TREATMENT PLANNING

Page 1

  • Title/identification: treatment planning in periodontology II

  • Author/affiliation: Paul Benzo I. Sia, DMD; Assistant Professor I, National University MOA- College of Dentistry

Page 2

  • Introduction

    • Periodontal disease and peri-implant disease are opportunistic infections caused by biofilm.

    • Treatment, in most cases, results in dental, periodontal, and peri-implant health.

    • Arrest of disease progression following treatment must be the goal of modern dental care.

Page 3

  • Introduction (continued)

    • Treatment is planned after the diagnosis and prognosis have been established.

    • The plan should encompass immediate, intermediate, and long-term goals.

Page 4

  • Phases of treatment

    1. Systemic phase of therapy

    • Includes smoking counseling.

    1. Initial (or hygienic) phase of periodontal therapy – cause-related therapy.

    2. Corrective phase of therapy

    • Periodontal surgery, and/or endodontic therapy,

    • Implant surgery, restorative,

    • Orthodontic and/or prosthetic treatment.

    1. Maintenance phase (care) – supportive periodontal therapy (SPT).

Page 5

  • Systemic phase

    • Includes smoking cessation counseling.

    • Goals:

    • Eliminate or decrease the influence of systemic conditions on the outcomes of therapy.

    • Protect the patient and dental care providers against infectious hazards.

    • May involve consultation with a physician or specialist (e.g., control of diabetes mellitus).

Page 6

  • Initial phase

    • Also known as the hygienic phase; infection control; major cause-related therapy.

    • Goals:

    • Achieve clean and infection-free conditions in the oral cavity through complete removal of all soft and hard deposits and their retentive factors.

    • Motivate the patient to perform optimal biofilm control.

    • May include caries excavation and provisional root canal medication.

    • Concluded by a re-evaluation and planning of additional and supportive therapies.

Page 7

  • Reevaluation after initial phase

    • The initial phase is completed with a thorough analysis of results with respect to elimination or degree of control of oral infections.

    • Re-evaluation of the patient’s periodontal conditions and caries activity must be performed.

    • To allow tissues to heal, re-evaluation should be performed not earlier than 6-12 weeks (Lindhe, 2022) following the last session of subgingival mechanical instrumentation.

Page 8

  • Corrective phase

    • Addresses sequelae of opportunistic infections.

    • Includes:

    • Periodontal surgery, and/or implant surgery;

    • Root canal filling; and

    • Restorative and/or prosthetic treatment.

    • Treatments can be determined only when the level of success of the cause-related therapy can be properly evaluated.

Page 9

  • Maintenance phase

    • Also called supportive periodontal and peri-implant therapy.

    • Goal: prevention of reinfection and disease recurrence.

Page 10

  • Treatment planning process

    • Examination → Diagnosis → Prognosis → Treatment.

    • Establish an INITIAL TREATMENT PLAN.

Page 11

  • Teeth considered "irrational-to-treat" and extraction criteria (part 1)

    • Periodontal:

    • Recurrent periodontal abscesses;

    • Combined periodontal-endodontic lesions;

    • Attachment loss to the apical region.

    • Endodontic:

    • Root perforation in the apical half of the root;

    • Extensive periapical lesions (i.e. diameter >6 mm).

Page 12

  • Teeth irrational to treat (part 2)

    • Dental:

    • Vertical fracture of the root (hairline fracture);

    • Oblique fracture in the middle third of the root;

    • Caries lesions extending into the root canal.

    • Functional:

    • Third molars without antagonists and with periodontitis/caries.

Page 13

  • Teeth with doubtful prognosis (need comprehensive therapy to secure prognosis)

    • Periodontal:

    • Furcation involvement (Class II or III);

    • Angular (vertical) bony defects;

    • Horizontal bone loss involving more than two-thirds of the root.

    • Endodontic:

    • Incomplete root canal therapy;

    • Periapical pathology;

    • Presence of voluminous posts/screws.

    • Dental:

    • Extensive root caries.

Page 14

  • Case presentation (essential component of the initial treatment plan)

    • Must include a description for the patient of different therapeutic goals and modalities to be reached.

    • Present benefits inherent to a given plan versus disadvantages.

    • Attitude to alternatives should guide the dentist in designing the overall treatment plan.

Page 15

  • Case 1: patient overview

    • A 27-year-old systemically healthy and non-smoker female (S.B.) evaluated for periodontal conditions.

    • Gingival sites with bleeding on probing (BOP) identified; probing depths (PPD) measured; periodontal attachment levels calculated; furcation involvements graded; tooth mobility assessed; radiographs analyzed to determine height and outline of the alveolar bone crest.

    • Mention of joint dysfunctions.

Page 16

  • Case 1 continued: clinical findings

    • The clinical characteristics of the dentition are shown in the periodontal chart and radiographs.

    • Each tooth diagnosed as gingivitis or periodontitis and a pretherapeutic prognosis assigned.

    • In addition to periodontal findings, detailed assessments of primary and recurrent caries were made for all tooth surfaces.

    • Patient also examined for endodontic and occlusal problems as well as temporomandibular joint (TMJ) dysfunctions.

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  • (No content provided in the transcript for this page.)

Page 18

  • Case 1 visuals (tooth chart data)

    • The page contains tooth chart data and radiographic/diagrammatic representations (e.g., numbers and locations for buccal surfaces and other landmarks).

    • Specific numeric values appear in diagram form; refer to the provided figures for exact measurements.

Page 19

  • Additional case data visuals

    • Lingual and buccal surface data are presented in tabular/diagrammatic form.

    • As with Page 18, exact values are shown in figures accompanying the case and are not described textually here.

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  • (No content provided in the transcript for this page.)

Page 21

  • Systemic phase (case specifics)

    • Because the patient was systemically healthy and a non-smoker, no medical examination or tobacco-use counseling was required.

Page 22

  • Initial phase (case specifics)

    • Motivation of the patient and instruction in oral hygiene practices with subsequent check-ups and reinstruction.

    • Scaling and root planing under local anesthesia in combination with removal of biofilm retentive factors and teeth irrational to treat, if any.

    • Excavation and restoration of carious lesions of teeth 16 and 26.

    • Endodontic treatment of tooth 46.

Page 23

  • Corrective phase (case specifics)

    • Periodontal surgery (i.e., open flap debridement) in the maxillary left and right quadrants as well as in the mandibular molar regions.

    • Guided tissue regeneration (GTR) for tooth 36.

    • Re-evaluation after periodontal surgery.

    • Orthodontic therapy in the maxillary front area.

    • Restorative therapy in the maxillary front area for esthetic reasons.

Page 24

  • Re-evaluation after corrective phase

    • The corrective phase concludes with a thorough analysis of results regarding elimination of the sequelae of periodontal tissue destruction.

    • The results of the periodontal risk assessment form the basis for the residual periodontal risk.

    • The outcomes of the risk assessment determine the recall frequency during the maintenance phase.

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Page 26

  • Maintenance phase

    • After completion of cause-related therapy, the patient should be enrolled in a recall system to prevent recurrence of oral infections.

    • 1) Update medical history and tobacco use history.

    • 2) Soft tissue examination as cancer screening.

    • 3) Recording of the full-mouth PPD ≥5 mm with concomitant BOP

    • 4) Re-instrumentation of bleeding sites with PPD ≥5 mm

    • 5) Polishing and fluoridation for caries prevention.

Page 27

  • Treatment plan timeline (for school) – Appointment 1

    • 1) Periodontal evaluation (includes all parameters).

    • 2) Oral hygiene instruction.

    • 3) Scaling and polishing (1st sitting).

    • Appointment 2 (at least 7 days after appointment 1)

    • 1) Oral hygiene instruction.

    • 2) Scaling and polishing (2nd sitting).

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  • Treatment plan timeline – Appointment 3 and 4

    • 3rd appointment (at least 7 days after 2nd):

    • Periodontal re-evaluation.

    • Records taking.

    • Oral hygiene instruction.

    • 4th appointment: Case presentation; oral hygiene instruction; non-surgical root planing (or debridement) of teeth 15, 14, 43, 44 (Q1 and Q4);
      impression taking for interim dentures.

Page 29

  • Treatment plan timeline – Appointment 5 and 6

    • 5th appointment (at least 1 day after 4th):

    • Oral hygiene reinforcement.

    • Non-surgical root planing (or debridement) of teeth 21, 22, 26, 36, 37 (Q2 and Q3).

    • Installation of all acrylic dentures.

    • 6th appointment (28–56 days after 5th):

    • Periodontal re-evaluation.

    • Scaling and polishing.

    • Selective non-surgical root planing.

    • Oral hygiene instructions.

Page 30

  • Treatment plan timeline – Appointment 7

    • 7th appointment (28–56 days after 6th):

    • Periodontal re-evaluation.

    • Scaling and polishing.

    • Selective non-surgical root planing.

    • Oral hygiene instructions.

Page 31

  • Sequence of treatment (summary)

    • A summarized outline of the sequencing used in the treatment plan.

Page 32

  • Periodontal evaluation

    • Comprehensive periodontal examination.

    • Diagnosis and prognosis.

    • Patient education.

    • Clinical findings and disease status.

    • Disease pathogenesis and prevention.

    • Personalized oral hygiene instruction.

    • Reduction of systemic and environmental risk factors.

    • Physician consultation.

    • Smoking cessation.

    • Periodontal treatment plan:

    • Oral hygiene assessment and education.

    • Nonsurgical therapy.

    • Periodontal reevaluation.

    • Periodontal supportive maintenance.

Page 33

  • Non-surgical therapy

    • Oral hygiene assessment and education.

    • Infection control.

    • Nonsurgical periodontal therapy: supragingival and subgingival scaling and root planing.

    • Extraction of hopeless teeth.

    • Reduction of local risk factors:

    • Removal or reshaping of overhangs and overcontoured restorations.

    • Restoration of carious lesions.

    • Restoration of open contacts.

Page 34

  • Periodontal reevaluation

    • Inquiries about new concerns or problems.

    • Inquiry of changes in medical and oral health status.

    • Oral hygiene assessment and education.

    • Comprehensive periodontal examination.

    • Assessment of outcome of nonsurgical therapy.

    • Determination of required additional nonsurgical and adjunctive therapy.

Page 35

  • Surgical therapy (adjunct to nonsurgical therapy)

    • Should only occur once the patient demonstrates proficient biofilm control.

    • Objectives:

    • Primary: Access for root instrumentation.

    • Secondary: Pocket reduction through soft tissue resection, osseous resection, or periodontal regeneration.

    • Periodontal access surgery:

    • Resective.

    • Regenerative.

    • Extraction of hopeless teeth.

    • Periodontal plastic surgery:

    • Mucogingival surgery.

    • Aesthetic crown lengthening.

Page 36

  • Surgical therapy (continued)

    • Preprosthetic surgery.

    • Prosthetic crown lengthening.

    • Implant site preparation and implant placement.

Page 37

  • Periodontal maintenance therapy

    • Inquiry of new concerns or problems.

    • Inquiry of changes in medical and oral health status.

    • Oral hygiene assessment and education.

    • Comprehensive periodontal examination.

    • Professional maintenance care:

    • Supragingival and subgingival biofilm and calculus removal.

    • Selective scaling and root planing.

    • Assessment of recall interval and plan for next visit.