Treatment plan In Periodontics

Definition,Treatment plan, phases of Treatment plan,sequence

1. TREATMENT PLAN IN PERIODONTICS

2. CONTENTS DEFINITION RATIONALE TREATMENT GOALS PHASES TIME OF REVALUATION

3. DEFINITION The treatment plan is the blueprint for case management Includes all procedures required for establishment & maintenance of oral health

4. Perio therapy can restore chronically inflamed gingiva The aim of the treatment plan is total treatment, that is, the coordination of all treatment procedures for the purpose of creating a well-functioning dentition in a healthy periodontium .

5. RATIONALE An objective of the overall treatment plan is the creation and maintenance of oral health, function, and esthetics. The outcome is thus long term and in most cases requires the coordination of several disciplines of dentistry Treatment planning should focus on the list of diagnoses for the patient. Treatment should be planned in phases. At the completion of each phase, the patient should be reevaluated to assess response to treatment, and the treatment plan may be modified based on this

6. TREATMENT GOALS Primary goal is elimination of gingival inflammation & correction of conditions that cause & perpetuate it Includes elimination of root irritants, Pocket eradication & reduction, Establishment of gingival contours & mucogingival relationships conducive to preservation of perio health , Restoration of carious areas & correction of existing restorations

7. 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

8. 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

9. 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 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

10. 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

11. 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 a in addition to proper function of dentition, esthetic considerations play increasingly important role in many cases

12. 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

13. PHASES OF PERIODONTAL THERAPY Preliminary Phase (Emergency phase): Treatment of emergencies Dental or periapical abscess Periodontal abscess Extraction of hopeless teeth and provisional replacement

14. Nonsurgical Phase (Phase I Therapy): Plaque control and patient education Diet control Scaling and root planing Demonstration of proper brushing technique Correction of restorative and prosthetic factors Excavation of caries and restoration Antimicrobial therapy (local or systemic) Occlusal adjustments Minor orthodontic movement Provisional splinting and prosthesis Evaluation of response to nonsurgical phase Pocket depth and gingival inflammation Plaque and calculus, caries

15. Surgical Phase (Phase II Therapy): Periodontal therapy Pocket reduction or elimination procedures: Gingivectomy Periodontal flap surgery Regenerative surgery Periodontal plastic surgery Preprosthetic surgical procedures Resective osseous surgery Implant surgery Endodontic therapy

16. Restorative Phase (Phase III Therapy): Final restorations Fixed and removable prosthesis Maintenance Phase (Phase IV Therapy): Periodic rechecking Plaque and calculus Gingival condition and periodontal status Occlusion , tooth mobility Other pathologic changes

17. 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 treatment Maintenance phase (care) – SPT Salvi , Lindhe & Lang 2008

18. SEQUENCE OF PERIODONTAL THERAPY

19. TO BE EXPLAINED Be specific Avoid vague statements Begin our discussion on positive note Talk about teeth that can be retained & long term service expected to render  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

20. 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 Treatment is directed to establishing & maintaining health of periodontium throughout mouth rather than to spectacular efforts to “tighten loose teeth

21. Thus 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

22. REFERRAL PROTOCOL: (AAP GUIDELINES 2006 Level 1: Patient who benefits from co-management by the referring dentist and the periodontist . Patients with periodontal inflammation and systemic diseases, under cancer therapy. Level 2 : Patient who benefits from co-management by the referring dentist and the periodontist . Patients with periodontitis who needs re-evaluation with one or more risk factors and indicators. Level 3: Patients who should be treated by periodontist . Patient with severe periodontitis, peri -implant disease, vertical bony defects, furcation involvement, recession.

23. RECALL OF PATIENTS Merin’s classification In the first year patient is recalled every 3 months if the patient is co-operative and has no systemic or environmental factors which affects the prognosis. In patients with one or more factors which affects the prognosis the patient is recalled every 1-2 months. After first year patients are classified as Class A: Good oral hygiene, minimal calculus, absence of prosthetic, environmental and systemic factors- 6 months to 1 year. Class B: Poor oral hygiene, heavy calculus, presence of some prosthetic, environmental and systemic factors- 3 - 4 months. Class C: Very poor oral hygiene, heavy calculus, presence of many prosthetic, environmental and systemic factors, many pockets remaining- 1 – 3 months.