If there is a single site in a quadrant that has pocket depth greater than 5 mm with symptoms of either bleeding or exudates, it may be feasible to utilize site-specific therapy,7 either surgical or chemotherapeutic. Stambaugh RV, Dragoo M, Smith DM, et al. Future aesthetic and restorative needs also should be determined during this first phase of treatment. In this manner, the necessary surgical treatment can be coordinated and planned. The effect of progressive tooth mobility on destructive periodontitis in the dog. If it is feasible to completely remove calculus present on the root and pocket depth and if symptoms remain decreased for a significant amount of time, site-specific therapy would be valuable. Schluger S, Yuodelis R, Page RC, et al. The goal of periodontal therapy is to provide an environment that the patient and professionals can maintain over a long-time period. If inadequate dentition is left to support function, then prosthetic and implant dentistry should be considered. The author wishes to thank Dr. Gordon Douglass for his help in preparation of the manuscript. 2001;72:1535-1544. When it does not achieve periodontal health, surgery may be indicated to restore periodontal health. Patients should also be provided with a written treatment plan and an estimate of costs. Informed consent should detail benefits, risks, other treatment options to be considered and what will happen if treatment is not carried out. By defining the cause of the patients disease, the therapist can determine how to control the factors that caused it. In patients with generalized severe attachment loss and mobility, it may be necessary to extend the posterior splint across the anterior to achieve cross-arch stabilization.9 Control of mobility can be determined by evaluating the provisional restoration. Deep infrabony defects were present throughout the dentition (Figure 7f). Philadelphia, Pa: Lea & Febiger; 1977:2. Older BSAC guidelines are still published in the British National Formulary (BNF), and medicolegally either is acceptable as the guidance and advice of a recognised and properly constituted expert group. J Clin Periodontol. Again, simpler, nonsurgical treatment options may be more appropriate for such patients. In occlusal disease, the bone loss initiates in the marrow cavities. Periodontal Disease: Basic Phenomena, Clinical Management, and Occlusal and Restorative Interrelationships. The next phase involved correcting the deformities the disease process caused, eg, periodontal surgery (resective and regenerative) and restorative dentistry (A-splinting and fixed bridgework). General risks are involved in any surgical procedure and should be discussed with the patient. With few exceptions, periodontal surgical procedures are elective in nature. The limits of subgingival scaling. Alcohol dependence will predispose to excess bleeding where liver function has been impaired. Treatment planning; Periodontology. The patient was followed for 10 years. An evaluation of the occlusion is made with respect to bidigital mobility, fremitus, mobility in function, tooth wear, and habits (center portion of Chart 1). The importance of education, therefore, cannot be overstated. Examine your mouth to look for plaque and tartar buildup and check for easy bleeding. To avoid errors, evaluation of a full series of radiographs is essential and should be coordinated with the clinical review. This is unfortunate since trauma from occlusion is one of the most significant contributing factors of periodontal disease and can lead to increased bone loss.8 Occlusal trauma has been shown to cause bone loss without pocket formation.9 In periodontitis, the bone loss initiates from the osseous crest inward. The best way to treat gum disease is to practise good oral hygiene, although additional dental and medical treatments are sometimes necessary. Periodontol 2000. The primary goal is to eliminate gingival inflammation and correction of conditions that cause and perpetuate it. Non-surgical periodontal treatment does have its limitations. 2. The beauty of … The diagnosis of periodontitis means that there has already been some bone loss, thus the therapist is not treating gingival disease. The aim of this chapter is to provide the reader with a philosophy for case selection and treatment planning in periodontal surgery. The disordered lifestyle led by some alcoholics may compromise the delivery of the planned regular care necessary for surgical success. a. inflammatory disease (plaque control, scaling, and root planing) b. occlusal disease (orthodontics, equilibration, splinting), 2. Gum disease treatments may cost between $500 and $10,000 . Non-Surgical Treatments The other key aspect of good surgical management is regular practice to guard against de-skilling. However, in the presence of inflammatory disease, it often leads to a more rapid progression of bone loss.10,11 This explains why a patient can have a rapid change in alveolar height or a patient with nonprogressive disease suddenly has significant bone loss. After the diagnosis and prognosis have been established, the treatment plan is chalked out. The loss of a single tooth no longer dictates full-coverage restorations on the adjacent teeth. A consultation with the restorative dentist, orthodontist, and periodontist permitted the team to develop the following treatment plan sequence: (1) scaling, root planing, and plaque control, a. orthodontics (retraction of the maxillary and mandibular anterior teeth), c. stabilization (splint teeth Nos. These guidelines have not, however, been universally accepted at the time of this book going to press. Int J Periodontics Restorative Dent. The World’s Top Dental Schools: 2018 Edition, Dentists Already Are Prepared for the Coronavirus, re-evaluate after initial visits to determine if additional root planing would eliminate surgical needs, orthodontic therapy, occlusal equilibration, night guard, inadequate periodontium/cannot withstand normal forces in the axial direction, orthodontic therapy, occlusal equilibration, improving the crown-to-root ratio, splinting, night guard, plaque control, root planing, site-specific Rx, surgical treatment, plaque control, root planing, surgical treatment, regenerative therapy, extraction and implants, Inflammatory Disease1. The effects of occlusal trauma are often overlooked or underestimated. All dentogingival manipulations for these patients require antibiotic cover. It is axiomatic that careful diagnosis and prescription of the right procedure are a sine qua non of surgical management. Leonardo’s drawing skills developed through his study of anatomy. Periodontal “gum” disease is typically a chronic infection caused by bacteria that works its way under the gum line, destroying the gum and eventually the bone that supports the teeth. The practitioner should be ready to appraise their own abilities and not undertake cases beyond their limits of competence; these may change throughout the course of their career. If pockets are small, sub-gingival scaling and root planning may be the only treatment required. All attempts should be made, therefore, to postpone surgery for medically compromised patients until such time as systemic complications are stabilised. This is often accomplished through non-surgical periodontal treatment. Today, as in the past, there is no substitute for accurate diagnosis and treatment planning. Periodontal considerations in restorative and implant therapy. To determine whether you have periodontitis and how severe it is, your dentist may: 1. Review your medical history to identify any factors that could be contributing to your symptoms, such as smoking or taking certain medications that cause dry mouth. Periodontal Case Rep. 1986;8:17-26. The development of a treatment plan for the patient with advanced periodontal disease can be imposing, but with proper sequencing, treatment planning need not be a complex process.1,2 In 1977 Saul Schluger,3 a founder of modern periodontology wrote, It is easy and attractive to adopt a single method to apply to all cases of periodontal disease, no matter how complex. J Periodontol. The treatment plan can then be communicated to the patient so the full scope of therapy is understood. In the United Kingdom, management of patients who require antibiotic prophylaxis for endocarditis has been greatly simplified through the introduction of new guidelines from the British Society of Antimicrobial Chemotherapy (BSAC) (Gould et al., 2006). Patient groups requiring antibiotic prophylaxis have been reduced to three: those with surgically constructed systemic or pulmonary shunts. The deepest areas in each of the 6 regions are recorded. 1981;1:30-41. The goal of these surgeries is to remove the pockets of space between the teeth and the bone that can be broken down or destroyed with periodontal disease. 1978;49:119-134. Splinting was required. Defining a treatment plan for the periodontal patient is a process that requires the assessment, preventive, therapeutic, and evaluative skills of the dental hygienist and the dentist. Score 3/4 – Root Planning or Root Surface Debridement and Oral Health instruction (over several visits to be effective) Don’t become a statistic. Thus, orthodontic therapy was required to close the spaces (Table 4). E.C. It is first necessary to evaluate functional needs, including inflammatory periodontal disease, occlusal factors, and restorative problems due to caries or failing restorations. Eskow RN, Wagenberg BD. Assessment of periodontal and restorative status is next. AFTER After aesthetic periodontal surgery the gums were positioned in a more pleasing position and contour. There was flaring of the maxillary and mandibular anterior teeth (Figure 7a). Long-term dental health and stability were achieved. It may be sensible to suggest other treatment approaches for these patients. 5. Clinical significance of non-surgical periodontal therapy: an evidenced-based perspective of scaling and root planing. A sequence of therapy was followed, which first involved controlling the factors that caused the disease, eg, inflammatory factors (root planing) and occlusal disease (orthodontics, equilibration, splinting). In addition, the patient exhibited a strong tongue thrust. Tooth movement was performed to close the diastema (Figure 7e). Before proceeding with therapy, it is equally important to assess the patients aesthetic concerns and expectations and incorporate them into the treatment plan. How to Prepare for the Procedure Equipment Needs. The question of when to extract a questionable or hopeless tooth often arises in patients with advanced periodontal disease. 4 to 13), Corrective Measures3a. 2002:29(suppl 2):6-16. Treatment plan in periodontics 6. Page  4 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. Intravenous sedation. Often a hopeless or questionable tooth can be retained until periodontal surgery when a final decision can be made, thus avoiding multiple surgeries for the patient. There is often controversy regarding the question of when to splint teeth. Once all of the data is collected, a diagnosis can be made that will define the necessary therapy. The Cost of Periodontal Disease Treatments: This post will help clarify and define the costs involved in available periodontal treatment options, including Regenerative Periodontal Endoscopy (RPE), Perioscopy, Osseous Periodontal Surgery, Extractions, Implants, traditional laser periodontal therapy, LANAP, and root planing combined with Arestin (antibiotics). 185 Twenty-three items taken from the periodontal examination generate a risk score for the patient that is used to develop a plan of prevention, adjust treatment plans, establish recall schedules, and evaluate outcomes of care. 10. Dental schools and dental hygiene schools: which may offer low-cost dental care Summary Original Medicare does not cover oral surgery that a person needs solely for dental health. The patient presented with moderate to advanced periodontal disease with secondary occlusal trauma in the anterior. Dentistry Today is The Nation's Leading Clinical News Magazine for Dentists. It is important first to make a diagnosis of all the disease entities contributing to the patients overall disease state. Nyman S, Lindhe J, Ericsson I. Diagnosis starts with a thorough examination of the patient. 5. Careful preoperative management and planning will often simplify surgery itself and allow a more predictable post-operative healing phase. Correct the deformities that the disease process has caused. The response to this series of root-planing visits depends on the quality of the tissue (Figures 2a and 2b). Periodontal surgery is both a science and an art. Simple orthodontic movement over a limited time (3 to 4 months) can result in improved axial alignment, correction of osseous defects, and improved crown-to-root ratios.12,13 As long as inflammation is controlled and orthodontic forces are not excessive, even teeth with ad-vanced bone loss can be moved.14 Another way to improve the crown-to-root ratio is to use bone regenerative therapy15 (Figures 5a and 5b). Scaling and Root Planing In severe cases, periodontal disease must be addressed with surgery. Periodontists are dentistry's e xperts in treating periodontal disease. Goldberg PV, Higginbottom FL, Wilson TG. Anyone who has had treatment for advanced periodontal disease knows that meticulous homecare is the key to keeping periodontal disease from rearing its ugly head – again. The effect of occlusal discrepancies on periodontitis. Once all diagnostic information is collected and evaluated and the treatment plan developed, the sequence of treatment can be finalized (Chart 2). This indicates trauma from occlusal interferences, and if it is left untreated, the mobility will likely increase. It is a part of … The periodontal surgeon should be both knowledgeable and ready to adapt their practice in line with the best research evidence. Having read this chapter the reader will be able to carefully plan a surgical case and identify potential pitfalls on a case-by-case basis. Implant dentistry should also be considered as a technique to break up long-span bridges if the adjacent teeth do not require stabilization. In the 45 to 60 minutes allocated for preventive treatment visits (PTV),* it is much easier to accomplish effective maintenance if there are a minimal number of pockets with depths greater than 5 mm. It is when these are not effective that they will suggest surgical intervention. 8. 1983;54:586-591. The treatment plan is the blueprint for case management. warfarinised patient with a high INR (international normalised ratio ≥ 3.5), significantly immunocompromised patients, e.g. 11. Next, the occlusal disease should be treated and stabilized. Waerhaug J. Healing of the dento-epithelial junction following subgingival plaque control. Since the introduction of implant dentistry by Professor P. I. Branmark, dentistry has had a predictable alternative for tooth replacement. Once the active disease processes are controlled and the patient is stable, the corrective therapy of periodontal surgery and final restorative dentistry can begin. restorative dentistry: A-splint teeth Nos. Gingiva can be edematous, fibrotic, or fibrous externally with the sulcus being ulcerated (Table 1). Periodontal disease affects the gingiva, alveolar bone and supporting tissues of the teeth. This will aid in the stability of the dentition, permit easier access to the teeth during surgery, and commit the patient to the desired endpoint early in treatment. Platelet levels below 60,000/ml of whole blood represent a risk for surgical intervention. Chart 2 delineates a sequence of treatment, which if followed will provide the therapist with an orderly treatment progression. Polson AM, Zander HA. Relationship of occlusal treatment to the progression of periodontal disease. The integration of procedures to meet these desires is essential to achieve an end result that satisfies everyone. b- After phase I therapy and before re-evaluation. Surgical skill comes through both didactic and observational learning, thorough experience and, to a lesser extent, the surgeon’s innate dexterity. Table 3 summarizes the therapy necessary for periodontitis of differing severities. 2. As discussed previously, the informed consent process is vital and should be well documented. They should be able to critically appraise this evidence in an objective manner. There are 2 aspects of developing a diagnostic plan: functional needs and aesthetic concerns. 3. Surgical management requires a marriage of both of these facets, if excellence is to be achieved. Oral hygiene Good oral hygiene involves: Radiographic evaluation demonstrated advanced bone loss in the anterior region with vertical bone lesions in the posterior region (Figures 7b, 7c, and 7d). Harrel SK, Nunn ME. a. periodontal surgery (flaps, osseous corrections, regenerative therapy) b. restortive dentistry (full-coverage restorations, splinting, aesthetics). All incisions for periodontal surgery are best accomplished with a number 15 or 11 scalpel blade. All areas exhibited a healthy periodontium with stability of all areas of the dentition. A diagnosis of secondary occlusal trauma was made with respect to the anterior segments (inadequate attachment to withstand normal forces). The standardised evidence-based protocols described will help to enhance the operator’s existing surgical preparation, irrespective of the type of surgery planned. The IV route is the most effective method of conscious sedation. secondary occlusal trauma, 2. occlusal therapy — orthodontics (retraction), equilibration, stabilization (teeth Nos. *PTV is used to replace a recall or maintenance visit. 1. If pockets are greater than 4 mm and the tissues are edematous, it is possible initially to decrease the pocket depth after the first root-planing visit, thus making more complete calculus removal feasible during subsequent visits. By taking a comprehensive, multidisciplinary approach, our chances of success are improved. If the problem cannot be relieved by occlusal equilibration, then other therapies such as orthodontics or restorative dentistry should be considered. 3-Dec-13 Q. This article will focus on inflammatory disease, periodontitis (slight, moderate, and severe), and occlusal trauma (primary and secondary). Careful occlusal equilibration will often eliminate the interferences and alleviate this problem. The whole procedure may be done in a single visit, although generally a quadrant (1/4th of the mouth) or half of the mouth is recommended per appointment. The surgical therapy may include both crown lengthening (to expose tooth structure, provide adequate biologic width, and even gingival margins) and gingival grafting (to decrease gingival recession and increase keratinized gingival tissues). 4 to 13. Under common law, a conscious and competent patient needs to provide verbal consent to any operative procedure, although where sedation or deeper anaesthesia is employed, written consent is mandatory. This should be communicated to the client prior to performing surgery. Performed when the bone supporting your teeth has been destroyed, this procedure stimulates bone and gum tissue growth. Addiction poses particular problems in the management of surgical patients. Treatment objectives for predictable surgical management will be detailed alongside the principles common to different surgical procedures. However, if uneven patterns of bone loss or calculus cannot be removed, chemotherapeutic therapy would not be indicated. Cobb CM. 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