Treatment Plan in Periodontics

DR AMIT DE 3rd YEAR M.D.S. STUDENT, DEPT. OF PERIODONTICS, GURU NANAK INSTITUTE OF DENTAL SCIENCES &

RESEARCH

Treatment Plan

Treatment

Plan

Ref. : Essentials of Public Health dentistry, Soben Peter, 5th Edition

Planning is a systematicapproach to defining theproblem, setting priorities,developing specific goalsand objectives anddetermining alternativestrategies and methods ofimplementation.

E.C. Banfield has presenteda basic definition of theterm plan : “ A plan is adecision about a course ofaction”

After the diagnosis and prognosis have been established, the treatment plan is chalked out.

The treatment plan is the blueprint for case management.

Treatment plan in periodontics

Goals of Treatment plan

Short-term Goals

Long-term Goals

Elimination of allinfectious andinflammatoryprocesses that causeperiodontal andother oral problemsthat may hinder thepatient’s generalhealth.

Reconstruction of a healthy dentition that fulfills all functional and esthetic requirements.Long term planning involves consideration of prosthetic reconstruction, which may require implant therapy. Also the need for orthodontic treatment should be evaluated.

MASTER PLAN FOR TOTAL TREATMENT

The aim of the treatment plan is total treatment, that is, the coordination of all the short- and long-term goals for the purpose of creating a well-functioning dentition in a healthy periodontal environment.

• Need for emergency treatment (pain, acute infections).

• Teeth that will require removal.• Periodontal pocket therapy techniques

(surgical or nonsurgical).• Endodontic therapy.• The need for occlusal correction,

including orthodontic therapy.• The use of implant therapy.• The need for caries removal and the

placement of temporary and final restorations.

• Prosthetic replacements that may be needed and which teeth will be abutments if a fixed prosthesis is used.

• Decisions regarding esthetic considerations in periodontal therapy.

It includes all procedures required for the establishment and maintenance of oral health and involves the following decisions:

Extracting or Preserving a Tooth

• Treatment is directed to establishing and maintaining the health of the periodontium throughout the mouth rather than attempting spectacular efforts to “tighten loose teeth.”

-- Carranza’s Clinical Periodontology, 11th Edition

Therefore attempts to save questionable teeth may jeopardize adjacent teeth and may lead to the loss of bone needed for implant therapy.

Teeth on the borderline of a hopeless prognosis do not contribute to the overall usefulness of the dentition.

Such teeth become sources of recurrent problem to the patient.

A tooth should be extracted underthe following conditions :1. It is so mobile that function

becomes painful.2. It can cause acute abscesses

during therapy.3. There is no use for it in the

overall treatment plan.

A tooth can be retained under thefollowing conditions: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 esthetic zone, a tooth can be retained during periodontal therapy and removed when treatment is completedand a permanent restorative procedure can be performed.

Except for emergencies, no therapyshould be initiated until a treatmentplan has been established.

When to plan? Why is called INITIAL treatment plan?

INITIAL TREATMENT PLAN

Unforeseen developments during treatment may necessitate modification of the initial treatment plan.

Phases of Periodontal Therapy

Preliminary Phase

Treatment of emergencies:• Dental or periapical• Periodontal• OtherExtraction of hopeless teeth and provisional replacement if needed(may be postponed to a more convenient time).

Phase I

Phase II

Phase III

Phase IV

Nonsurgical Phase (Phase I Therapy)Plaque control and patient education:• Diet control (in patients with rampant caries)• Removal of calculus and root planing• Correction of restorative and prosthetic irritational factors• Excavation of caries and restoration • Antimicrobial therapy (local or systemic)• Occlusal therapy• Minor orthodontic movement• Provisional splinting and prosthesis

Surgical Phase (Phase II Therapy)• Periodontal therapy, including placement of implants• Endodontic therapyRestorative Phase (Phase III Therapy)• Final restorations• Fixed and removable prosthodontic appliances• Evaluation of response to restorative procedures• Periodontal examination

Maintenance Phase (Phase IV Therapy)Periodic rechecking:• Plaque and calculus• Gingival condition (pockets, inflammation)• Occlusion, tooth mobility• Other pathologic changes

Although, the phases of treatment in this model have been numbered, the recommended sequence does not follow the numbers.

SEQUENCE OF THERAPEUTICPROCEDURES

(Preliminary Phase)

(Phase I Therapy)

(Phase II Therapy) (Phase III Therapy)

(Phase IV Therapy)

Ref. : Khalid G Azouni, Bassel Tarakji : The Trimeric Model: A New Model of Periodontal Treatment Planning, Journal of Clinical and Diagnostic Research. 2014 Jul, Vol-8(7): ZE17-ZE20

Trimeric Model

THE EXTENDED TRIMERIC MODEL

1. It has a unique position in the periodontal treatmentplan, as it should be undertaken only after activeperiodontal disease has been controlled .

2. Failure to control active periodontitis can result in acuteexacerbations and bone loss during tooth movement.

1. The Expansion of the Surgical Phase

Periodontal Surgery

E.g. pocket reduction surgeries

Preprosthetic Surgery

E.g. crown lengthening surgery, root coverage surgery

2. Adjunctive Orthodontic Therapy

PH

AS

E

II

THE EXTENDED TRIMERIC MODEL

The greenhighlightingindicate the diseasecontrol phase whichincludes the initialphase and part of thesurgical phase(specificallyperiodontal surgery)but not AdjunctiveOrthodonticTherapy.

Patients must understand the purpose of the maintenance program, and the dentist must emphasize that preservation of the teeth depends on maintenance therapy.

RATIONALE FOR MAINTENANCE THERAPY

• Inadequate plaque control• Incomplete subgingival plaque removal• Bacteria are present in the gingival tissues in

chronic and aggressive periodontitis cases.• Bacteria transmitted between spouses and

other family members• Microscopic nature of the dentogingival unit

healing after periodontal treatment

OBJECTIVES

To prevent the progression and recurrence of periodontal disease in patients who have previously been treated for gingivitis and periodontitis

10 minutes

36 minutes

14 minutes

Maintenance Recall Procedures

1st Qtr2nd Qtr3rd Qtr

Oral hygiene reinforcementScalingPolishingChemical irrigation or site-specific antimicrobial placement

Write report in chart.Discuss report with patient.Clean and disinfect operatory.Schedule next recall visit.Schedule further periodontal treatment.Schedule or refer for restorative or prosthetic treatment.

Patient greetingMedical history changesOral pathologic examinationOral hygiene statusGingival changesPocket depth changesMobility changesOcclusal changesDental cariesRestorative, prosthetic, and implant status

MERIN’S CLASSIFICATION FOR RECALL INTERVALS

References Caranza’s Clinical Periodontology, 11th Edition Clinical Periodontology and Implant Dentistry, J

Lindhe, 5th Edition Khalid G Azouni, Bassel Tarakji : The Trimeric

Model: A New Model of Periodontal Treatment Planning, Journal of Clinical and Diagnostic Research. 2014 Jul, Vol-8(7): ZE17-ZE20

Essentials of Public Health dentistry, Soben Peter, 5th Edition

THANK YOU