Introduction

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 “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 ……….. Contents available in the book ……….. Contents available in the book ……….. Contents available in the book ……….. Contents available in the book……..




Accurate treatment plan

Once a correct diagnosis has been 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:

  • 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 edematous 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. Edematous 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 ……….. Contents available in the book ……….. Contents available in the book ……….. Contents available in the book ……….. Contents available in the book……..

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Risk factor/s management:

All the risk factors associated with the progression of periodontal disease should be assessed for every patient. Patient counseling should be done for modifiable risk factors such as smoking or stress. In diabetic patients, consultations with specialists regarding control of diabetes should be done. After a thorough dental and periodontal examination of the patients, all the local risk factors such as overhanging restorative margins should be identified and their correction should be included in the treatment plan.

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 “Trauma from occlusion”. 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 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 the symptoms of occlusal traumatism is appropriate during any phase of periodontal therapy. Except in the case of acute conditions, occlusal corrections are usually addressed during the initial therapy, followed by efforts to ……….. Contents available in the book ……….. Contents available in the book ……….. Contents available in the book ……….. Contents available in the book……..



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. Due to chronic inflammation, the gingiva becomes fibrotic due to continuous repair during the long duration of time. Along with treatment of periodontal pockets, this is one indication of periodontal surgical therapy to re-establish the knife-edge margins of the gingiva around the teeth.

     The surgical therapy should be carefully planned, keeping in mind the periodontal pocket depth, the architecture of the underlying bone, area of the dentition to be operated (anterior areas are of esthetic concern), the thickness of the gingiva and adequacy of attached gingiva. The design of the flap should be selected keeping all these factors in mind. A detailed description regarding the design of the periodontal flaps has been given in, “ Periodontal flap surgeries: current concepts”. In the case of vertical bone defects, the architecture of the defect should be identified and if indicated, regenerative periodontal therapy should be planned. If there are teeth with recession, it should be determined whether the recession is stable or progressing. Attached gingiva plays a very important role in preventing a recession. So, along with recession the dimensions of the attached gingiva should also be noted. Secondly, it should be assessed whether the recession is affecting the esthetics of the patient. Considering all these factors, surgical therapy suitable for a particular patient should be planned.

     After surgical therapy, junctional epithelium can be ……….. Contents available in the book ……….. Contents available in the book ……….. Contents available in the book ……….. Contents available in the book……..

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 anti-coagulants.
  • Myocardial infarction: within six months of an attack.
  • Severe neuropsychiatric disease, mental disability, and narcotic drug addicts.
  • Patients who are concurrently taking bisphosphonates.

     The patient should be carefully evaluated for implant therapy. During the comprehensive treatment plan, the implant placement can be scheduled along with other surgical procedures to reduce the number of surgical appointments. Different aspects of implant therapy have been discussed in “Dental implant therapy” 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 ……….. Contents available in the book ……….. Contents available in the book ……….. Contents available in the book ……….. Contents available in the book……..




     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 “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 periodontal tissue free of inflammation. Initial therapy (cause-related therapy) should be done to eliminate local factors thus reducing inflammation. Radiographic examination is required to access the periodontal bone levels and bone defects. If the bone condition around the teeth do not permit orthodontic forces, periodontal regenerative therapy should be done to achieve sufficient bone to initiate orthodontic treatment.

     It is particularly important to intercept ……….. Contents available in the book ……….. Contents available in the book ……….. Contents available in the book ……….. Contents available in the book……..



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 ……….. Contents available in the book ……….. Contents available in the book ……….. Contents available in the book ……….. Contents available in the book……..

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 followed by any dental emergency 7. So, the phases of treatment plan are,
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 phases of treatment plan and treatments rendered in these phases are given in the following table,

Phases of treatment plan
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 the 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/her 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, phenytoin, 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).
  • Grade C periodontitis (formerly known as aggressive 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.

References

References are available in the hard-copy of the website.

Periobasics: A Textbook of Periodontics and Implantology

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