilitation, either tooth- or implant-
supported/retained .

These phenotypes and associated clinical case types may

overlap on occasion, as one arch may require treatment
according to a specific scenario while the other might require
a different approach.
Journal of clin.periodontology 2020.

Sequence for the treatment of stage IV periodontitis

The treatment plan for the management of stage IV periodontitis
should include a successful outcome after completing the interventions
in steps 1, 2 and 3, according to the EFP S3 Level clinical practice
guideline for treatment of stage I–III periodontitis (Sanz, Herrera,et
al.,2020). The sequence of the different steps, however, requires the
introduction of specific additional treatment measures to meet the
specific demands of stage IV periodontitis. In these cases, rehabilitation
of function, restoration of masticatory comfort and treatment of
secondary occlusal trauma and, sometimes, restoration of the vertical
dimension of the occlusion are also necessary and need to be planned
from the beginning, and even implemented simultaneously with steps
1–3.As is the case for the treatment of periodontitis in stages I–III, an
essential pre-requisite to therapy is to inform the patient of the
diagnosis, including etiology of the condition, risk factors, treatment
alternatives and expected risks and benefits, including the option of no
treatment. This discussion should be followed by agreement on a
personalized care plan. The plan might need to be modified during the
course of treatment, depending upon initial treatment outcomes,
patient preferences, clinical findings and changes to the patient's
overall state of health. It must be recognized that in stage IV
periodontitis, a“no treatment”option must be discouraged, given the
expected high risk of loss of the dentition .Key to the care of these
patients is:•The need to combine periodontal therapy, which is
modelled in line with the recent guidelines for the treatment of stage I–
III periodontitis (Sanz, Herrera, et al.,2020), with rehabilitation
.•Identification of the appropriate timing/sequence of implementation
of the adjunctive orthodontic/restorative treatment and the
periodontal treatment
Journal of clin.periodontology 2020.
specific treatment pathways according different stage IV case
types periodontitis
Common to all clinical case types is the need to perform a careful
diagnosis and a case study that includes both periodontal and
rehabilitation phases (orthodontics and/or restorative dentistry, as
appropriate). Furthermore, adequate self-performed oral hygiene,and
risk factor control must be realized, alongside satisfactory initial treat-
ment outcomes prior to progressing the case to subsequent periodon-
tal/oral rehabilitation.
•Case type 1: the patient with tooth hypermobility due to secondary
occlusal trauma that can be corrected without tooth
replacement.Temporary tooth splinting and initial occlusal adjustment
(mostly relief of fremitus in combination with splinting) can be
implemented during step 1 of therapy to manage secondary occlusal
trauma and the impact of tooth hypermobility on patient comfort. The
need forand the implementation of longer-term splinting needs to be
re-assessed following completion of steps 2 and 3 of periodontal
therapy.
•Case type 2: the patient with pathological tooth migration, charac-
terized by tooth elongation, drifting and flaring, which is amenable to
orthodontic correction.Orthodontic therapy can be planned during step
2 of care (sub-gingival instrumentation with or without adjunctives)
and, in some cases, step 3 (subgingival re-instrumentation and
periodontal sur-gery) of treatment, but should not be implemented
before achiev-ing the periodontal treatment objectives of shallow
maintainable pockets and control of periodontal inflammation. Special
consider-ations apply to the regenerative treatment of intra-bony
defects.
•Case type 3: partially edentulous patients who can be prostheti-cally
restored without full-arch rehabilitation.The timing of intermediate
restorations, if required, should be care-fully evaluated based on the
individuality of the case and keeping in mind patient wishes and
aesthetic considerations. Ideally, interim tooth-retained restorations or
dental implants should not be placed before completion of step 2 of
treatment and, if possible, deferred until the periodontal treatment
objectives have been achieved (after re-evaluation following steps 2
and 3 of periodontal treatment).Definitive restorative treatment or
placement of dental implants must be performed after successful
completion of periodontal therapy and any additional conservative
treatment of the abutment teeth.
•Case type 4: partially edentulous patients who need to be restored by
means of full-arch rehabilitation, either tooth- or implant-retained, and
either fixed or removable. The timing of treatment differs for cases with
tooth-supported full-arch restorations and cases with implant-
supported full-arch restorations.
In tooth-supported cases, an intermediate restoration is frequently
placed following successful completion of step 1 of periodontal
treatment. Step 2 of periodontal treatment, including scaling and root
surface instrumentation of the abutment teeth, is performed with the
intermediate restoration in place. Insertion of a definitive restoration
(or long-term intermediate restoration) follows successful completion
of periodontal therapy and achievement of shallow maintainable
pockets and control of periodontal inflammation .For implant-
supported cases requiring extraction of the terminal dentition, in one
or both arches, teeth are extracted, and implants placed after
successful completion of step 1 of periodontal treatment if one arch
still has natural teeth. The sequence of treatment and the insertion of
intermediate fixed or removable prostheses aims to reconcile the
biology of wound healing with the need to manage patient
expectations and ensure an adequate level of com-fort during the
transition.
Journal of clin.periodontology 2020.

supportive periodontal care in stage IV periodontitis patients

As for the treatment of stage I–III periodontitis (Sanz, Herrera,et
al.,2020), supportive periodontal care (Trombelli et al.,2015)is a crucial
step to achieve periodontal stability and long-term tooth/implant
retention.
The role of SPC is highly relevant to patients with all stages of
periodontitis. In the systematic review (Leow et al.,2021), it was not
possible to identify studies focussed on stage IV periodontitis and the
findings are therefore relevant to all stages of disease. Five components
or combinations thereof contribute to SPC interventions:
1.Interview: periodontal health symptoms, medical and social his-tory,
risk factors including tobacco use, stress, diabetes and reported plaque
control regime;
2.Assessment: plaque and calculus deposits, periodontal health status,
including inflammation, PPDs and bleeding pockets;
3.Evaluation: intervention needs including risk factor management ,oral
hygiene and re-treatment;
4.Practical Intervention: oral hygiene coaching, instrumentation of
supra- and sub-gingival plaque and calculus, treatment of sites with
recurrence (finding of periodontitis at a previously healthy/stable site)
or residual periodontitis (a deep periodontal pocket remains despite
active therapy);
5.Planning: interval before next SPC visit. The control was no or
irregular SPC, defined as greater than a frequency of 3-monthly.
Journal of clin.periodontology 2020.