Treatment Planning for Periodontal Patients WLAC DH 308 Lecture

Treatment Planning for the Periodontal Patient WLAC DH 308 1  Introduction  Defining a treatment plan for the patient with periodontal disease is a process that requires assessment, preventive, therapeutic, and evaluative skills of the dental...

Treatment Planning for the Periodontal Patient WLAC DH 308 1  Introduction  Defining a treatment plan for the patient with periodontal disease is a process that requires assessment, preventive, therapeutic, and evaluative skills of the dental hygienist and dentist.  The treatment plan is the blueprint for the management of the dental patient and is an essential aspect of successful therapy. 2  Goals of Treatment  Treatment plan: defines the methods and sequence of delivering appropriate treatment.  Dental hygiene treatment plan: consists of services that are performed by the dental hygienist within the total treatment plan.  Treatment planning occurs after the assessment of all clinical data is complete and reflects the diagnosis and the prognosis of the patient. 3  Goals of Treatment  Goals of the treatment plan:  eliminate and control the etiologic and predisposing factors of disease  maintain health  prevent the recurrence of disease.  The problems and the treatment goals must be explained to the patient in understandable terms.  The patient’s perceived needs, as well as the disease identified by the clinician, need to be addressed. 4  Phases of Treatment  Treatment sequence  preliminary phase: addresses the immediate treatment needs of the patient such as extractions or endodontic treatment.  Preliminary phase is followed by:  Phase I–etiologic treatment  Phase II–surgical treatment  Phase III–restorative treatment  Phase IV–maintenance treatment 5  Phases of Treatment  Purpose of the preliminary phase  bring all emergency and other critical situations under control.  Phase I therapy is the etiologic phase of treatment and includes the procedures that control or eliminate the etiologic factors of the disease process.  Providing patient education and plaque control instruction  Scaling and root planing  Administering antimicrobial agents  Periodontal re-evaluation 6  Phases of Treatment  Phase II therapy: surgical phase of treatment and includes the procedures that reduce the effects of disease.  Gingival augmentation therapy  Regenerative therapy  Bone graft  Tissue graft  Resective therapy  Flaps with or without osseous surgery  Gingivectomy 7  Phases of Treatment  Phase III therapy: restorative phase of treatment and involves the restoration and replacement of missing teeth.  Providing restorative dentistry, orthodontics, or any needed occlusal therapy 8  Phases of Treatment (Cont.)  Phase IV therapy: Periodontal Supportive Therapy  Patients remain in this phase for a lifetime.  The accepted term for phase IV therapy  periodontal maintenance / periodontal recare/recall.  Sub and supragingival plaque and calculus removal  Selective SRP (sites >5mm with BOP) 9  Phases of Treatment (Cont.)  Phase IV therapy: Periodontal Supportive Therapy.  The periodontal condition and the plaque control that the patient is able to attain and maintain determine the interval of maintenance visits.  Most patients who have been treated for Stage II, III, or IV periodontal disease require maintenance visits every 3 months. 10 10 weeks after 11  Role of the Dental Hygienist  The dental hygienist is often responsible for the treatment of the patient with periodontal disease in phases I and IV. 12 Role of the Dental Hygienist 13 Role of the Dental Hygienist 14 Role of the Dental Hygienist 15  Role of the Dental Hygienist  Disease classifications are useful for diagnosis, prognosis, and treatment planning.  Various periodontal classification systems have been used over the years and have been modified to reflect advances in knowledge and research.  A classification system  method for comparing treatment approaches and the likely results. 16  Role of the Dental Hygienist  The American Academy of Periodontology (AAP) approved a classification system that is based on the clinical manifestations of diseases and conditions.  This system separates gingival diseases from the periodontal diseases and conditions that affect the periodontium. 17  Role of the Dental Hygienist  Early AAP classification system (before 1999)  The case type classification system includes:  Case Type I–Gingivitis  Case Type II–Slight Chronic Periodontitis  Case Type III–Moderate Chronic or Aggressive Periodontitis  Case Type IV–Advanced Chronic or Aggressive Periodontitis  Case Type V–Refractory Chronic or Aggressive Periodontitis  Current periodontal and peri-implant diseases and conditions classification system*  Gingival disease  Periodontal disease  Conditions affecting the periodontium 18  Role of the Dental Hygienist  Severity of disease is described in terms of clinical attachment loss (CAL):  Review the current World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions.  The workshop was co-sponsored by the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) and included expert participants from all over the world. 19  Role of the Dental Hygienist (Cont.)  Disease is also characterized as generalized or localized, depending on the extent of the dentition that is affected.  How many appointments needed to treat a patient?  the severity of disease  the extent of disease  the amount of calculus  the patient education process 20  Role of the Dental Hygienist (Cont.)  Patient education to attain plaque biofilm control is a critical element of treatment and is often the responsibility of the dental hygienist.  Plaque control and prevention instruction makes a significant difference in the overall success of periodontal treatment.  The patient education process continues throughout the treatment sessions and during all phases of care.  Reinforcement at all recare appointments 21  Treatment Planning for Periodontal Disease  The systemic and periodontal condition of the patient dictates how the dental hygienist sequences either a single session or a series of nonsurgical treatment sessions.  The patient may have systemic conditions that alter the number and length of treatment appointments.  Patients with physical or mental disabilities can also present challenges that require a modification of the treatment plans. 22  Treatment Planning for Periodontal Disease (Cont.)  Currently accepted scaling technique  completely scale a sextant, quadrant, or more teeth during a single session.  Practice often requires local anesthesia  Patient comfort  The immediate goal of each session of instrumentation is the complete removal of all adherent bacterial plaque biofilm and calculus deposits. 23  Prognosis  Prediction of probable disease  Course  Duration  Outcome  Determined upon diagnosis 24  Prognosis  Individual tooth  CAL  PD  BOP  Type of bone loss  Furcation  Mobility  Fremitus  Widening of PDL  Crown-to-root ratio 25  Prognosis  Excellent  Good  Fair  Poor  Questionable  Hopeless 26  Prognosis  Excellent  No bone loss  Excellent tissue condition  Good patient compliance  Excellent OH  No systemic or risk factors 27  Prognosis  Good  Adequate periodontal support  Easy maintenance  Patient compliance 28  Prognosis  Fair  25-40% attachment loss  Class I furcation  Adequate maintenance possible  Acceptable patient cooperation  Limited systemic or risk factors 29  Prognosis  Poor  40-50% attachment loss  Class I or II furcation  Mobility  Difficult to maintain areas  Doubtful patient cooperation  Systemic or risk factors 30  Prognosis  Questionable  Advanced bone loss  Mobility  Class II or III furcation  Poor crown-to-root ratio  Systemic or risk factors 31  Prognosis  Hopeless  Advanced bone loss  Non-maintained areas  Class III mobility  Class III furcation  Recurrent abscesses  Uncontrolled risk factors 32  Treatment Planning in Dental Hygiene  The dental hygiene care plan is an individualized approach to treatment that details the care to be provided by the dental hygienist.  The plan is adapted to the needs of the patient and is presented in an orderly sequence to allow for thoroughness in completing each procedure. 33  Treatment Planning in Dental Hygiene  Determining the débridement sequence(s) is influenced by a number of factors  location and extent of infection  the presence of pain  medical or physical limitations of the patient.  All aspects of the patient’s condition must be considered in choosing which area to begin treatment, the length of the appointment time, and homecare recommendations. 34  Treatment Planning in Dental Hygiene  The patient with periodontal disease requires a follow-up visit to evaluate the response of the tissues to the scaling and débridement procedures.  This appointment is often called the periodontal re-evaluation  Tissue healing and the patient’s progress toward effective plaque control can be observed and evaluated approximately 4-6 weeks after débridement.  Pockets will re-epithelialize in approximately 1 week, but connective tissue healing will not 35  Treatment Planning in Dental Hygiene  At the re-evaluation appointment, the dental hygienist assesses and determines the appropriate interval for periodontal maintenance.  Assess and reinforce OHI  In many practices, the re-evaluation visit is also the logical and convenient time for the periodontist or dentist to examine the patient and initiate the next step in the total treatment plan. 36  Treatment Planning in Dental Hygiene  Treatment planning is considered part of the dental hygiene process of care.  The components of dental hygiene care are divided into five categories: assessment, diagnosis, planning, implementation, and evaluation.  Treatment planning incorporates both assessment and diagnosis in defining a set of procedures to restore the patient to a state of health. 37  Treatment Planning in Dental Hygiene  The treatment plan is the guideline for the management of comprehensive care and is an essential part of successful therapy for every dental patient. 38