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CRITICAL DECISIONS
IN PERIODONTOLOGY

WALTER B. HALL, BA, DDS, MSD

Professor Emeritus
Department of Periodontics
University of the Pacific School of Dentistry
San Francisco, California

4th Edition
2003

BC Decker Inc
Hamilton • London

with 250 illustrations

2
BC Decker Inc

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All rights reserved. No part of this publication may be reproduced, stored in a

retrieval system, or transmitted, in any form or by an means, electronic, mechanical,
photocopying, recording, or otherwise, without prior written permission from the
publisher.

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Printed in Spain

3
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4
 NOTICE
The authors and publisher have made every effort to ensure that the patient care
recommended herein, including choice of drugs and drug dosages, is in accord with
the accepted standard and practice at the time of publication. However, since research
and regulation constantly change clinical standards, the reader is urged to check the
product information sheet included in the package of each drug, which includes
recommended doses, warnings, and contraindications. This is particularly important
with new or infrequently used drugs. Any treatment regimen, particularly one
involving medication, involves inherent risk that must be weighed on a case-by-case
basis against the benefits anticipated. The reader is cautioned that the purpose of this
book is to inform and enlighten; the information contained herein is not intended as,
and should not be employed as, a substitute for individual diagnosis and treatment.

5
 DEDICATION

To my wife, Frencella, and my sons, Scott and Gregory,

for their love, support, and understanding during the
preparation of this text

8
 CONTENTS
Preface, vii
Contributors, ix
Introduction, 1
PART 1 History Taking

PART 2 Laboratory Tests

PART 3 Indications for Collecting and Recording Data

PART 4 Signs and Symptoms

PART 5 Detecting and Recording Findings

PART 6 Differential Diagnosis

PART 7 Prognosis

PART 8 Treatment Planning and Treatment

PART 9 Initial Therapy Evaluation

PART 10 Guided Tissue Regeneration

PART 11 Surgical Treatment

PART 12 Decision Making in Postsurgical Reevaluations

PART 13 Osseointegrated Implants

PART 14 Esthetics in Periodontics

PART 15 Miscellaneous Issues, Problems, and Treatments

6
 PREFACE
Earlier editions of this book, which were titled Decision Making in Periodontology,
illustrated the thought processes used in determining optimal therapy for individual
patients as conceived by various experts of the field. This fourth edition takes learning
a step farther by providing readers with the means to use the knowledge they have
already acquired in the practice of periodontics. Renamed Critical Decisions in
Periodontology, this fourth edition describes common clinical problems and how
practitioners go about deciding what should be done. The approach offers an
algorithm (decision tree) for solving each clinical problem as it may be experienced in
practice. Chapters describe common clinical problems and, guided by the thinking of
experts, allow the reader to arrive at decisions that would take much longer to
contrive if guided only by classical teaching texts. Several commonly available
additional readings are provided for further details.

This updated and enhanced text should continue to serve the needs of several groups
in the fields of dental care. Experienced clinicians may seek answers to specific
problems and compare their methods with those outlined. Teachers of periodontology
may use this text as a stimulus to rethink modes of presenting information and as a
model to test whether students have grasped the concepts they have been taught and
are able to use them in a practical manner. Undergraduate students will find this
material useful in integrating concepts that they have been taught in a more
conventional way, and postgraduate students may argue the merits of the decision-
making process as outlined and rewrite the decision trees. Auxiliary personnel will
find the material helpful in understanding why specific things happen in certain ways
within the dental office. In the rapidly progressing and contentious field of
periodontology, some of the decision making presented by our international group of
authors may be controversial; however, if the decision trees presented here stimulate
thought and discussion, the book will have fulfilled its purpose.

Many thanks to Brian Decker who conceived the idea of books that help dental care
providers use their knowledge to make decisions in dental care, and to Charmaine
Sherlock and Paula Presutti, who edited this text. Thanks also to all of those talented
individuals who contributed chapters. Special thanks to Dr. Eric Curtis, who provided
the illustrations, and to my family, Fran, Scott, and Greg, for their encouragement
during the preparation of this book.

Walter B. Hall
October 2002

7
 CONTRIBUTORS
Donald F. Adams, DDS, MS Gretchen J. Bruce, DDS, MBA
Professor and Director Emeritus Assistant Professor of Periodontics
Department of Periodontology University of the Pacific School of
School of Dentistry Dentistry
Oregon Health Sciences University San Francisco, California
Portland, Oregon
Francesco Cairo, DDS
Edward P. Allen, DDS, PhD Research Fellow of Periodontology
Department of Periodontics Dental School, University of Florence
Baylor College of Dentistry Florence, Italy
Dallas, Texas
Paulo M. Camargo, DDS, MS
Tamer Alpagot, DDS, PhD Assistant Professor of Periodontics
Associate Professor of Periodontics UCLA School of Dentistry
University of the Pacific School of Los Angeles, California
Dentistry
San Francisco, California Jordi Cambra, MD, DDS, ME
Private Practice
Tiziano Baccetti, DDS Periodontics
Department of Orthodontics Barcelona, Spain
University of Florence
Florence, Italy Miguel Carasol, MD, DDS
Professor of Periodontology
Roberto Barone, DDS European University School of
Private Practice Dentistry
Florence, Italy Madrid, Spain

Antonio Bascones, MD, DDS, PhD Carlo Clauser, MD

Professor of Periodontics, Oral Private Practice
Medicine, and Surgery Florence, Italy
School of Dentistry
Universidad Complutense Pierpaolo Cortellini, MD
Madrid, Spain Department of Periodontology
Eastman Dental Institute
Carrie Berkovich, DDS, MS University College of London
Assistant Professor of Periodontics London, United Kingdom
University of the Pacific School of
Dentistry Mithridade Davarpanah, MD, DMD
San Francisco, California Clinical Assistant Professor of
Periodontology
Burton E. Becker, DDS University of Paris
Professor of Stomatology, Paris, France
Periodontics, Graduate Periodontics
University of Texas Daniel Etienne, DCD, MS
Houston, Texas Associate Professor of Periodontology
University of Paris
William Becker, DDS, MSD Paris, France
Private Practice
Periodontics
Tuscon, Arizona

9
Lavin Flores-de-Jacoby, DDS Brian J. Kenyon, BA, DMD
Professor Assistant Professor of Oral Medicine
Department of Periodontology University of the Pacific School of
Phillipps-Universitat Dentistry
Marburg, Germany San Francisco, California

Craig Gainza, DDS, MSD Perry R. Klokkevold, DDS, MS

Private Practice Associate Professor and Clinical
Periodontics Director of Periodontics
Vallejo, California UCLA School of Dentistry
Los Angeles, California
James Garibaldi, DDS, MA
Associate Professor of Oral Surgery John Y. Kwan, DDS
University of the Pacific School of Private Practice
Dentistry Periodontics
San Francisco, California Oakland, California

Timothy F. Geraci, DDS, MSD Eugene E. LaBarre, BA, DMD, MS

Private Practice Associate Professor and Chair of
Periodontics Removable Prosthodontics
Oakland, California University of the Pacific School of
Dentistry
William Grippo, DDS San Francisco, California
Private Practice
Periodontics Alan S. Leider, DDS, MA
Napa, California Professor Emeritus of Pathology
Department of Diagnostic Sciences
Walter B. Hall, DDS, MSD University of the Pacific School of
Professor Emeritus of Periodontics Dentistry
University of the Pacific School of San Francisco, California
Dentistry
San Francisco, California Casimir Leknius, DDS, MBA
Associate Professor of Restorative
Lisa A. Harpenau, DDS, MS, MBA Dentistry
Assistant Professor of Periodontics University of the Pacific School of
University of the Pacific School of Dentistry
Dentistry San Francisco, California
San Francisco, California
Vojislav Lekovic, DDS, PhD
Stephen K. Harrel, DDS Professor of Periodontics and Dean
Private Practice University of Belgrade
Periodontics Belgrade, Yugoslavia
Dallas, Texas
Joseph Levy, BA, MS, PhD
Luther H. Hutchens Jr, DDS, MSD Professor and Chair of Physiology and
Professor Emeritus of Periodontics Pharmacology
School of Dentistry University of the Pacific School of
University of North Carolina Dentistry
Chapel Hill, North Carolina San Francisco, California

10
Larry G. Loos, DDS Michael G. Newman, BA, DDS
Professor and Chair of Restorative Professor of Periodontics
Dentistry UCLA School of Dentistry
University of the Pacific School of Los Angeles, California
Dentistry
San Francisco, California Giovan Paolo Pini-Prato, MD, DDS
Professor and Chair of Periodontology
William P. Lundergan, DDS, MA Dental School, University of Florence
Professor and Chair Florence, Italy
Department of Periodontics of the
Pacific School of Dentistry Mauricio Ronderos, DDS, MS, MPH
San Francisco, California Assistant Professor of Periodontics
University of the Pacific School of
Benjamin J. Mandel, DDS Dentistry
Chair and Founder San Francisco, California
Santa Clara Periodontics Study Club
Tiburon, California Roberto Rotundo, DDS
Research Fellow in Periodontics
Alex R. McDonald, DDS, PhD University of the Pacific School of
Associate Professor of Oral Surgery Dentistry
University of the Pacific School of San Francisco, California
Dentistry
San Francisco, California Randal W. Rowland, DMD, MS
Professor of Clinical Periodontology
Reiner Mengel, DDS Director Postgraduate Periodontology
Department of Periodontology University of California
Phillipps-Universitat Marburg San Francisco, California
Marburg, Germany
Richard S. Rudin, DDS
Scott W. Milliken, DDS, MS Assistant Professor of Oral Medicine
Assistant Professor of Periodontics University of the Pacific School of
University of the Pacific School of Dentistry
Dentistry San Francisco, California
San Francisco, California
Mariano Sanz, MD, DDS
Francisco Martos Molino, MD, DDS Professor and Chair of Periodontology
School of Dentistry University of Madrid School of
Universidad Complutense Dentistry
Madrid, Spain Madrid, Spain

Kathy I. Mueller, MS, DMD Thomas Schiff, MD, DDS

Assistant Professor of Fixed Professor and Chair of Dental
Prosthodontics Radiology
University of the Pacific School of University of the Pacific School of
Dentistry Dentistry
San Francisco, California San Francisco, California

Leonardo Muzzi, DDS Alberto Sicillia, MD, DDS

Research Fellow in Periodontology Associate Professor of Periodontics
Dental School, University of Florence School of Stomatology
Florence, Italy University of Oviedo
Oviedo, Spain

11
E. Robert Stultz Jr, DMD, MS Vicki Vlaskalic, BDS, MDSc
Adjunct Professor of Periodontics Assistant Professor of Orthodontics
University of the Pacific School of University of the Pacific School of
Dentistry Dentistry
San Francisco, California San Francisco, California

Charles F. Sumner III, DDS, JD Galen W. Wagnild, DDS

Associate Professor of Periodontics Associate Clinical Professor of
University of the Pacific School of Restorative Dentistry
Dentistry University of California School of
San Francisco, California Dentistry
San Francisco, California
Maurizio Tonetti, DDS, MS
Department of Periodontics Borja Zabelegui, MD, DDS
University of Bern School of Dentistry Professor Titular
Bern, Switzerland Estomatologia
Universidad Pais Vasco
Steven A. Tsurudome, DDS, MS Bilbao, Spain
Assistant Professor of Periodontics
University of the Pacific School of Jon Zabelegui, MD, DDS
Dentistry Visiting Professor in Postgraduate
San Francisco, California Periodontology
Universidad Complutense
Gonzalo Hernndez Vallejo, MD, Madrid, Spain
DDS, PhD
Professor of Periodontics, Oral Mark Zablotsky, DDS
Medicine, and Surgery Adjunct Assistant Professor of
School of Dentistry Periodontics
Universidad Complutense University of the Pacific School of
Madrid, Spain Dentistry
San Francisco, California
Ian Van Zyl, DDS, MS
Assistant Professor of Restorative Giliana Zuccati, MD
Dentistry Private Practice
University of the Pacific School of Florence, Italy
Dentistry
San Francisco, California

12
 INTRODUCTION
Each two-page chapter in this text consists of an algorithm or decision tree, which
usually appears on the right-hand page, and a brief explanatory text with illustrations
and additional readings, which begin on the left-hand page. The decision tree is the
focus of each chapter and should be studied first in detail. The letters on the decision
tree refer the reader to the text, which provides a brief explanation of the basis for
each decision. Boxes have been used on the decision tree to indicate invasive
procedures or the use of drugs. A combination of line drawings and halftones were
selected to clarify the text. Cross-references have been inserted to avoid repeating
information given in other chapters. Additional readings that are likely to be readily
available to the practitioner have been selected.

Chapters have been grouped by general concepts in the order that follows the typical
sequence of therapy in periodontal practice. An index is included to guide the reader
further in locating specific information.

The decisions outlined here relate to typical situations. Unusual cases may require the
clinician to consider alternatives; however, in every case, the clinician must consider
all aspects of an individual patients data. The algorithms presented here are not meant
to represent a rigid guideline for thinking but rather a skeleton to be fleshed out by
additional factors in each individual patients case.

17
 PART 1
HISTORY TAKING

1 Medical History
Walter B. Hall

2 Laboratory Tests and Their Significance

Richard S. Rudin

3 Dental History
Walter B. Hall

4 Plaque-Control History
Walter B. Hall

18
PART 1 History Taking

1 Medical History
Walter B. Hall

Before examining a new patient, the dentist should take a med- E Infectious diseases such as hepatitis, acquired immuno-
ical history. At each subsequent visit, a simple question such as deficiency syndrome (AIDS), and tuberculosis (TB) should
“How have you been since I saw you last?” may elicit an impor- be included in the questionnaire. Establish whether a
tant response, such as “I found out I’m pregnant,” which the patient who has had hepatitis B is a carrier. Encourage the
patient might consider unimportant to her dental treatment. At patient to be tested, for family safety if for no other rea-
recall visits, before any dental examination, the dentist should son. (The test is simple and inexpensive.) HIV+ often has
question the patient more extensively regarding visits to a an associated periodontal problem (see Chapters 32 and
physician, any illnesses, and any changes in medication. In the 33). Questioning regarding this disease must be managed
treatment record the dentist should indicate the medical history discreetly. TB is uncommon among native-born Ameri-
was updated by noting, “No changes in medical history,” or by cans but quite prevalent among recent immigrants and
recording specific changes that have occurred. The medicolegal increasingly common among patients in general.
importance of such notations cannot be overemphasized.
F Hepatitis (see E) and cirrhosis are common problems that
A A health questionnaire (“yes or no” format) is useful in affect dental care. Cirrhosis may impair a patient’s heal-
making the patient responsible for the accuracy of the ing potential. Recurrent kidney infections may require
medical history. The patient may complete such a ques- antibiotic prophylaxis before periodontal treatment.
tionnaire while waiting to see the dentist. Usually, ques-
tions are grouped according to systems. The dentist uses G Patients with seizure disorders may require additional med-
this form as a guideline in questioning the patient further ication before periodontal treatment. Those taking diphenyl-
about positive answers and writes additional information hydantoin sodium (Dilantin) often develop a “hyperplastic”
in the chart. gingival response (see Chapter 29).

B The new patient’s age is important in developing a treat- H Asthma can complicate periodontal treatment, especially
ment plan and as a guide to certain age-related diseases. when anesthetics containing epinephrine are used. Sinusi-
Note the date and findings of the patient’s last physical tis can complicate the differential diagnosis of periodontal
examination. List the names and addresses of any physi- pain in the maxillary posterior area.
cians treating the patient, as well as medications the patient
is currently taking and reasons for their use. Refer to I Avoid nonemergency periodontal treatment of any com-
important medications in an easily seen place, or use col- plexity throughout pregnancy but especially in the first and
ored stickers to indicate these medications in a standard third trimesters. Pregnancy can modify gingivitis. Such
area on the chart. “pregnancy gingivitis” often does not respond to treatment
until several months after gestation.
C Note heart attacks, rheumatic heart disease, heart surgery,
and replacement parts in the heart so that precautions such J Gastric or duodenal ulcers may complicate periodontal
as antibiotic prophylaxis for patients with rheumatic heart healing because of dietary restrictions. Gingival changes
disease or artificial valves can be taken. The patient may may accompany colitis.
even require medication before periodontal probing. Many
patients are aware of blood pressure abnormalities, but oth- K Various types of cancer present complications in periodon-
ers are not. Many dentists obtain a baseline blood pressure tal treatment. Leukemia may be accompanied by gingival
reading at this time. enlargement. The prognosis for the more severe or
advanced types of cancer can force modification of usual
D Diabetes is a major problem in successful management of treatment plans. Radiation therapy may make surgical
periodontal diseases. For a known diabetic, determine treatment inadvisable. The treating physician should be
whether (1) the disease is controlled and (2) the patient has contacted if chemotherapy is being used or has been used
visited a physician within the past 3 to 6 months. If the recently.
patient is unaware of having diabetes, questions regarding
a personal history of periodontal abscesses and blood rela- L Many medicaments and drugs used in periodontal treat-
tives with diabetes may suggest a problem requiring med- ment are significant allergens that may have to be avoided
ical evaluation. with sensitized patients.

2
 Patient for PERIODONTAL EXAMINATION

New patient R Recall

patient

A Questionnaire
Update history:
New medical
B Determine history: problems
Age Status of previously
Physician’s name reported problems
and address Changes in medication
Latest physical Visits to physician
examination
and findings
Medications
Assess:
Blood pressure

C Heart disease D Diabetes E Infectious F Liver or G Seizure

(controlled?) diseases kidney disorders
(hepatitis, disease
HIV + , TB)

H Respiratory I Pregnancy J Gastrointestinal K Cancer L Allergies

problems problems (prognosis,
radiation)

M Dermatologic N Arthritis O Physical P Habits Q Medications

diseases or mental
disabilities

M Some dermatologic diseases, such as lichen planus, pem- Q Medications used for the treatment or management of any
phigus, and pemphigoid, have periodontal components. medical problem may affect periodontal treatment. Some
medications, such as β-blockers, may require changes in
N Some types of arthritis can restrict dexterity required for anesthetics. Others, such as antibiotics, may produce tem-
plaque removal. Corticosteroid therapy often delays heal- porary improvements in periodontitis. A dentist must have
ing after periodontal treatment. a recent edition of the Physicians’ Desk Reference or a similar
reference to determine possible effects of new medications
O Physical or medical disabilities may help explain the etiol- on the treatment plan.
ogy of inflammatory periodontal disease if the patient is
unable to perform adequate oral hygiene procedures. Dis- R Update the medical history of a recall or continuing patient
abilities may also influence the prognosis and treatment at every visit. New medical problems, altered status of pre-
planning. viously diagnosed medical problems, and changes in med-
ications can affect periodontal treatment.
P Heavy smoking, excessive alcohol consumption or drug use
influence the periodontal diagnosis, prognosis, and treat- Additional Readings
ment planning. Vigorous tooth brushing, especially with a
hard brush, may explain root exposure. Self-mutilating Carranza FA Jr, Newman MG. Clinical periodontology. 8th ed. Philadel-
habits may alter gingival appearance. phia: WB Saunders; 1996. p. 344.
Genco RJ, Goldman HM, Cohen DW. Contemporary periodontics. St.
Louis: Mosby; 1990. p. 203.

3
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