Clinical diagnosis and treatment planning for periodontal diseases

Periodontal diseases are one of the most prevalent oral diseases associated with teeth. Our current knowledge suggests that along with local factors, there are many other factors responsible for periodontal disease progression. These include genetic factors and environmental factors like smoking, stress etc. An accurate diagnosis and appropriate treatment planning require a thorough knowledge of the etiopathogenesis of periodontal diseases. The following steps are involved in an appropriate treatment of a patient with a periodontal problem,

Accurate diagnosis

Accurate treatment plan

Accurate diagnosis:

The treatment of periodontal diseases is dependent on an accurate diagnosis. An accurate diagnosis can only be made by a thorough evaluation of data that have been systematically collected by recording a detailed case history which includes: 1) patient interview, 2) medical consultation, as indicated, 3) clinical periodontal examination, 4) radiographic examination, and 5) laboratory tests, as needed. A detailed description of the procedure of case history taking has been discussed in chapter 39 “Art of history taking in periodontics”.

Briefly, during the first appointment after the case history of the patient has been recorded, the impressions are made for diagnostic mounting, clinical photographs are taken for record and consultations with concerned specialists such as endodontist or orthodontist are arranged. After the case discussion, a comprehensive treatment plan is formulated for the patient.

During the second appointment, the proposed treatment plan is explained to the patient, which can be modified based on patient desires, finances, and availability. After the patient fully understands the proposed treatment plan as well as the complications that may appear during treatment, a signed informed consent is taken from the patient. It is important from the medico-legal point of view.

Accurate treatment plan:

Once a correct diagnosis is made and the prognosis is established, treatment planning is done. An accurate treatment plan needs to be formulated before initiation of the treatment. It is the blueprint of procedures which are planned for case management. The first and the foremost task is to eliminate inflammation. Scaling and root planning are done in multiple sittings and patient is instructed about the maintenance of good oral hygiene along with instructions about correct toothbrushing technique. The major objectives and decisions made during treatment planning are as follows,

Initial emergency and patient comfort:

If the patient presents with a dental emergency, it should be immediately addressed and appropriate treatment should be done to relieve the pain of the patient. Except for relieving acute pain or any other emergency no other treatment should be started before the establishment of a proper treatment plan.

The most common cause of dental emergency is an acute pain due to the endodontic involvement of tooth/teeth. In these cases, root canal treatment is initiated so that the pain can be relieved and is completed during the course of the treatment.

To retain or extract the tooth:

It is important to decide which tooth/teeth need to be extracted. Every effort should be made to save a tooth if it has a good prognosis, but at the same time, any heroic attempt to save a tooth with a questionable prognosis may lead to problems both for the patient as well as the operator. In periodontitis cases, the major indication for tooth extraction is the severe periodontal disease with severe bone loss, grade 3 mobility, and furcation involvement with severe bone loss. If retaining a periodontally compromised tooth does not improve the treatment plan, it should be extracted. The extraction of the teeth should be done during the periodontal surgery so that the number of appointments for surgery can be reduced.

Major indications for restoring a tooth are: it is acting as a posterior stop and if it is present in the esthetic zone. If the tooth is preventing the bite collapse by acting as a posterior stop, it should be retained during the treatment and should be extracted only after the re-establishment of posterior stops by the placement of a removable or fixed prosthesis. If the tooth is present in the esthetic zone, it can be extracted after periodontal therapy to avoid the need for the temporary appliance. It should be remembered that retaining a tooth during the periodontal therapy should not adversely affect the treatment plan.

Resolution of inflammation:

The first step in periodontal treatment is the resolution of the inflammation. Due to the presence of plaque and calculus the gingiva is usually inflamed. The patient is explained about the association of local factors and gingival inflammation in simple language which he/she is able to understand. Oral hygiene procedures, accurate brushing technique, interdental cleansing techniques are explained to the patient in detail. In subsequent appointments, the patient is reassessed for the maintenance of oral hygiene. If the patient is not following the instructions, all the oral hygiene techniques, as well as their importance, should be re-explained to the patient.

The inflamed gingiva may be oedematous or fibrotic. The fibrotic gingiva is a result of long-standing inflammation due to constant repair by deposition of collagen fibers. The removal of local factors, by scaling and smoothening of root surface by root planning leads to resolution of inflammation. Oedematous gingiva may become absolutely normal within a few days but fibrotic gingiva may not and requires a surgical intervention.

After the Phase I therapy (Explained later), the patient is put on the maintenance phase to observe the improvement in periodontal condition. If surgical intervention is required, the patient is scheduled for surgery i.e., Phase II therapy.

 Treatment of occlusal abnormalities:

Treatment of occlusal abnormalities is an important component of comprehensive periodontal treatment. It can be confirmed clinically by “Fremitus test”. The procedure of doing this test is explained in chapter 39 “Art of history taking in periodontics”. Clinical findings of occlusal abnormalities include tooth hypermobility, tooth migration, tooth pain or discomfort on chewing or percussion, pathological occlusal wear and fractures of teeth/restorations, cervical dentin hypersensitivity, abfractions, vertical bone loss or localized bone destruction (secondary to periodontal disease), tenderness of the muscles of mastication or other signs or symptoms of temporomandibular dysfunction. The detailed description of occlusal abnormalities and their treatment have been discussed in the chapter 34 “Temporomandibular joint and occlusal considerations in periodontics”.

The timing of occlusal therapy is an important factor. According to the parameters on occlusal traumatism in patients with chronic periodontitis given by the American Academy of Periodontology 1, the treatment of………………

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Surgical periodontal therapy:

Once the initial therapy is completed, the inflammation subsides because of which the inflammatory gingival swelling also subsides. After the patient has been treated with scaling and root planing, healing of the periodontal tissues is initiated. The patient is re-evaluated for periodontal pocket depth after completion of initial therapy and if indicated the surgical therapy is planned. After surgical therapy, junctional epithelium can be expected to take approximately one week to heal whereas underlying connective tissue can take 4-6 weeks 2-4. Therefore, probing should be avoided for at least one month following periodontal surgery. In chronic inflammation, the gingiva becomes fibrotic due to continuous repair during the long duration of time. This is one indication of periodontal surgical therapy to re-establish the knife-edge margins of the gingiva around the teeth.

 

Know more…………..

What pocket depth is indicated for periodontal flap surgery?

It is important to know the indications and contraindications for non-surgical and surgical periodontal therapy. What is the critical probing depth beyond which periodontal surgery should be done? This question was addressed by Lindhe et al. (1982) 5. Using regression analysis of published data, they described the “critical probing depth” for which periodontal therapy resulted in either gain or loss of clinical attachment. The critical probing depth for scaling and root planing was 2.9 ± 0.4 mm and the critical probing depth for modified Widman flap surgery was 4.2 ± 0.2 mm. They suggested that for patients with a large number of shallow pocket depth sites, non-surgical therapy would be more beneficial, while in patients with a large number of sites > 4.2 mm, surgical treatment may lead to more clinical attachment gain.

Implant therapy:

Implant therapy has provided us with a very predictable and successful therapy for the replacement of missing teeth. Many patients are not comfortable with the removable appliances. In such situations implants provide a very good option for tooth replacement as implants are closest to natural teeth in function. It is important to understand that patient should be thoroughly evaluated before confirming the implant treatment because many situations do not allow implant treatment. Some of these are,

Local contraindications for implant therapy:

  • Insufficient bone for implant placement
  • Destructive parafunction
  • Poor hygiene and motivation
  • Very abnormal ridge relations
  • Inadequate interocclusal space
  • Severe TMJ or occlusal disharmony
  • Active, destructive periodontal disease

 Systemic/medical contraindications for implant therapy:

  • Severe hematological disorders (hemophilia etc.).
  • Severe immunodeficiency.
  • Patients who are undergoing strong chemotherapy.
  • Cerebral infarction where the condition of the disease is serious and the patient is concurrently taking anticoagulants.
  • Myocardial infarction: within six months of an attack.
  • Severe neuropsychiatric disease, mental disability, and narcotic drug addicts.
  • Patients who are concurrently taking bisphosphonates.

During the comprehensive treatment plan, the implant placement can be scheduled during the same surgical procedure to reduce the number of surgical appointments. Different aspects of implant therapy have been discussed in “implantology” section.

Esthetic considerations:

Surgical periodontal therapy and implant therapy in the esthetic zone requires esthetic considerations. After periodontal surgery during healing, there is shrinkage of gingiva which may cause recession. This recession is expected in modified Widman flap surgery as the internal bevel incision is given 0.5-2 mm away from the gingival margin. The periodontal flap design in the esthetic zone is designed in such a way that esthetically acceptable gingival margins are achieved. The conventional flap or papilla preservation flap elevation in this area is generally recommended to avoid recession. In the same way, implant placement is planned to achieve best esthetic results. Precise placement of implant buccolingually and mesiodistally is required to achieve best esthetic results.

In recession cases where root coverage is planned, the case should be examined thoroughly before deciding the root coverage procedure. There are indications and contraindications of every root coverage procedure. A detailed description of root coverage procedures is given in chapter 70 “Periodontal esthetic surgeries”.

Restorative treatment:

Temporary or permanent restorations are done during restorative treatment phase. Caries control is initiated in Phase I therapy and other restorative treatments like replacement of missing teeth which require longer time duration are done in Phase III (explained later). In patients with rampant caries diet control is implemented. If it is decided that the missing teeth are to be replaced by implants, the implant placement surgery can be combined with the periodontal surgery of that quadrant. When faulty restorations are present, these are corrected or replaced with new restorations. Faulty restorations play an important role in harboring food debris and plaque thereby favoring periodontal disease progression.

Need for orthodontic treatment:

As already explained occlusal abnormalities need to be corrected to equally distribute occlusal forces on the teeth. Trauma from occlusion and traumatic occlusion are important findings during diagnosis of the patient. Selective grinding or coronoplasty can be done to achieve occlusal harmony, but in the case of major discrepancies orthodontic treatment is required to correct occlusal problems.

Orthodontic treatment is based on the remodeling of the tissue surrounding the tooth. There is bone apposition on the side under tension and bone resorption on the side under pressure. If the tissue surrounding the tooth is inflamed, this movement may further deteriorate the condition and tooth under orthodontic forces may have attachment loss. So, the prime requirement for orthodontic treatment is…………………………

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Endodontic therapy:

If there is root canal involvement of any tooth/teeth, they must be treated with endodontic treatment. As already stated, if the patient has an endodontic emergency, root canal treatment is started during the first visit to eliminate the pain. If the pain is not present, but the tooth is indicated for an endodontic treatment, it should be started during the initial phase of the treatment and completed during the corrective phase with permanent crown or bridge placement during restorative phase i.e. Phase III therapy.

Phases of treatment plan:

Any dental emergency is treated first to achieve patient comfort. Principally, the comprehensive periodontal therapy can be divided into four main phases 7: phase I. Initial or cause-related therapy, phase II. Surgical therapy, phase III. Restorative therapy, and phase IV. Periodontal maintenance.

Emergency phase

Phase I therapy or Etiotropic Phase

Phase II therapy or Surgical Phase

Phase III therapy or Restorative Phase

Phase IV therapy or Maintenance Phase or supportive periodontal therapy

Various treatments provided during different phases of treatment plan include the following:

Phases of treatment plan 7

Emergency phase/Preliminary Phase
• Due to endodontic or periapical pathology
• Due to periodontal pathology
• Any other reason
• Extraction of hopeless teeth and provisional replacement if required.
Phase I Therapy or Etiotropic Phase
• Patient education about plaque control and maintaining oral hygiene. Demonstration of accurate brushing technique indicated for patient.
• Scaling and root planing to remove soft deposits and calculus
• Restorative and/or prosthetic corrections
• Excavation of caries and restoration (temporary or final, depending on whether a definitive prognosis for the tooth has been arrived at and on the location of caries)
• Antimicrobial therapy (local drug delivery or systemic)
• Diet control (in patients with rampant caries)
• Treatment of occlusal abnormalities
• Minor orthodontic movement
• Provisional splinting and prosthesis
Evaluation of Response to Etiotropic Phase
• Pocket depth and gingival inflammation
Phase II Therapy or Surgical Phase
• Periodontal surgical procedures including placement of implants.
• Endodontic therapy completion
Phase III Therapy or Restorative Phase
• Final restorations
• Fixed and/or removable prosthodontics
Phase IV Therapy or Maintenance Phase or supportive periodontal therapy for Periodic rechecking
• Plaque and calculus evaluation
• Gingival and periodontal status
• Occlusion, tooth mobility
• Any other pathologic changes

When to refer the patient to a periodontist?

It is the duty of a dentist to provide the best possible treatment to his/her patients. This duty includes the responsibility of a dentist to timely refer a patient whom he/she believes, requires care that is beyond his training, experience or expertise to a dentist who can appropriately treat the patient. It is important to know the conditions were a general dentist should refer the patient to a periodontist. These include,

  • Any patient who continues to lose bone and/or attachment despite an appropriate treatment or has unresolved inflammation.
  • Any patient needing bone regeneration procedures around teeth supporting bridgework.
  • Any patient needing grafting procedures.
  • Any patient with gingival overgrowth issues that do not resolve after the cause of the overgrowth has been addressed.
  • Implants requiring advanced surgical procedures.
  • Any patient whom the dentist does not feel comfortable treating, for any reason.

The AAP guidelines stratify three levels of patients

American academy of periodontology in 2006 gave guidelines 8 helping clinicians to identify patients who require a referral for the better management of their periodontal condition. In this paper patients have been divided into three levels which are,

Level 1:

Patients who may benefit from co-management by the referring dentist and the periodontist.

Any patient with periodontal inflammation/infection and the following systemic conditions:

  • Diabetes
  • Pregnancy
  • Cardiovascular disease
  • Chronic respiratory disease

Any patient who is a candidate for the following therapies who might be exposed to the risk of periodontal infection, including but not limited to the following treatments:

  • Cancer therapy
  • Cardiovascular surgery
  • Joint-replacement surgery
  • Organ transplantation

Level 2:

Patients who would likely benefit from co-management by the referring dentist and the periodontist.

Any patient with periodontitis who demonstrates at re-evaluation or any dental examination one or more of the following risk factors/indicators known to contribute to the progression of periodontal diseases:

Periodontal risk factors/indicators 

  • Early onset of periodontal diseases (prior to the age of 35 years)
  • Unresolved inflammation at any site (for example, bleeding upon probing, pus, and/or redness)
  • Pocket depths greater than 5 mm
  • Vertical bone defects
  • Radiographic evidence of progressive bone loss
  • Progressive tooth mobility
  • Progressive attachment loss
  • Anatomic gingival deformities
  • Exposed root surfaces
  • A deteriorating risk profile

Medical or behavioral risk factors/indicators 

  • Smoking/tobacco use
  • Diabetes
  • Osteoporosis/osteopenia
  • Drug-induced gingival conditions (for example, phenytoins, calcium channel blockers, immunosuppressants, and long-term systemic steroids)
  • Compromised immune system, either acquired or drug induced
  • A deteriorating risk profile

Level 3:

Patients who should be treated by a periodontist

Any patient with:

  • Severe chronic periodontitis
  • Furcation involvement
  • Vertical/angular bony defect(s)
  • Aggressive periodontitis (formerly known as juvenile, early-onset, or rapidly progressive periodontitis)
  • Periodontal abscess and other acute periodontal conditions
  • Significant root surface exposure and/or progressive gingival recession
  • Peri-implant disease
  • Periodontal diseases, regardless of severity, which the referring dentist prefers not to treat.

Conclusion:

The clinical findings of the patient guide us to reach an accurate diagnosis and establishing individual tooth and overall prognosis.  Both of these are used to develop a logical treatment plan for the patient to eliminate or alleviate the signs and symptoms of periodontal diseases, thereby arresting or slowing the progression of periodontal diseases. It must be kept in mind that various other factors like systemic conditions, environmental factors, and genetic factors also affect the progression of periodontal diseases. Identifying these factors is equally important to successfully treat a patient. The sequence of therapy, as well as treatment modalities to be used during periodontal therapy, including non-surgical, surgical, regenerative or implant therapy, are carefully planned. Keeping in mind all the factors explained earlier in the discussion, an accurate treatment plan can be established for a patient.

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References:

References available in the hard copy of the website

Periobasics: A textbook of periodontics and implantology

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