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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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