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Perio - The treatment plan

Resident Doctor. Department Periodontology & Oral Implantology, Kathmandu, Nepal

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Perio - The treatment plan

  1. 1. Introduction Rationale for Perio Treatment Local & Systemic Therapy Treatment Goals Master plan for total treatment Extracting or preserving tooth Therapeutic procedures 2
  2. 2. Phases of Perio Therapy Explaining TP to Patient Summary Conclusion References 3
  3. 3. TP is blueprint for case management Treatment is planned after diagnosis & prognosis established Includes all procedures required for establishment & maintenance of oral health 4
  4. 4. 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 5
  5. 5. 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 6
  6. 6. Unforeseen developments during treatment may necessitate modification of initial treatment plan except for emergencies, no treatment should be started until TP established 7
  7. 7. Perio therapy can restore chronically inflamed gingiva – clinical & structural view - is almost identical with gingiva never exposed to excessive plaque accumulation 8
  8. 8.  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 9
  9. 9. 10
  10. 10.  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 11
  11. 11.  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 12
  12. 12. 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) 13
  13. 13. 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 16
  14. 14. 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 17
  15. 15. 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 19
  16. 16. 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” 20
  17. 17. 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 21
  18. 18. 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 22
  19. 19. Tooth should be extracted when any of following occurs: It is so mobile that function becomes painful It can cause acute abscesses during therapy There is no use for it in overall TP 23
  20. 20. 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 24
  21. 21. 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 25
  22. 22. 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 26
  23. 23. 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 27
  24. 24. In complex cases, interdisciplinary consultation with other specialty areas is necessary before final plan made 29
  25. 25. May necessitate: Occlusal adjustment Restorative, prosthetic, & orthodontic procedures Splinting & Correction of bruxism & clamping & clenching habits 30
  26. 26. 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 31
  27. 27. 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 32
  28. 28. 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 33
  29. 29. 34
  30. 30. 35
  31. 31. Preliminary phase Non surgical phase (Phase I Therapy) Evaluation of response to Nonsurgical Phase Surgical Phase (Phase II Therapy) Restorative Phase (Phase III Therapy) Maintenance Phase (Phase IV Therapy) 36
  32. 32. A. Preliminary Phase Treatment of emergencies: Dental/ periapical Periodontal Other Extraction of hopeless teeth and provisional replacement if needed (may be postponed to more convenient time) 37
  33. 33. B. Nonsurgical Phase (Phase I Therapy) Plaque control and patient education: Diet control (in patients with rampant caries) Removal of calculus & root planing Correction of restorative & prosthetic irritational factors Excavation of caries & restoration (temporary/ final, depending on whether a definitive prognosis for tooth has been determined & on location of caries) 38
  34. 34. Antimicrobial therapy (local/ systemic) Occlusal therapy Minor orthodontic movement Provisional splinting & prosthesis C. Evaluation of response to Nonsurgical phase Rechecking: Pocket depth & gingival inflammation Plaque & calculus, caries 39
  35. 35. 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 40
  36. 36. F. Maintenance Phase (Phase IV Therapy) Periodic rechecking: Plaque & calculus Gingival condition (pockets, inflammation) Occlusion, tooth mobility Other pathologic changes 41
  37. 37. Preferred sequence of periodontal therapy 43
  38. 38. 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 44
  39. 39. 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 45
  40. 40. 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 46
  41. 41. 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 47
  42. 42. 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 48
  43. 43. 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 49
  44. 44. 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 50
  45. 45. 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) 51
  46. 46. Aim: Prevention of reinfection & disease recurrence For each patient – recall system designed: 1. Assessment of deepened sites with bleeding on probing 2. Instrumentation of such sites 3. Fluoride application for prevention of dental caries 52
  47. 47. 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) 53
  48. 48. 54
  49. 49. 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 55
  50. 50. 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 56
  51. 51. 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 57
  52. 52. 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 58
  53. 53. 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 60
  54. 54. 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 61
  55. 55. 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 62
  56. 56. 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 63
  57. 57. 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 64
  58. 58. 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 66
  59. 59. 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 69
  60. 60. 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. 70
  61. 61. 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. 71
  62. 62. 72