Treatment Planning in Periodontics (Case History)

The ultimate goal for every patient is to bring his or her mouth to a state of health and maintain it long term. This begins with educating the patient on the problems in his or her mouth and the etiologies, treatment, and prevention of these problems. A properly formulated treatment plan is paramount to achieving this goal. A treatment plan is a plan for therapy formulated only after a thorough examination has been completed, the diagnosis and prognosis have been determined, and the needs and desires of the patient have been taken into consideration. It must be recognized that as the diagnosis (in select cases) and prognosis will change with treatment, therapeutic needs may also change. As such, the treatment plan must be changed accordingly.

1. CASE HISTORY -
TREATMENT PLAN
Dr. Akriti
III MDS

2. CONTENT
●INTRODUCTION
●GOALS OF TREATMENT PLANNING
●AIM OF TREATMENT PLANNING
●TREATMENT SEQUENCE
●PRELIMINARY PHASE
●PHASE I THERAPY
●EVALUATION OF RESPONSE TO
NONSURGICAL PHASE
●PHASE II THERAPY
●PHASE III THERAPY
●PHASE IV THERAPY
●CONCLUSION
●TAKE-AWAY

3. INTRODUCTION
●Blueprint for case management
●Done after diagnosis and prognosis are established
●Includes all procedures required for the establishment and maintenance of oral health
●Involves the following decisions to be made -
○Emergency treatment
○Removal of nonfunctional and diseased teeth
○Treatment of periodontal diseases
○Endodontic therapy
○Caries removal and placement of temporary and final restorations
○Occlusal adjustment and orthodontic therapy
○Replacement of missing teeth
○Aesthetic considerations
○Sequence of therapy
Newman MG, Takie HH, Klokkevold PR, Carranza FA. Carranza’s Clinical Periodontology, Ed 14. St. Louis: Saunders Elsevier;

6. GOALS OF TREATMENT PLANNING
●IMMEDIATE GOAL
○Elimination of all infectious and inflammatory processes
○Patient education
○Pocket reduction
○Good gingival contour
○Extraction of hopeless teeth,
○Restoration of carious lesions, and
○Correction of poor existing restoration
Newman MG, Takie HH, Klokkevold PR, Carranza FA. Carranza’s Clinical Periodontology, Ed 14. St. Louis: Saunders Elsevier;

7. GOALS OF TREATMENT PLANNING
●INTERMEDIATE GOAL
○Restoration of
■Health,
■Function,
■Aesthetics, and
■Longevity
●LONG-TERM GOAL
○Maintenance of health through prevention and professional supportive therapy
○Patient education
○Daily home care
○Recall
Newman MG, Takie HH, Klokkevold PR, Carranza FA. Carranza’s Clinical Periodontology, Ed 14. St. Louis: Saunders Elsevier;

8. AIM OF TREATMENT PLANNING
The aim of the treatment plan is total treatment—that is, the coordination of all the
immediate, intermediate, and long-term goals for the purpose of creating a
well-functioning dentition in a healthy periodontal environment.


Newman MG, Takie HH, Klokkevold PR, Carranza FA. Carranza’s Clinical Periodontology, Ed 14. St. Louis: Saunders Elsevier;

9. Loos BG, Needleman I. Endpoints of active periodontal therapy. Journal of Clinical Periodontology. 2020 Jul;47:61-71.

10. Loos BG, Needleman I. Endpoints of active
periodontal therapy. Journal of Clinical
Periodontology. 2020 Jul;47:61-71.

12. TREATMENT SEQUENCE

13. To retain or extract?
●It is so mobile that function becomes painful or if it poses an aspiration risk.
●It can cause acute abscesses during therapy.
●In some cases, a tooth can be retained temporarily, postponing the decision to extract
until after treatment is completed -
○It maintains posterior stops; the tooth can be removed after treatment when it can be
replaced by an implant or another type of prosthesis.
○It maintains posterior stops and may be functional after implant placement in
adjacent areas. When the implant is restored, these teeth can be extracted.
○In the anterior aesthetic zone, a tooth can be retained during periodontal therapy
and removed when treatment is completed and a permanent restorative procedure
can be performed.
●Extraction of hopeless teeth can be delayed during the nonsurgical periodontal therapy
and can be performed during periodontal surgery of the adjacent teeth.
Newman MG, Takie HH, Klokkevold PR, Carranza FA. Carranza’s Clinical Periodontology, Ed 14. St. Louis: Saunders Elsevier;

15. TREATMENT SEQUENCE - Trimeric Model
●The arrangement of treatment steps that resembles the petals of a trimeric flower
(Mariposa Lilly)
●Treatment planning is done in stages (phases) that are ended with, centered, and
aimed towards the maintenance phase (Phase IV) which is the final aim that the patient
will be placed in for lifetime.
●Each phase is followed by a Re-evaluation Phase in which decision of the next step of
treatment is made.
●Phases -
○Phase I (Initial therapy – Disease Control Phase)
○Phase II (Surgical therapy)
○Phase III (Restorative therapy)
○Phase IV (Maintenance Phase - Supportive Periodontal therapy)
Azouni KG, Tarakji B. The trimeric model: A new model of periodontal treatment planning. Journal of clinical and diagnostic research: JCDR. 2014 Jul;8(7):ZE17.

17. Extended trimeric model
●The trimeric model of periodontal treatment planning can be extended by including the
preparation of the periodontium for restorative dentistry and Adjunctive Orthodontic
Therapy. This extended trimeric periodontal treatment planning model adds the
following two aspects to the original Trimeric model:
○Expansion of the Surgical Phase
■Periodontal surgery
■Preprosthetic surgery
○Adjunctive orthodontic therapy
Azouni KG, Tarakji B. The trimeric model: A new model of periodontal treatment planning. Journal of clinical and diagnostic research: JCDR. 2014 Jul;8(7):ZE17.

18. The broken red arrows doesn’t
indicate jumping from a stage
to the next stage but only the
logical order of treatment
phases as re-evaluation phase
should be reached between
each phase and the other with
transfer to maintenance phase
(and thus finishing the
treatment) once treatment
objectives are accomplished
even if the phases of treatment
are not all done.

The green highlighting indicate
the disease control phase
which includes the initial phase
and part of the surgical
phase (specifically periodontal
surgery) but not adjunctive
Orthodontic therapy.

19. Extended trimeric model
●Advantages of the extended Trimeric Treatment plan model:
○Introduces a clear and logical framework of the steps of treatment of periodontal
disease.
○Clarifies the stabilization (Disease Control) stage of periodontal therapy as not all
surgical procedures are needed for stabilization of periodontal disease and as
other procedures are clearly indicated for the preparation to restorative therapy.
○Indicates the placement of adjunctive orthodontic therapy after the stabilization of
periodontal infection and before any restorative or surgical preparation to
restorative therapy.

Azouni KG, Tarakji B. The trimeric model: A new model of periodontal treatment planning. Journal of clinical and diagnostic research: JCDR. 2014 Jul;8(7):ZE17.

22. PRELIMINARY (EMERGENCY) PHASE
●Treatment of emergencies
○Dental OR Periapical
○Periodontal
●Extraction of hopeless teeth and provisional replacement if needed

Newman MG, Takie HH, Klokkevold PR, Carranza FA. Carranza’s Clinical Periodontology, Ed 14. St. Louis: Saunders Elsevier;

23. Harpenau L. Hall's Critical Decisions in Periodontology & Dental Implantology, 5e. PMPH USA; 2013 Jul 31.

24. PHASE I THERAPY (NON-SURGICAL PHASE)
●The following list of elements makes up phase I therapy:
○Patient education and oral hygiene instruction
○Complete removal of supragingival calculus
○Correction or replacement of poorly fitting restorations and other prosthetic device
○Restoration or temporization of carious lesions
○Orthodontic tooth movement
○Treatment of food impaction areas
○Treatment of occlusal trauma
○Extraction of hopeless teeth
○Possible use of antimicrobial agents, including necessary plaque or biofilm
sampling and sensitivity testing
Newman MG, Takie HH, Klokkevold PR, Carranza FA. Carranza’s Clinical Periodontology, Ed 14. St. Louis: Saunders Elsevier;

25. PHASE I THERAPY (NON-SURGICAL PHASE)
●Conditions to be considered when determining the phase I treatment plan:
○General health and tolerance of treatment
○Number of teeth present
○Amount of subgingival calculus
○Probing pocket depths
○Attachment loss
○Furcation involvement
○Alignment of teeth
○Margins of restorations
○Developmental anomalies
○Physical barriers to access the dentition (e.g., limited opening or tendency to gag)
○Patient cooperation and sensitivity to therapy
○Presence of dental implants in the oral cavity
Newman MG, Takie HH, Klokkevold PR, Carranza FA. Carranza’s Clinical Periodontology, Ed 14. St. Louis: Saunders Elsevier;

26. PHASE I THERAPY (NON-SURGICAL PHASE)
●Step 1: Plaque or Biolm Control Instruction
○essential component of successful periodontal therapy
○instruction should begin at the first treatment appointment
○explanation of the etiology of the disease must be presented to the patient
●Once the patient understands the nature of periodontal disease and the etiology, it will
be easier to teach the hygiene that he or she must practice.
○applying the bristles at the gingival third of the clinical crowns, where the tooth
meets the gingival margin (targeted oral hygiene - H. Takei, 2009)
○interdental cleaning with dental floss and interdental brushes
●Multiple appointment approach - permits the use of numerous appointments to
evaluate, reinforce, and improve the patient’s oral hygiene skills
Newman MG, Takie HH, Klokkevold PR, Carranza FA. Carranza’s Clinical Periodontology, Ed 14. St. Louis: Saunders Elsevier;

27. Vilar Doceda M, Petit C, Huck O.
Behavioral Interventions on
Periodontitis Patients to Improve
Oral Hygiene: A Systematic
Review. J Clin Med. 2023 Mar
15;12(6):2276.

28. PHASE I THERAPY (NON-SURGICAL PHASE)
●Step 2: Removal of Supragingival and Subgingival Plaque or Biofilm and
Calculus
○Scalers, curettes, ultrasonic instrumentation, or combinations of these devices in
one or more appointments
○Laser treatment
○Curettage of the soft tissue pocket wall
○Photodynamic therapy - adjunct to scaling and root planing
○Pocket irrigation with antiseptics
○Nonsurgical therapy and adjunctive local antimicrobial delivery or systemic
antimicrobials
Newman MG, Takie HH, Klokkevold PR, Carranza FA. Carranza’s Clinical Periodontology, Ed 14. St. Louis: Saunders Elsevier;

29. Heitz-Mayfield LJ, Lang NP. Surgical and nonsurgical periodontal
therapy. Learned and unlearned concepts. Periodontol 2000. 2013
Jun;62(1):218-31. doi: 10.1111/prd.12008. PMID: 23574468.

30. PHASE I THERAPY (NON-SURGICAL PHASE)
●Step 3: Recontouring Defective Restorations and Crowns
○Corrections of restorative defects
■smoothing the rough surfaces
■removing overhangs from the faulty restorations with burs or hand
instruments
○Complete replacement of the failing restorations
Newman MG, Takie HH, Klokkevold PR, Carranza FA. Carranza’s Clinical Periodontology, Ed 14. St. Louis: Saunders Elsevier;

31. PHASE I THERAPY (NON-SURGICAL PHASE)
●Step 4: Management of Carious Lesions
○Removal of the carious lesions and placement of either temporary or permanent
restorations are indicated in phase I therapy because of the infectious nature of
the carious process.
○Healing of the periodontal tissues is maximized by removing the reservoir of
bacteria in these lesions so that they cannot repopulate the microbial plaque.
Newman MG, Takie HH, Klokkevold PR, Carranza FA. Carranza’s Clinical Periodontology, Ed 14. St. Louis: Saunders Elsevier;

32. PHASE I THERAPY (NON-SURGICAL PHASE)
●Step 5: Tissue Reevaluation
○ approximately 4 weeks to heal
■allows the connective tissues to heal
■accurate probe depths can be measured
●Patients will also have the opportunity to improve their home care skills to reduce
gingival inflammation and adopt new habits that will ensure the success of treatment.
Newman MG, Takie HH, Klokkevold PR, Carranza FA. Carranza’s Clinical Periodontology, Ed 14. St. Louis: Saunders Elsevier;

33. PHASE I THERAPY (NON-SURGICAL PHASE)
●Halitosis
○Supportive and Sympathetic Reassurance
○Mechanical Debridement of Tongue Biofilm
○Mouth Rinses
■antibacterial agents such as chlorhexidine, zinc, triclosan, and cetylpyridinium
chloride are recommended for usage
○Other Ancillary Measures
■Tea tree oil
■Masking agents like mint or fluoride in toothpaste or flavored chewing gum
■Photodynamic waves
■Avoidance of smoking, tobacco, alcohol, cutting down onions, garlic, spices
■Increased fluid intake.
○ Extraoral causes - Antibiotics for respiratory infections, antacids for GERD, or
surgical intervention if adenoids are enlarged and infected.
Tungare S, Zafar N, Paranjpe AG. Halitosis. [Updated 2023 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan.

34. EVALUATION OF RESPONSE TO NONSURGICAL PHASE
●Assessment of outcome of nonsurgical therapy
●Inquiry of new concerns or problems
●Review and update of patient medical and dental history;
●Oral hygiene assessment and education
●Comprehensive periodontal examination
●Changes in the prognostic profile of the patient as referred to well‐established
modifiable risk factors
●Determination of required additional nonsurgical and adjunctive therapy
●Behavior modification (such as oral hygiene re‐instruction, compliance with suggested
periodontal maintenance intervals, and counseling on control of risk factors);
●Delivery of antimicrobial agents as needed.
Newman MG, Takie HH, Klokkevold PR, Carranza FA. Carranza’s Clinical Periodontology, Ed 14. St. Louis: Saunders Elsevier;

35. Kwon T, Lamster IB, Levin L. Current concepts in the management of periodontitis. International dental journal. 2021 Dec 1;71(6):462-76.

36. EVALUATION - Recall frequency
●The American Academy of Periodontology's position paper on the subject of Periodontal
Maintenance stated that for “most patients with a history of periodontitis, visits at every
3-month interval may be required initially.
●Wide range of recommended periods in the published literature, including 2 weeks, 2–3
months, 3 months, 3–4 months,3–6 months, and even as long as 18 months
●Using known risk factors/indicators in each individual patient, aims to enable the
practitioner to determine the frequency and extent of professional support necessary to
maintain periodontal health following active therapy.

Farooqi OA, Wehler CJ, Gibson G, Jurasic MM, Jones JA. Appropriate recall interval for periodontal maintenance: a systematic review. Journal of Evidence Based Dental Practice. 2015
Dec 1;15(4):171-81.

37. Harpenau L. Hall's Critical Decisions in Periodontology & Dental Implantology, 5e. PMPH USA; 2013 Jul 31.

38. PHASE II THERAPY (SURGICAL PHASE)
●Critical probing depth (Lindhe et al., 1982)
○Baseline probing-depth value above which the outcome of a therapy will result in
attachment gain and below which the outcome of therapy will result in clinical
attachment loss.
○NSPT (scaling and root planing) - 2.9mm
○The critical probing depth value of 4.2mm, indicates that surgical interventions
would only be beneficial for achieving clinical attachment gain if lesions with a
probing depth of at least 4.2mm are treated.
○Critical probing depth of 5.4mm means that a probing depth of about 5.5mm would
benefit from additional surgical therapy, while sites with a shallower probing depth
require only nonsurgical therapy.
Lindhe J, Socransky SS, Nyman S, Haffajee A, Westfelt E. "Critical probing depths" in periodontal therapy. J Clin Periodontol. 1982 Jul;9(4):323-36.

39. PHASE II THERAPY (SURGICAL PHASE)
●The third step of periodontal therapy is indicated for the treatment of sites which did not
respond appropriately to the second step of periodontal therapy, resulting in persistent
pocketing (PD ≥ 6 mm) and/or inflammation (PD > 4 mm with bleeding on probing).
●The aim of phase 2 therapy is -
○access to the root surfaces for effective subgingival instrumentation
○access to alveolar defects for regenerative or resective treatment through the
following interventions:
■Repeating Subgingival Instrumentation
■Access Flap Periodontal Surgery
■Resective Periodontal Surgery
■Regenerative Periodontal Surgery
Newman MG, Takie HH, Klokkevold PR, Carranza FA. Carranza’s Clinical Periodontology, Ed 14. St. Louis: Saunders Elsevier;

40. PHASE II THERAPY (SURGICAL PHASE)
●Indications -
○Areas with irregular bony contours, deep craters, and other defects
○Pockets around teeth where access to the root surface for complete removal of
root irritants is not clinically possible.
○Furcation involvement of grade II or III
○Intrabony pockets distal to the last molars,.
○Persistent inflammation in areas after past procedures
Newman MG, Takie HH, Klokkevold PR, Carranza FA. Carranza’s Clinical Periodontology, Ed 14. St. Louis: Saunders Elsevier;

41. Harpenau L. Hall's Critical Decisions in Periodontology & Dental Implantology, 5e. PMPH USA; 2013 Jul 31.

42. Harpenau L. Hall's Critical Decisions in Periodontology & Dental Implantology, 5e. PMPH USA; 2013 Jul 31.

43. PHASE II THERAPY (SURGICAL PHASE)
●Regenerative therapy
○Reproduction of reconstitution of a lost or injured part so that the form and function
of lost structures is restored
○Factors affecting -
■Intrabony Site Evaluation
■Patient-Related Factors
■Site-Related Factors
■Technical Factors
■Source of Regenerative Tissues

Ivanovski S. Periodontal regeneration. Australian dental journal. 2009 Sep;54:S118-28.

47. PHASE II THERAPY (SURGICAL PHASE)
●Resective therapy
○OBJECTIVES -
■Establishing soft and hard tissue physiologic architecture
■Providing acceptable soft tissue contours and probing depths
■Facilitating access to underlying structures to enhance visibility, confirm
diagnosis, and effectively remove calculus
○CONTRAINDICATIONS -
■Poor plaque control/systemic disease/habits
■A patient’s refusal to accept the treatment plan
■Shallow probing depths;
■Soft and/or hard tissue defects amenable to regenerative treatment;
■Severely advanced periodontal disease
■Anticipation of an unacceptable postoperative cosmetic result.
Newman MG, Takie HH, Klokkevold PR, Carranza FA. Carranza’s Clinical Periodontology, Ed 14. St. Louis: Saunders Elsevier;

48. Harpenau L. Hall's Critical Decisions in Periodontology & Dental Implantology, 5e. PMPH USA; 2013 Jul 31.

49. PHASE II THERAPY (SURGICAL PHASE)
●Management of furcation
○In Class I furcation defects, regenerative therapy may be beneficial in certain
clinical scenarios, although most Class I furcation defects may be successfully
treated with non-regenerative therapy.
○Periodontal regeneration has been demonstrated histologically and clinically for
the treatment of maxillary facial or interproximal and mandibular facial or lingual
Class II furcation defects.
○Although periodontal regeneration has been demonstrated histologically for the
treatment of mandibular Class III defects, the evidence is limited to one case
report.
○Evidence supporting regenerative therapy in maxillary Class III furcation defects in
maxillary molars is limited to clinical case reports.
Avila-Ortiz G, De Buitrago JG, Reddy MS. Periodontal regeneration - furcation defects: a systematic review from the AAP Regeneration Workshop. J Periodontol. 2015 Feb;86(2
Suppl):S108-30. doi: 10.1902/jop.2015.130677. PMID: 25644295.

50. Harpenau L. Hall's Critical Decisions in Periodontology & Dental Implantology, 5e. PMPH USA; 2013 Jul 31.

51. PHASE II THERAPY (SURGICAL PHASE)
●Management of gingival recession
○Non-surgical treatment - establishment of optimal plaque control, removal of
overhanging subgingival restorations, behaviour change interventions, and use of
desensitising agents.
○Surgical approach - CAF and tunnelling procedures combined with a CTG
○If there is a contraindication for harvesting a CTG from the palate or the patient
wants to avoid a donor site surgery, adjunctive use of acellular dermal matrices,
collagen matrices, and/or EMD can be a valuable alternative.
○For gingival recession defects associated with NCCLs a combined
restorative-surgical approach can provide favourable clinical outcomes.
○If a patient refuses a surgical intervention or there are other contraindications for
an invasive approach, gingival conditions should be maintained.
Imber JC, Kasaj A. Treatment of Gingival Recession: When and How? Int Dent J. 2021 Jun;71(3):178-187. doi: 10.1111/idj.12617. Epub 2021 Jan 29. PMID: 34024328

52. Harpenau L. Hall's Critical Decisions in Periodontology &
Dental Implantology, 5e. PMPH USA; 2013 Jul 31.

53. Harpenau L. Hall's Critical Decisions in Periodontology & Dental Implantology, 5e. PMPH USA; 2013 Jul 31.

54. Harpenau L. Hall's Critical Decisions in Periodontology & Dental Implantology, 5e. PMPH USA; 2013 Jul 31.

55. PHASE II THERAPY (SURGICAL PHASE)
●Esthetic crown lengthening
○Altered passive eruption
■1A
■1B
■2A
■2B
Coslet JG, Vanarsdall R, Weisgold A. Diagnosis and classification of delayed passive eruption of
the dentogingival junction in the adult. The Alpha Omegan. 1977 Dec 1;70(3):24-8.

57. Harpenau L. Hall's Critical Decisions in Periodontology & Dental Implantology, 5e. PMPH
USA; 2013 Jul 31.

58. PHASE II THERAPY (SURGICAL PHASE)
●Ridge augmentation
○Indications -
■Loss of alveolar ridge height, width and decreases vestibular depth and
denture bearing area
■Considerable basal bone resorption in the mandible, resulting in
neurosensory disturbances
■Increased susceptibility to fracture of the atrophic jaws
■Replacement of necessary supportive bone
■Progressive loss of denture stability and retention
■Implant placement
Milinkovic I, Cordaro L. Are there specific indications for the different alveolar bone augmentation procedures for implant placement? A systematic review. International journal of oral and
maxillofacial surgery. 2014 May 1;43(5):606-25.

60. Harpenau L. Hall's Critical Decisions in
Periodontology & Dental Implantology, 5e.
PMPH USA; 2013 Jul 31.

61. Harpenau L. Hall's
Critical Decisions in
Periodontology & Dental
Implantology, 5e. PMPH
USA; 2013 Jul 31.

62. PHASE II THERAPY (SURGICAL PHASE)
●High frenal attachment
○The treatment modalities involve frenectomy using -
■Miller's technique,
■Conventional technique,
■Z-plasty, and
■V-Y plasty
○Frenotomy
○Scalpel, Laser, Electrocautery
Shirbhate U, Bajaj P, Oza R, et al. (April 05, 2024) Management Using V-Y Plasty Approach for Abnormal Frenal Attachment: A Case Report. Cureus 16(4): e57663.

63. PHASE II THERAPY (SURGICAL PHASE)
●Depigmentation
○SURGICAL METHODS
■Scalpel surgical technique
■Bur abrasion method
■Electrosurgery
■Cryosurgery
■Lasers
■Radiosurgery
○CHEMICAL METHODS
■90% phenol in combination with 95% alcohol
○Methods used to mask the gingival pigmentation:
■Free gingival graft
■Acellular dermal matrix allograft
Moneim RA, El Deeb M, Rabea AA. Gingival pigmentation (cause, treatment and histological preview). Future Dental Journal. 2017 Jun 1;3(1):1-7.

64. PHASE II THERAPY (SURGICAL PHASE)
●Dental implants
○INDICATIONS
■Partial edentulous patients who have intermediate gaps or free-end edentulism.
■When a patient is not satisfied with the existing unstable and nonretentive
conventional complete dental prosthesis.
■To preserve existing removable partial prostheses
○CONTRAINDICATIONS
■Absolute Contraindication - Acute illness, the magnitude of defect or anomaly,
uncontrolled metabolic disease, bone or soft tissue pathology/infection
■Relative Contraindications - Diabetes, osteoporosis, parafunctional habits, HIV,
AIDS, bisphosphonate usage, chemotherapy, irradiation of head and neck,
behavioral, neurogenic, psychosocial, psychiatric disorders
Gupta R, Gupta N, Weber, DDS KK. Dental Implants. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan

65. Harpenau L. Hall's Critical Decisions
in Periodontology & Dental
Implantology, 5e. PMPH USA; 2013
Jul 31.

67. PHASE II THERAPY (SURGICAL PHASE)
●Management of peri-implantitis
○The etiology of the implant infection is conditioned by the status of the tissue
surrounding the implant, implant design, degree of roughness, external
morphology, and excessive mechanical load.
○Diagnosis is based on changes of color in the gingiva, bleeding and probing depth
of peri-implant pockets, suppuration, X-ray, and gradual loss of bone height
around the tooth.
○Treatment will differ depending upon whether it is a case of peri-implant mucositis
or peri-implantitis.
○The management of implant infection should be focused on the control of infection,
the detoxification of the implant surface, and regeneration of the alveolar bone.
Prathapachandran J, Suresh N. Management of peri-implantitis. Dent Res J (Isfahan). 2012 Sep;9(5):516-21.

68. Harpenau L. Hall's Critical Decisions in Periodontology & Dental
Implantology, 5e. PMPH USA; 2013 Jul 31.

69. PHASE III THERAPY (RESTORATIVE PHASE)
●Final restorations
●Fixed & removable prosthodontic appliances
●Evaluation of response to restorative procedures

Newman MG, Takie HH, Klokkevold PR, Carranza FA. Carranza’s Clinical Periodontology, Ed 14. St. Louis: Saunders Elsevier;

70. PHASE IV THERAPY (MAINTENANCE PHASE)
●Preservation of the periodontal health of the treated patient is as important as the
elimination of periodontal disease.
●In the maintenance phase, patients are placed on a schedule of periodic recall visits for
maintenance care to prevent recurrence of the disease.
●The intervals between recall appointments are varied according to the patient condition.
●This should be the end goal of periodontal treatment. The long-term success of
periodontal treatment depends on the maintenance of the results achieved in the other
phases of the periodontal treatment plan.


Newman MG, Takie HH, Klokkevold PR, Carranza FA. Carranza’s Clinical Periodontology, Ed 14. St. Louis: Saunders Elsevier;

71. Berglundh T, Giannobile WV, Lang NP, Sanz M, eds. Lindhe’s Clinical Periodontology and Implant Dentistry. Seventh edition. Wiley Blackwell; 2021. Accessed May 22, 2024.

72. Rahul Patel and Ranjit Singh Uppal. “Supportive Periodontal Therapy: A Brief Review”. SVOA Dentistry 2:1 (2021) pages 25-31.

73. PHASE IV THERAPY (MAINTENANCE PHASE)
●Recall schedule (Merin’s Classification)
○On the basis of severity of gingival or periodontal disease, oral hygiene
maintenance by the patient and compliance, Merin et al. in 1996 proposed
classification for recall interval for different types of patients

Merin RL. Supportive periodontal treatment. In: Carranza FA,Newman MG,clinical periodontology W.B. saunders company., 1996:8th edition:743-52.

75. CASE SCENARIOS

79. CONCLUSION
The ultimate goal for every patient is to bring his or her mouth to a state of
health and maintain it long term. This begins with educating the patient on the
problems in his or her mouth and the etiologies, treatment, and prevention of
these problems. A properly formulated treatment plan is paramount to achieving
this goal. A treatment plan is a plan for therapy formulated only after a thorough
examination has been completed, the diagnosis and prognosis have been
determined, and the needs and desires of the patient have been taken into
consideration. It must be recognized that as the diagnosis (in select cases) and
prognosis will change with treatment, therapeutic needs may also change. As
such, the treatment plan must be changed accordingly.

80. TAKE-AWAY!
●Diagnosis requires thorough and careful examination.
●Prognosis is based on accurate diagnosis.
●Treatment decisions are based on the prognosis.
●Treatment decisions are made to improve the prognosis.
●Diagnosis (in select cases) and prognosis could change with treatment.