Diagnosis and Treatment
Planning-II
Dr Kanisha Handapangoda
Department of Oral Medicine and
Periodontology
Learning Objectives
1. Learn the importance of prognosis
2. Draw a treatment plan based on diagnosis and information from
patient’s records
Prognosis
The expected outcome of the disease in general and the likelihood of maintaining a
tooth or achieving stability with treatment
It is an estimate of how a tooth or the overall dentition will respond to periodontal
therapy over time
A situation of uncertainty as it depends on
1. Patient’s compliance with management
2. Biological response of tissues for treatment
Prognostic categories
Good/ favorable, Questionable, Poor
Formulating the treatment plan/ care plan
for periodontitis patient (Stage I-III)
(According to the EFP S3-level clinical practice
guideline)
Step 1
1. Supragingival plaque control by patient
a. Patient education :explain the disease, risk factors, treatment alternatives and risk,
benefits
b. Modification of oral hygiene practices
Explain importance of oral hygiene, encourage and support for behavior change ,
individually tailored OHI and introduction of ICDs, adjunct mouth washes,
dentrifices
2. Professional supragingival plaque control
a. Professional mechanical plaque removal (PMPR)
b. Control of plaque retentive factors
3. Risk factor control
a. Tobacco smoking cessation interventions
b. Diabetes control interventions
c. Control of other identified risk factors
• Aim: Guiding behaviour change by motivating the patient to undertake
• Successful removal of supragingival dental biofilm
• Risk factor control
• Should be implemented in all periodontitis patients, irrespective of the stage of
their disease
• Frequent re-evaluation in order to
• Continue to build motivation and adherence, or explore other alternatives to overcome the
barriers
• Develop skills in dental biofilm removal and modify as required
• Allow for the appropriate response of the ensuing steps of therapy
Step 2
Subgingival instrumentation (PMPR on root/ RSD)
a. Treat periodontitis with reduction of pocket depths, gingival inflammation and the number of diseased sites.
b. Performed with hand or powered (sonic/ultrasonic) instruments, either alone or in combination
c. Can be performed with either traditional quadrant-wise or full mouth delivery within 24 hours
• Routine use of adjunctive antiseptics /antibiotics (local or systemic) to subgingival instrumentation
not recommended
• Chlorhexidine mouth rinses for a limited period of time & locally administered sustained-release
chlorhexidine may be considered as adjuncts to subgingival instrumentation
• Specific locally administered sustained-release antibiotics may be considered as an adjunct to
subgingival instrumentation
• The adjunctive use of specific systemic antibiotics may be considered for specific patient
categories(e.g. generalized stage III periodontitis in young adults
• Use of adjunctive physical agents to subgingival instrumentation not recommended
a. Lasers subgingival instrumentation
b. Adjunctive photo-dynamic therapy at wavelength ranges of either 660-670 nm or 800-900 nm
• Use of adjunctive host-modulating agents (local or systemic) to subgingival
instrumentation
• Administration of statin gels / systemic or local bisphosphonates / systemic or local
nonsteroidal anti-inflammatory drug / omega-3 polyunsaturated fatty acids and metformin gel
are not recommended to be added to subgingival instrumentation not recommended
• Systemic administration of sub-antimicrobial dose doxycycline is not suggested
• Probiotics are not suggested
Aim:
• Controlling (reducing/eliminating) the subgingival biofilm and calculus (subgingival
instrumentation) with possible removal of root surface (cementum)
• It should be implemented in all periodontitis patients, irrespective of the stage of
their disease and it should be re-evaluated after an adequate healing period
Recall
• No periodontal pockets ≥ 5 mm with bleeding on probing
• No deep pockets [≥ 6 mm]
• If these endpoints are achieved, the patient should join a SPC program
Step 3
• If periodontal pockets > 4 mm with bleeding on probing and/or deep pockets [≥ 6
mm] are still present at re-evaluation, different options for step 3 can be
considered
• Repeated subgingival instrumentation with or without adjunctive therapies
• Access flap periodontal surgery
• Resective periodontal surgery
• Regenerative periodontal surgery
Aim:
• Treating those sites noT responding adequately to the second step of therapy
• Purpose is to get access to deep pocket sites, regeneration or resection of those lesions, that add
complexity in the management of periodontitis (infrabony and furcation lesions).
vModerately deep residual pockets (4-5 mm): repeated non-surgical subgingival
instrumentation
vDeep residual pockets (PPD ≥ 6 mm)
• Access flap surgery: Different flap designs can be used
• Resective/ pocket elimination periodontal surgery (potential increase of
gingival recession)
vIntra-bony defects (residual deep pockets associated with intrabony defects
3 mm or deeper)
• Periodontal regenerative surgery
vFurcation lesions
• Molars with Class II and III furcation involvement and residual pockets : Non-
surgical periodontal therapy, OFD, periodontal regeneration, root
separation or root resection
• Furcation involvement is no reason for extraction
• Surgery should be performed by dentists with additional specific training or by
specialists
• Adequate first and second steps of treatment should be performed
• Surgery should not be perfomed in patients not achieving adequate levels of self-
performed oral hygiene
Recall
• No periodontal pockets ≥ 5 mm with bleeding on probing
• No deep pockets [≥ 6 mm]
• If these endpoints are achieved, the patient should join a SPC program
Step 4
Supportive periodontal care
