The Treatment Plan

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Overview

Introduction Rationale for Perio Treatment Local & Systemic Therapy Treatment Goals Master plan for total treatment Extracting or preserving tooth Therapeutic procedures

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Overview

Phases of Perio Therapy Explaining TP to Patient Summary Conclusion References

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Introduction

TP is blueprint for case management

Treatment is planned after diagnosis & prognosis established

Includes all procedures required for establishment & maintenance of oral health

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Involves following decisions:

Teeth to be retained/ extracted

Pocket therapy techniques – surgical/ nonsurgical

Need for occlusal correction – before/ during/ after pocket therapy

Use of implant therapy

Need for temporary restorations

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Final restorations that will be needed after therapy & which teeth will be abutments if fixed prosthesis used

Need for orthodontic consultation

Endodontic therapy

Decisions regarding esthetic considerations in perio therapy

Sequence of therapy

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Unforeseen developments during treatment may necessitate modification of initial treatment plan

except for emergencies, no treatment should be started until TP established

Rationale For Periodontal Treatment

Perio therapy can restore chronically inflamed gingiva – clinical & structural view - is almost identical with gingiva never exposed to excessive plaque accumulation

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Properly perfomed perio T/t Eliminate pain, Exudate, gingival inflammation & bleeding, Reduce perio pockets & eliminate infection, Stop pus formation, Arrest destruction of soft tissue & bone, Reduce abnormal tooth mobility, Establish optimal occlusal function, Restore tissue destroyed by disease, Reestablish physiologic gingival contour, Prevent recurrence of disease & Reduce tooth loss

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Local therapy

Removal of plaque & all factors that favor its accumulation

Elimination of trauma – chances of bone regeneration & gain of attachment

Creating occlusal relations that are more tolerable to perio tissues – reduce tooth mobility & increases margin of safety of periodontium to minor buildup of plaque

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Systemic therapy

Employed as adjunct to local measures & for specific purposes:

Control of systemic complications from acute infections

Chemotherapy to prevent harmful effects of posttreatment bacteremia

Supportive nutritional therapy & Control of systemic diseases that aggravate

patient’s perio status/ necessitate special precautions during T/t

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Systemic antibiotics – to completely eliminate mo’s that invade gingival tissues & can repopulate pocket after SRP

NSAIDs – flurbiprofen & ibuprofen – slow down development of gingivitis, loss of alveolar bone (Heasman & Seymour 1989, Howell & Williams 1993)

Alendronate, bisphosphonate – studies in monkey – reduce bone loss asso with periodontitis (Brunsvold, Chaves, Kornman et al 1992, Weinreb et al 1994)

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Treatment Goals Reduction/ resolution of gingivitis – full mouth

mean BoP ≤ 25 %

Reduction in probing pocket depth (PPD) – no residual pockets with PPD > 5 mm

Elimination of open furcation – initial furcation involvement should not exceed 3 mm

Absence of pain

Individually satisfactory esthetics & function

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MASTER PLAN FOR TOTAL TREATMENT

Aim of TP is Total Treatment - coordination of all treatment procedures for purpose of creating well–functioning dentition in healthy perio environment

Primary goal is elimination of gingival inflammation & correction of conditions that cause & perpetuate it

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Includes not only elimination of root irritants, but also pocket eradication & reduction, establishment of gingival contours & mucogingival relationships conducive to preservation of perio health, restoration of carious areas & correction of existing restorations

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Extracting or Preserving a Tooth

Perio T/t requires long range planning

Its value to patient is measured in years of healthy functioning of entire dentition, not by no. of teeth retained at time of treatment

Treatment is directed to establishing & maintaining health of periodontium throughout mouth rather than to spectacular efforts to “tighten loose teeth”

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Welfare of dentition should not be jeopardized by heroic attempt to retain questionable teeth

Perio condition of teeth to be retained is more important than no. of such teeth

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Teeth on borderline of hopelessness do not contribute to overall usefulness of dentition, even if they can be saved

become sources of recurrent annoyance to patient & detract from value of greater service rendered by establishment of perio health in

remainder of oral cavity

Teeth that can be retained with minimal doubt & maximal margin of safety provide basis for total TP

Teeth on borderline of hopelessness do not contribute to overall usefulness of dentition, even if they can be saved in somewhat precarious state

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Extract - Yes

Tooth should be extracted when any of following occurs:

It is so mobile that function becomes painfulIt can cause acute abscesses during therapyThere is no use for it in overall TP

Removal, retention, or temporary/ interim retention of one/ more teeth is very important part of overall TP

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Tooth can be retained temporarily, postponing decision to extract it until after treatment, when any of following occurs:

It maintains posterior stops - removed after T/t when it can be replaced by prosthesis

Extract - No

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It maintains posterior stops & may be functional after implant placement in adjacent areas – When implant is exposed, these teeth can be extracted

In anterior esthetic areas, tooth can be retained during perio therapy & removed when T/t is completed, & permanent restorative procedure can be performed

avoids need for temporary appliances

avoids need for temporary appliances & can be considered when retention of tooth will not jeopardize adjacent teeth

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Removal of hopeless teeth can also be performed during perio surgery of neighboring teeth - reduces appointments for surgery in same area

In formulation of TP in addition to proper function of dentition, esthetic considerations play increasingly important role in many cases

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According to their age, gender, profession, social status & other reasons

Different patients value esthetics differently

Clinician should carefully evaluate & consider final outcome of T/t that will be acceptable to

patient without jeopardizing basic consideration of attaining health

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In complex cases, interdisciplinary consultation with other specialty areas is necessary before final plan made

Opinion of orthodontists & prosthodontists is especially important for final decision in these patients

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Considerations of Occlusal relationships

May necessitate:

Occlusal adjustmentRestorative, prosthetic, & orthodontic

proceduresSplinting & Correction of bruxism & clamping & clenching

habits

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Systemic conditions

Carefully evaluated

May require special precautions during course of perio T/t

May also affect tissue response to T/t procedures/ threaten preservation of perio health after treatment is completed

Patient’s physician

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Supportive periodontal care

Paramount importance for case maintenance Entails all procedures for maintaining perio

health after it has been attained

Consists of instruction in oral hygiene & checkups at regular intervals, acc to patient’s needs

To examine condition of periodontium & status of restoration as it affects periodontium

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THERAPEUTIC PROCEDURES

Periodontal therapy is inseparable part of dental therapy

Includes perio procedures & other procedures not considered within province of periodontist

They are listed together to emphasize close relationship of perio therapy with other phases of therapy performed by general dentists/ other specialists

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Phases of Perio Therapy

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Phases of Perio Therapy

Preliminary phaseNon surgical phase (Phase I Therapy)Evaluation of response to Nonsurgical PhaseSurgical Phase (Phase II Therapy)Restorative Phase (Phase III Therapy)Maintenance Phase (Phase IV Therapy)

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A. Preliminary Phase

Treatment of emergencies:Dental/ periapicalPeriodontalOther

Extraction of hopeless teeth and provisional replacement if needed (may be postponed to more convenient time)

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B. Nonsurgical Phase (Phase I Therapy)

Plaque control and patient education:

Diet control (in patients with rampant caries)Removal of calculus & root planingCorrection of restorative & prosthetic irritational

factorsExcavation of caries & restoration (temporary/

final, depending on whether a definitive prognosis for tooth has been determined & on location of caries)

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Antimicrobial therapy (local/ systemic)Occlusal therapyMinor orthodontic movementProvisional splinting & prosthesis

C. Evaluation of response to Nonsurgical phase

Rechecking:Pocket depth & gingival inflammationPlaque & calculus, caries

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D. Surgical Phase (Phase II Therapy) Perio therapy, including placement of implants Endodontic therapy

E. Restorative Phase (Phase III Therapy) Final restorations Fixed & removable prosthodontic appliances Evaluation of response to restorative

procedures Periodontal examination

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F. Maintenance Phase (Phase IV Therapy)

Periodic rechecking:

Plaque & calculusGingival condition (pockets, inflammation)Occlusion, tooth mobilityOther pathologic changes

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Preferred sequence of periodontal therapypreferred sequence, which covers vast majority of cases, is shown

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Although phases of T/t have been numbered, recommended sequence does not follow nos.

Phase I/ Nonsurgical phase - directed to elimination of etiologic factors of gingival & perio diseases

When successfully performed, this phase stops progression of dental & perio disease

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Immediately after completion of Phase I therapy, - patient should be placed on Maintenance phase (Phase IV)

To preserve results obtained & prevent any further deterioration & recurrence of disease

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While on maintenance phase, with its periodic checkups & controls, patient enters into Surgical phase (Phase II) & Restorative (reparative) phase (Phase III) of T/t

Include perio surgery to repair & improve condition of perio & surrounding tissues & their esthetics, rebuilding of lost structures, placement of implants & construction of necessary restorative work

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Phases of Perio Therapy

Systemic phase of therapy including smoking counseling

Initial (or hygiene) phase of periodontal therapy – cause related therapy

Corrective phase of therapy – surgery, endo therapy, implant, restorative, ortho/ prosthetic T/t

Maintenance phase (care) – SPT• Salvi, Lindhe & Lang 2008

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Systemic phase

Goal :

To eliminate/ decrease influence of systemic conditions on outcome of therapy

To protect patient & dental care providers against infectious hazards

Efforts – to enroll smokers into cessation program

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Initial/ Hygiene phase

Represents cause related therapy

Objective: Clean & infection free oral cavity Motivating patients to perform optimal plaque

control

Phase concluded by – reevaluation & planning of both additional & supportive measures

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Corrective phase(additional therapeutic measures)

Addresses sequelae of opportunistic infections & includes therapeutic measures:

Perio & implant surgery Endodontic therapy Restorative &/ prosthetic T/t

Amount of corrective therapy required – determined only when degree of success of cause related therapy – properly evaluated

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Patient’s willingness & ability to cooperate in overall therapy – determine type of corrective T/t

If inadequate – permanent improvement of oral health, function & esthetics not achieved – may not be worth initiating rest of perio procedures

(Lindhe & Nyman 1975, Rosling et al 1976, Nyman et al 1975, 1977, 1979)

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Maintenance phase(supportive perio therapy)

Aim: Prevention of reinfection & disease recurrence

For each patient – recall system designed:1. Assessment of deepened sites with bleeding

on probing2. Instrumentation of such sites3. Fluoride application for prevention of dental

caries

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Additionally – phase involve regular control of prosthetic restorations incorporated during corrective phase

Tooth sensitivity testing – be applied to abutment teeth as loss of vitality is frequently encountered complication

(Bergenholtz & Nyman 1984; Lang et al 2004, Lulic et al 2007)

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EXPLAINING TREATMENT PLAN TO

PATIENT

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Be specific Tell our patient, “You have gingivitis,” or “You

have periodontitis,” then explain exactly what these conditions are, how they are treated, & prognosis for patient after treatment

Avoid vague statements - “You have trouble with your gums,” or “Something should be done about your gums” Patients do not understand significance of such statements & disregard them

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Begin our discussion on positive note

Talk about teeth that can be retained & long term service expected to render

Not begin our discussion with statement, “Following teeth have to be extracted” - creates negative impression - adds to hopelessness patient already may have regarding their mouth

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Make it clear that every effort - to retain as many teeth as possible, but do not dwell on patient’s loose teeth

Emphasize that important purpose T/t is to prevent other teeth from becoming as severely diseased as loose teeth

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Present entire treatment plan as unit

Avoid creating impression that T/t consists of separate procedures

Do not speak in terms of “having gums treated & then taking care of necessary restorations later” as if these were unrelated treatments

Make it clear - dental restorations & prostheses contribute as much to health of gums as elimination of inflammation & perio pockets

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Explain that “doing nothing” or holding onto hopelessly diseased teeth as long as possible is inadvisable for following reasons:

1. Periodontal disease is microbial infection, & research - important risk factor for severe life-threatening diseases - stroke, cardiovascular disease, pulmonary disease, & diabetes, as well as for premature low-birth-weight babies

Correcting perio condition eliminates serious potential risk of systemic disease, which in some cases ranks as high on danger list as smoking

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2. It is not feasible to place restorations/ bridges on teeth with untreated perio disease because usefulness of restoration would be limited by uncertain condition of supporting structures

3. Failure to eliminate perio disease not only results in loss of teeth already severely involved, but also shortens life span of other teeth that, with proper treatment, could serve as foundation for healthy, functioning dentition

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Therefore dentist should make it clear to patient that:

If perio condition is treatable, best results are obtained by prompt treatment

If condition is not treatable, teeth should be just as promptly extracted

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It is dentist’s responsibility to advise patient of importance of perio T/t

if treatment is to be successful - patient must be sufficiently interested in retaining natural teeth to maintain necessary oral hygiene

Individuals who are not particularly perturbed by thought of losing their teeth are generally not good candidates for perio T/t

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Summary

Objective of overall TP is creation & maintenance of oral health, function, & esthetics

Outcome is long term & in most cases requires coordination of several disciplines of dentistry

A motivated patient is prerequisite, & success will depend on this motivation being sustained through maintenance care

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TP should focus on list of diagnoses for patient

T/t should be planned in phases

At completion of each phase, patient should be reevaluated to assess response to treatment, & TP may be modified based on this assessment

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Conclusion

Treatment plan is guiding map for perio treatment – no treatment should be initiated without forming a solid TP &

Although Its clinician’s responsibility to make individual patient realize the value of Treatment – motivated patient is a prerequisite for optimum outcome of perio therapy

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References

Carranza’s Clinical Periodontology 8th, 9th, 10th & 11th edition

Clinical periodontology & Implant dentistry 5th edition – Jan Lindhe

Bruce L. Philstrom. Periodontal risk assessment, diagnosis & treatment planning. Perio 2000. 2001;25:37-58.

Renz & Newton. Changing the behavior of patients with periodontitis. Perio 2000. 2009;51:252-68.

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References Schuz B, Sniehotta FF, Wiedemann A, Seemann

R. Adherence to a daily flossing regimen in university students: effects of planning when, where, how and what to do in the face of barriers. J Clin Periodontol 2006; 33: 612–619.

Kwok, Caton, Polson & Hunter. Application of evidence-based dentistry: from research to clinical periodontal practice. Perio 2000. 2012;59:61-74.

Heasman PA, Seymour RA. The effect of a systemically administered non-steroidal anti-inflammatory drug (flurbiprofen) on experimental gingivitis in humans. J Clin Periodontol. 1989;16:551.

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Thank You