Periodontics

Lec. 14
Treatment guide lines for patients
With periodontal disease PART 1

BY : Dr. Abdullah Amer

 Introduction

A treatment plan is a therapy plan formulated only

after a thorough examination has been completed,
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 a diagnosis and prognosis will
change with treatment, therapy needs may also change.
As such, the treatment plan must be changed accordingly.
 The treatment plan for patients with periodontal
disease include the following phases:
Phase I Phase II Phase III
• Initial
• Cause related
• Surgical therapy • Restorative therapy
• therapy
Non surgical therapy

Phase IV

• Maintenance therapy
The aim of the treatment plan is for total treatment, that is,
coordination of all the immediate, intermediate, and long-
term goals for the purpose of creating a well-functioning
dentition in a healthy periodontal environment.
The Immediate Goals

• Are the elimination of all infections and inflammatory processes that cause
periodontal and other oral problems that may hinder the patient’s general health.
The Intermediate Goals

• Is the reconstruction of a healthy dentition that not only fulfils all functional
and aesthetic requirements but lasts many years.
 The Long-term Goals
• Is maintenance of health through prevention and professional, supportive
therapy. The long-term goal is set, and both the patient and the clinician work
toward it from the very first visit.

•Maintenance of health requires

1. patient education on disease prevention
2. oral hygiene at the onset of treatment and meticulous daily home care by the
patient,
3. patient adherence to professional recall maintenance at a regular interval.
 The treatment plan involves decisions regarding the following:

-Emergency treatment (pain, acute infections).

-Removal of nonfunctional and diseased teeth, and possibly strategic extraction of healthy
teeth to facilitate the prosthetic reconstruction of the patient.
-Treatment of periodontal diseases (surgical or nonsurgical, regenerative or resective).
Endodontic therapy (necessary and intentional).
-Caries removal and placement of temporary and final restorations.
-Occlusal adjustment and orthodontic therapy.
-Replacement of missing teeth with removable or fixed dental prostheses or dental
implants.
-Aesthetic demands.
-Sequence of therapy.
Extracting or Preserving a Tooth
Tooth Removal, retention, or temporary(interim)retention
of one or more teeth is an important part of the overall
treatment plan. A tooth should be extracted under the
following conditions:
-It is so mobile that function becomes painful.

- It can cause acute abscesses during therapy.

- There is no use for it in the overall treatment plan

 In some cases, a tooth can be retained temporarily,
postponing the decision to extract until after
treatment is completed. A tooth in this category can be
retained under the following conditions:
• 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. The retention of this tooth should not
jeopardize the adjacent teeth. This approach avoids the
need for temporary appliances during therapy.
• Extraction of hopeless teeth can also be performed
during periodontal surgery of the adjacent teeth. This
approach reduces the number of appointments
needed for surgery in the same area.
Sequence of Therapy

The periodontal treatment sequence is presented

in the following figures. Immediately after
completion of phase I therapy, the patient should
be placed on the maintenance phase IV to preserve
the results obtained and prevent any further
deterioration and recurrence of the disease. While
in the maintenance phase, with its periodic
evaluation, the patient enters into the surgica
.phase II and the restorative phase III of treatment
Sequence For The Treatment of Periodontitis Stages I, II and III :
1. The first step in therapy is aimed at guiding behavior change by motivating the
patient to undertake successful removal of supragingival dental biofilm and risk
factor control and may include the following interventions:
•Supragingival dental biofilm control.

•Interventions to improve the effectiveness of oral hygiene

[motivation, instructions (oral hygiene instructions , OHI) ].

•Adjunctive therapies for gingival inflammation.

• Professional mechanical plaque removal
(PMPR), which includes the professional
intervention aim at removing supragingival
plaque and calculus, as well as possible
plaque-retentive factors that impair oral
hygiene practices.
• Risk factor control, which includes all the
health behavioural change interventions
eliminating/mitigating the recognized risk
factors for periodontitis onset
and progression (smoking cessation,
improved metabolic control of diabetes, ).
This first step of therapy should
be implemented in all periodontitis patients,
irrespective of the stage of their disease, and
should be re-evaluated frequently 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.
2.The second step of therapy (cause-related therapy)The aim of the second step of
therapy, cause-related therapy, is to control the etiology of periodontitis, leading
to a reduction in gingival inflammation, probing depth (PD) and an improvement in
biofilm and calculus control in the patient. This is accomplished by the physical
removal of the subgingival biofilm and subgingival calculus through the following
interventions:

• Use of Subgingival instrumentation.

• Use of adjunctive host-modulating agents (local or systemic)
• Use of adjunctive chemotherapeutic agents.
• Use of adjunctiveantimicrobial agents (local or systemic).
• This second step of therapy should be used for all periodontitis patients, irrespective
of their disease stage, only in teeth with loss of periodontal support and / or
periodontal pocket formation. such as for preventing periodontal abscess
development.
• The individual response to the second step of therapy should be assessed once the
periodontal tissues have healed (periodontal re-evaluation). If the endpoints of
therapy (no periodontal pockets >4 mm with bleeding on probing or no deep
periodontal pockets [≥6 mm]) have not been achieved, the third step of therapy
should be considered after 3 month. If the treatment has been successful in
achieving the endpoints of therapy, patients should be placed in a supportive
periodontal care (4th step) program.
3. The third step(surgical phase) of therapy Prior to initiating
the third step of periodontal therapy, patients should
demonstrate proper supragingival and subgingival biofilm
control as well as improved OH and risk factor control
following the first and second step of therapy. 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) to gain further
access to subgingival instrumentation, or aim at
regenerating or resecting those lesions that add
complexity in the management of periodontitis (intra-
bony and furcation lesions)
4. Supportive periodontal care (maintenance phase) is aimed at maintaining periodontal
stability in all treated periodontitis patients combining preventive and therapeutic
interventions defined in the first and second steps of therapy, depending on the gingival
and periodontal status of the patient's dentition. This step should include Reinforcement
of proper biofilm control through oral hygiene and modification if necessary • Assessment
and modification of risk factors for periodontitis (smoking cessation, evaluation of
glycemic control for diabetes) • Professional supragingiva land subgingival biofilm and
calculus control.
 Objectives of initial cause–related therapy(phase I or( 1st and 2nd step)) :

The objective is to alter or eliminate the microbial etiology and factors that
contribute to gingival and periodontal diseases to the greatest extent possible ,
thereby halting the progression of disease and returning the dentition to a state of
health and comfort . The phase I therapy aimed at removal of pathogenic biofilms,
toxins and calculus and the reestablishment of a biologically acceptable root
surface. This is accomplished by :
•Patient education and oral hygiene instruction for plaque or biofilm control.
•Complete removal of supragingival and subgingival plaque or biofilm and
calculus ( Scaling & root planing).
•Possible use of Antimicrobial agents (local or systemic).
• Correction or replacement of poorly fitting restorations and other prosthetic
devices.
• Restoration or temporization of carious lesions.
• Treatment of Occlusal trauma .
• Treatment of food impaction areas.
• Orthodontic tooth movement treatment.
• Extraction of hopeless teeth.
 Motivation
Steps of Motivation:
The patients must understand that they have a problem.

The problem has serious effect for the patient.

There is a solution to the problem.

The patient must participate in the solution.

Treatment will bring benefits for the patient.

•The problem and solution should be explained to the patient in simple language,
avoiding technical terms , so detailed information must be given to the patient
regarding his/her periodontal disease, its etiological factors, symptoms,
consequences, prognosis and the relationship between the presence of dental
biofilm and calculus in the mouth and the location of sites showing dental disease
by using plaque disclosing agents.
• Mechanical plaque control demands active • In addition, dental professionals
participation of the individual subject and the should try to emphasize on the role
establishment of proper oral homecare habits is a of the patient personal oral hygiene
process that depends on the behavioral changes, procedures in the prevention of
thus the patient's positive attitude to treatment dental diseases &they should
may have a positive long-term effect on his/her encourage the patient to take
tooth cleaning efforts. responsibility for his/her own oral
health.
• Finally , if the clinician can establish
the link between oral health &
general health for the patient, this
individual may be more willing to
establish proper hygiene measures
as part of his/her lifestyle.
 Disclosing agent
• Since dental plaque is white, sometimes it cannot easily
be identified, particularly if it is not thick enough and/or
the observer is not well trained. A disclosing agent is a
chemical compound (tablets or solution) that stains
• dental biofilm such as erythrosine, fuschsine or a
fluorescein. These agents should be used to demonstrate
the presence and location of plaque in addition to the
evaluation of the efficacy of the patient's homecare
• technique thus they should be applied after tooth
brushing and interdental cleaning.
THANK
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