treatment planning in periodontics- dr harshavardhan patwal

TREATMENT PLANNING IN PERIODONTICS Dr Harshavardhan PatwalDr Harshavardhan Patwal

INTRODUCTIONAfter the diagnosis and prognosis is established, the treatment is planned.

The treatment plan is blueprint for case management.

It includes all procedures required for establishment and maintenance of oral health

Treatment plan is based on Diagnosis Disease severity Desirable therapeutic end points

AIM OF TREATMENT PLANNING To do total treatment that is coordinating of all treatment procedures for the purpose of creating a well-functioning dentition in a healthy periodontal environment .

The primary goal is to eliminate gingival inflammation and correction of conditions that cause and perpetuate it.

For many years, dental treatment planning could be described as authoritarian.

Although at present dentist are still influenced by this approach, the climate is rapidly changing.

Thus the treatment planning becomes a discussion rather than a plan devised, directed and dispensed by the dentist.

Notable attempts have been made to develop dental practice guidelines and protocols by specialty groups such as AAP

. Decision pathways.

provide direction in identifying the range of treatment options.

indicating some of the key decisions leading to appropriate treatment LIMITATION they tend to difficult for routine use, especially for experienced practitioner.

DECISION TREES

Decision trees represent a more sophisticated expansion on this aspect.

These not only have key decision nodes but also include research- based success rates for each of these treatment options.

SEQUENCE IN TREATMENT PLANNING

TREATMENT PLANNING INCLUDES

Teeth to be retained or extracted.

Pocket therapy techniques surgical or non surgical that will be used.

The need for occlusal correction before, during or after pocket therapy.

The need for temporary restorations.The use of implant

Final restorations that will be needed after therapy, and which teeth will be abutments if a fixed prosthesis is used.

The need for orthodontic consultations.Endodontic therapy.Decisions regarding esthetic considerations in periodontal therapy.

Sequence of therapy.

EXPLAINING TREATMENT PLAN TO THE PATIENT

Understandable terms Informed of the disease process, Treatment options & expected results, Potential adverse events or complications. The consequences of not having treatment should also be explained to the patient .

Be specific Begin your discussion on positive note Present the entire treatment plan as whole unit

UNREALISTIC WANTS OF PATIENT

Most often pt want to retain the hopelessly diseased teeth. But explain following reasons:

Periodontal disease is a microbial infection. Correcting the condition eliminates serious potential risk of systemic disease.

It is not feasible to place restorations or bridges on teeth with untreated periodontal condition.Periodontal disease also shortens the life span of other teeth.

TREATMNET PLANNING IN PERIODONTICS

Ramfjord (1953). This plan included four phases: 1) systemic, 2) hygienic, 3) corrective 4) maintenance or supportive care

LINDHE INTIAL CAUSE- RELATED THERAPY ADDITONAL THERAPEUTIC MEASURES SUPPORTIVE PERIODONTAL THERAPY

In every patient with periodontitis, a treatment strategy should includes the elimination of the opportunistic infection

The treatment goal may be specified:

No sites with PPD >5mm but preferable less than 4 mm

No furcations involvement of degreeII or III.

<10% of sites Bop

TREATMENT PLANNING

FERMIN CARRANZA, HENRY TAKEI

PHASES OF PERIOODNTAL THERAPY

CORRECT SEQUENCE OF PERIODONTAL TREATMENT

EXTRACTING OR PRESERVING THE TOOTH

PHASE I TREATMENT

SEQUENCE OF PROCEDURESSTEP 1 Limited plaque control instruction:STEP 2 Supragingival removal of calculusSTEP3 Recontouring defective restorations

and crownsSTEP 4 Obturation of carious lesionsSTEP 5 Comprehensive plaque control instructions

STEP 6 Subgingival root treatment.STEP 7 Tissue revaluation

ANTIMICROBIAL THERAPYSINGLE AGENT REGIMEN DOSAGE/DURATIONAMOXICILLIN 500 mg 3 times daily for 8 days

AZITHROMYCIN 500 mg Once daily for 4-7 days

CIPROFLOXACIN 500 mg Twice daily for 8 daysCLINDAMYCIN 300 mg 3times daily for 10 days

DOXYCYCLINE/MINOCYCLINE 100-200mg Once daily for 21 days

METRONIDAZOLE 500mg 3 times daily for 8 days

COMBINATION THERAPY REGIMEN DOSAGE / DURATION

METRONIDAZOLE+ AMOXICILLIN 250mg of each 3 times daily for 8 days

METRONIDAZOLE + CIPROFLOXACIN

500of each mg Twice daily for 8 days

OCCLUSAL THERAPY

STEP1 Remove retrusive prematurities and eliminate the deflective shift from retruded contact position to intercuspal.

STEP 2 Adjust ICP to achieve stable, simultaneous multipointed widely distributed contacts

STEP 3 Test for excessive contact on incisor teeth

STEP 4 Remove posteriors protrusive supra contacts and establish contacts that are bilateraly distributed on anterior teeth

Step 5 Remove or lessen mediotrusive interferences.

STEP 6 Remove excessive cusp steepness on laterotrusive contacts

STEP 7 Eliminate gross occlusal disharmoniesSTEP 8 recheck tooth contact relationshipSTEP 9 Polish all rough tooth surfaces

SPLINTING Mobility of teeth that is increasing and impairs pt comfort

Migration of teeth Prosthetics where multiple abutments are necessary

Excessive occlusal forces from parafunction or deflective tooth contacts are frequent causes of mobility. Than occlusal therapy is performed.

Any inflammation should be reduced before splinting.

REVALUATION AFTER PHASE I THERAPY

The assessment is generally made no less than 1 to 3 months as much as 9month s after therapy

REPROBE COBB in 1996

SURGEY VERSUS ROOT PLANING

Surgery is an options : To control or eliminate periodontal disease.

Correct anatomic conditions which favor periodontal disease, impair esthetics or obstruct placement of prosthetic appliances. To place implant to replace an missing teeth.

PERIODONTAL SURGERY

SELECTION OF SURGICAL PROCEDURES

PERIODONTAL SURGERY

DRUG INDUCED GINGIVAL ENLARGEMENT

PERIODONTAL SURGERY

NO CRATER

CRATER

SHALLOW

WIDEMOD/ DEEP WIDE

NARROW

POCKET ELIMINATION RESECTION

PRICHARD FILL

TECHNIQUE

GTR/ RESECTION

FURCATION

ROOT COVERAGE GINGIVAL RECESION

APICAL CORONAL COMBINATION

FGG, FCTG SCTG, SEMILUNAR GTR , CTG APICAL DISPLACED LATERAL POSITIONED EMDOGAIN CORONAL POSITINING PRP, PRF DOUBLE PAPILLA

INTER DENTAL PAPILLA RECONSTRUCTION

PREPROSTHETIC SURGERYCROWN LENGHTENING PROCEDURES Indications Excessive gingival display when

smiling Inadequate amount of tooth structure for proper restorations.

Subgingival location of fracture lines and carious lesions

RIDGE AUGMENTATION

IMPLANT THERAPY

ENDODONTIC THERAPYPrimary endodontic lesion = RCTPrimary periodontal lesion = PERIODONTAL THERAPY

Primary endodontic lesion with secondary periodontal involvement = RCT + PERIODONTAL THERAPY

Primary periodontal lesion with secondary endodontic involvement = RCT + PERIODONTAL THERAPY

True combined lesion =RCT+ PERIODONTAL THERAPY

RESTORATIVE THERAPY

BIOLOGIC WIDTH It is defined as the physiologic dimension of the junctional epithelium and connective tissue attachment. The measurement is approximately 2mm

GUIDELINES FOR PLACEMENT OF MARGINS

Rule 1) If the sulcus probes 1.5 mm or less, place the restoration margin 0.5 mm below the gingival tissue crest.

Rule 2) If the sulcus probes more than 1.5mm, place the margin half the depth of the sulcus below the tissue crest. This places the margin far enough below the tissue so that it will be covered when pt is at high risk of recession

Rule 3) If a sulcus is greater than sulcus. 2 mm is found esp on facial aspect gingivectomy should be done to lengthen the crown and create 1.5mm than pt can be treated using rule 1

SUPPORTIVE PERIODONTAL THERAPYAfter phase I therapy the pt is placed on a schedule of periodic recall visits for maintenance care to prevent recurrence of the disease.

The pt must understand the importance of the program.

The dentist must also emphasize the importance of the program

RATIONALE FOR SPT

SPT SCHEDULING

ERD 10-15 MIN

MRI 30-40 MIN

TRS

PFD 5- 10 MIN

SCHALHORN IN 1981

CLASSIFICATION OF POSTOPERATIVE TREATMENT PATIENTS

CUMULATIVE INTERCEPTIVE SUPPORTIVE THERAPY

TREATMENT OF PLANNING

CONCLUSION

An objective of the overall treatment plan is the creation and maintenance of oral health, function and esthetics. The outcome is thus long term. It requires coordination of several disciplines of dentistry. Apart from this a motivated patient is pre-requiste and overall success of this treatment plan will depend on this motivation

treatment planning in periodontics- dr harshavardhan patwal

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