Jan Lindhe. Clinical Periodontology

Подождите немного. Документ загружается.

TREATMENT PLANNING • 415

Fig. 19-1a-e. Clinical illustration of the basic periodontal examination scores. (a)

BPE

score O. (b)

BPE

score 1. (c)

BPE

score 2. (d)

BPE

score 3. (e)

BPE

score 4.

can be properly evaluated. The patient's ability to

cooperate in the overall therapy must determine the

content of the corrective treatment. If this ability is

failing or lacking, it may at times not be worth initiat-

ing treatment procedures which only in the fully co-

operative patient will permanently improve oral es-

thetics and function. The validity of this statement can

be exemplified by the results of studies aimed at as-

sessing the relative value of different types of surgical

methods in the treatment of periodontal disease. Thus,

a number of clinical trials (Lindhe & Nyman 1975,

Nyman et al. 1975, 1977, Rosling et al. 1976a,b, Nyman

& Lindhe 1979) have demonstrated that gingivectomy

and flap procedures performed in patients with

proper plaque control levels often result in gain of

alveolar bone and clinical attachment, while surgery

in plaque-contaminated dentitions may cause addi-

tional destruction of the periodontium.

Supportive periodontal therapy (SPT)

The aim of this treatment is the prevention of disease

recurrence. For each individual patient a recall system

must be designed which includes (1) self-performed

but professionally monitored plaque control pro-

grams, (2) scaling and root planing measures, (3) fluo

ride application, etc. In addition, this treatment in-

volves the regular control of fillings and other resto-

rations made during the corrective phase of therapy.

SCREENING FOR PERIODONTAL

DISEASE

A patient seeking dental care is usually screened for

the presence of carious lesions by means of clinical

probing and bitewing radiographs. Likewise it is im-

416 • CHAPTER

perative that such a patient is screened for the pres-

ence of periodontitis using a basic procedure termed

basic periodontal examination (BPE) (or periodontal

screening record (PSR)).

Basic periodontal examination (BPE)

The goal of the BPE is to screen the periodontal con-

dition of a new patient and to facilitate treatment

planning. BPE scoring will allow the therapist to iden

tify:

A patient with reasonably healthy periodontal con-

ditions, but in need of long term preventive meas-

ures

A patient with periodontitis and in need of peri-

odontal therapy.

In the BPE screening each tooth or implant is evalu-

ated. A thin graduated periodontal probe is recom-

mended and applied to at least two sites (mesio-buccal

and disto-buccal) of the teeth or implants. Each den-

tate sextant within the dentition is given a BPE score,

whereby the

highest

individual site score is used.

BPE scoring system

Score 0 = PPD 3 mm, BoP negative, no calculus or

overhanging fillings (Fig. 19-la)

Score 1 = PPD 5 3 mm, BoP positive, but no calculus

or overhanging fillings (Fig. 19-lb)

Score 2 = PPD 3 mm, BoP positive, presence of supra

and/or subgingival calculus and/or overhanging

fillings (Fig. 19-1c)

Score 3 = PPD > 3 mm but 5 mm, BoP positive (Fig.

19-1d)

Score 4 = PPD > 5 mm (Fig. 19-le).

If an examiner identifies one single site with a PPD >

5 mm within a sextant, the sextant will receive a score

of 4, and no further assessment needs to be made in

this particular sextant. Patients with sextants scored 0,

1 or 2 belong to the relatively healthy category. A

patient that exhibits a sextant scoring 3 or 4 must

undergo a more comprehensive periodontal examina-

tion (for details see Chapter 18).

The aim of the present text is to explain the overall

objectives of the treatment planning for patients with

BPE scores of 3 and 4 and who therefore have under-

gone a comprehensive diagnostic process.

DIAGNOSIS

The basis for the treatment planning described in this

chapter is established by the clinical data collected

from the examination of the patient presented in

Chapter 18. This particular patient (U.N., male, 55

years of age) was examined with respect to his peri-

odontal conditions, i.e. gingival sites displaying signs

of bleeding on probing

were identified,

pocket depths

and

furcation involvements

were measured and graded,

tooth mobility

was assessed and the radiographs were

analyzed to determine the

height

and

outline

of the

alveolar bone crest.

The clinical characteristics of the dentition of this

patient are shown in Fig. 19-2a-c. The periodontal

chart and the radiographs are presented in Fig. 19-

3a,b. Based on the findings, each tooth in the dentition

was given a proper periodontal diagnosis (Fig. 19-3b).

In addition to the examination of the periodontal con-

dition, detailed assessments of primary and recurrent

caries were made for all tooth surfaces in the dentition.

Furthermore, the patient was also examined with re-

spect to endodontic problems, occlusal problems,

temporomandibular joint dysfunction etc.

The present patient had secondary caries lesions

adjacent to several restorations, particularly in the

molar regions (Fig. 19-2b), and root caries in the distal

surface of 25 and mesial surface of 26 (Fig. 19-3a). It

should be observed that in a patient with a large

number of caries lesions an additional number of

examination procedures, e.g. assessments of secretion

rate and buffering capacity of the saliva, number of

lactobacilli and

Streptococcus mu tans

etc., will facilitate

the selection of proper therapeutic measures. In addi-

tion, a periapical lesion was observed in 47 and several

defective root fillings were identified (Fig. 19-3a).

TREATMENT PLANNING

Initial treatment plan

Not until a detailed diagnosis of all pathologic condi-

tions has been made, have proper prerequisites been

established for an appropriate tentative treatment

plan. At this early stage in the management of a pa-

tient, it is in most instances impossible to make defi-

nite decisions regarding all aspects of the corrective

therapy, because:

1. The degree of success of the initial treatment remains

unknown:

the result of the initial cause-related treat

ment of an individual case forms the basis for the

selection of means for additional therapy. The de-

gree of disease elimination that can be reached

depends on the outcome of subgingival scaling and

root planing, but also on the patient's ability to

adopt adequate dietary habits and to exercise

proper plaque control techniques.

2. The patient's "subjective" need for treatment is not

known:

when the dentist has completed the exami-

nation of the patient and an inventory has been

made regarding, for example, periodontal disease,

caries, pulpal disease and temporomandibular

joint disease, the observations are presented — "the

case presentation" — for the patient. During the case

presentation session it is important to find out if the

patient's subjective need for dental therapy coin-

TREATMENT PLANNING • 4

Fig. 19-2a-c. Clinical status of a 55-year-old male patient (U.N.) with periodontitis.

Fig. 19-3a. Radiographs relating to patient U.N. described in Fig. 19-2.

cides with the dentist's professional appreciation of

the kind and volume of therapy that is required.

It is

important that the dentist understands that the

main

objective of dental therapy, besides

elimination of

pain, is to satisfy the patient's demands regarding

esthetics and chewing function (comfort),

demands

which certainly vary considerably from one indi-

vidual to another.

3. The result of certain parts of the treatment cannot be

predicted:

in patients exhibiting advanced forms of

caries and periodontal disease it is often impossible

to anticipate if all teeth which are present at the

initial examination can be successfully treated, or

predict the result of certain parts of the intended

therapy. In other words, critical and difficult parts

of the treatment must be performed first, and the

outcome of this treatment must be evaluated before

all aspects of the definitive corrective treatment can

be properly anticipated and described.

Single tooth risk assessment

Based on the result of the comprehensive examination

(

including assessments of periodontitis, caries and the

endodontal status) and the resulting diagnosis, as well

as considering the patient's needs regarding esthetics

and function, a pre-therapeutic risk assessment is

made for all teeth (roots) present.

Three major questions are addressed:

Which tooth/root has

a good

prognosis?

Which tooth/root is

"irrational-to-treat"?

Which tooth/root has

a questionable

prognosis?

418 • CHAPTER 19

Fig. 19-3b. Periodontal chart relating to patient U.N.

(Fig. 19-2).

Teeth with

a good

prognosis will require a relatively

simple therapy and may be regarded as secure abut-

ments for function.

Teeth which are considered "irrational-to-treat"

should be extracted during initial, cause-related ther-

apy. Such teeth may be identified on the basis of the

following criteria:

Periodontal

•

Recurrent periodontal abscesses

•

Periodontic-endodontic lesions

•

Attachment loss to the apex

Endodontal

•

Root perforation in the apical half of the root

•

Periapical pathology in the presence of obturating

post and core

Dental

•

Long fracture of the root

•

Oblique fracture in the middle third of the root

•

Caries lesions that extend into the root canal

Functional

•

Third molars without antagonists and with perio-

dontitis/caries

Teeth with a

questionable

prognosis are in need of

comprehensive therapy and must be brought into the

category of teeth that have a

good

prognosis. Such teeth

may be identified on the basis of the following critera:

Periodontal

•

Furcation involvement

•

Angular bone defects

•

"Horizontal" bone loss involving > two-thirds of

the root

Endodontal

•

Incomplete root canal therapy

•

Periapical pathology

•

Presence of voluminous posts/screws

Dental

•

Extensive root caries

Case presentation

The "Case presentation" is an essential component of

the initial treatment and must include a description

for the patient of different therapeutic goals. At the

case presentation for Mr. U.N. the following treatment

plan was described:

•

The teeth in the dentition from 15 to 24 and from 45

to 35 probably will not present the dentist with any

major therapeutic challenges. For the remaining

teeth in the dentition, however, the treatment may

involve several complicated or unpredictable meas-

ures.

Based on the pre-therapeutic risk assessment (Fig.

19-4), the following scenario was presented to the

patient:

•

and

47 extraction: cannot be treated due to the

advanced loss of supporting tissue at the buccal

aspect of the teeth in combination with deep furca-

tion involvements and periapical periodontitis as

far as 47 is concerned (Fig. 19-3).

•

16 extraction: even if it is possible, from a

therapeu

tic point of view, to preserve the palatal

root, the

maintenance of this root does not improve

esthetics

or chewing comfort; the tooth has no

antagonist

after extraction of 47 (Fig. 19-3).

• 25 and

27 extraction: 25 cannot be treated due to

advanced root caries in combination with advanced

loss of periodontal tissue support at the distal aspect

of the tooth; 27 has a periodontal pocket communi

cating with periapical lesions in combination with

furcation involvement of degree 3 (Fig. 19-3).

•

26, 36

and

37 present a number of therapeutic

prob

lems:

26 shows signs of deep and extended root caries

TREATMENT PLANNING • 419

16 15 14 13 12

21 22 23 24 25 26 27

Good prognosis

+ + + + + + + + +

Questionable prognosis

Irrational-to-treat

+ + +

48 47 45 44 43 42

31 32 33 34 35 36 37

Good prognosis

+ + + + + + + + + +

Questionable prognosis

+ +

Irrational-to-treat

+ +

Fig. 19-4. Outcome of the pre-therapeutic risk assessment made for patient U.N. described in Fig. 19-2.

in the mesiobuccal root in combination with furca-

tion involvement of degree 2 m,b,d (Figs. 19-2c &

19-3). Note the unfavorable root- and root canal

anatomy of the buccal roots; predictable endodontic

treatment? The palatal root of 26 can, however, be

maintained.

In 36 there is a deep angular bony defect at the

mesial aspect and furcation involvements of degree

2 at both the buccal and lingual surface; 37 has a

deep infrabony pocket at the distal surface (10 mm,

see the periodontal chart) and furcation involve-

ment of degree 2 b. The distal root of 36 or the mesial

root of 37 (or both) are available for treatment.

Two different

alternatives for treatment

were presented

to the patient:

• Alternative 1.

Extraction of 25 and all molars and

the

maintenance of a dentition comprising 15-24

and 45-35. This alternative may be adequate with

spect to "chewing comfort" but may be question-

able from an esthetic point of view.

• Alternative 2.

Extraction of the molars in the right

side of the maxilla and mandible (16, 48, 47) and also

of 25 and 27; root separation of 26 with the mainte

nance of the palatal root to be used as abutment for

a 3-unit bridge to replace the extracted 25; root

separation of one of the molars 36 or 37 with the

maintenance of one root to be used as abutment for

a 3-unit bridge to obtain occlusal contact with the

maxillary bridge.

It should be observed that

alternative 2

involves a

considerably larger volume of therapy than

alternative

In a situation like this, expected benefits inherent in

certain treatment versus obvious disadvantages

should always be explained to and discussed with the

patient. His/her attitude to the alternatives presented

must guide the dentist in the design of a proper plan

for the overall treatment. In the present case the pa-

tient preferred the treatment described as

alternative 2.

INITIAL (CAUSE-RELATED)

THERAPY

The treatment was initiated and included the follow-

ing measures to eliminate or control the plaque infec-

tion:

1. Instruction

in oral hygiene measures with sub-

sequent check-ups and reinstruction.

2. Scaling and root planing

in combination with re-

moval of retention factors for plaque.

3. Excavation and restoration

of carious lesions.

4. Endodontic treatment 26

(palatal root) and 37 (mesial

root). Endodontic treatment was carried out at an

early stage to allow a proper evaluation of healing

before the restorative treatment was initiated.

5. Extraction

of 16, 48, 47. Temporary prosthetic re-

placement (for esthetic and functional reasons) of

teeth which, during this initial phase of the treat-

ment, have to be extracted should preferably be

made in the form of removable partial dentures.

The use of a removable prosthesis allows the den-

tist to eventually choose between a removable par-

tial denture and a fixed bridge as permanent pros-

thetic therapy. If, on the other hand, the temporary

prosthetic reconstruction is made in the form of a

fixed bridge, the permanent prosthetic therapy

must inevitably include fixed bridgework. Such an

alternative may, however, during the course of

treatment appear to be contraindicated. In the pre-

sent case a temporary prosthesis was not made.

RE-EVALUATION

The initial phase of therapy is terminated with a thor-

ough analysis of the results obtained with respect to

the elimination or degree of control of the dental

infections. This implies that a re-evaluation of the

patient's caries activity must be performed as well as

new assessments of gingival conditions, pocket

depths, tooth mobility, etc. The result of this re-evalu

ation forms the basis for the selection, if necessary, of

additional or corrective measures which are to be

performed in the phase of definitive treatment.

420 • CHAPTER

Fig. 19-5a-c. Clinical status of patient U.N. after periodontal and restorative treatment. Compare with Fig. 19-2.

Fig. 19-6. Radiographs of patient U.N. after periodontal and restorative treatment. Compare with Fig. 19-3a.

Planning of additional therapy (definitive

treatment plan)

If the results from the re-evaluation, made 1-2 months

after the termination of the initial treatment phase,

show that caries and periodontal disease have been

brought under control, the additional treatment may

be carried out in the following sequence:

Extraction

of teeth that cannot be maintained. If

such extractions include teeth which must be re-

placed for esthetic or functional reasons, a tempo-

rary removable partial denture or a temporary

fixed bridge must be inserted.

2. Additional endodontic treatment

3. Periodontal surgery:

The type and extent of surgical

treatment should be based on probing depth, and

bleeding on probing" measurements should be

made at re-evaluation. Periodontal surgery is often

limited to those areas of the dentition where the

inflammatory lesions were not resolved by scaling

and root planing and in areas where furcation in-

volvements persist.

4. Installation of dental implants:

In regions of the den-

tition where tooth abutments are missing, implant

TREATMENT PLANNING • 421

Fig. 19-8. Radiographs of patient U.N. obtained 11 years after treatment.

Fig. 19-9. Flow chart describing

the sequence of delivery of vari-

ous treatment procedures in the

overall therapy.

422 • CHAPTER

therapy for esthetic and functional reasons may be

considered. It is essential to realize that implant

therapy must be initiated first when dental infec-

tions are under control, i.e. after successful peri-

odontal therapy.

Definitive restorative and prosthetic treatment

including

permanent restorative therapy (crown and

bridge,

removable partial dentures, etc.).

ADDITIONAL (CORRECTIVE)

THERAPY

The present patient exhibited, after initial therapy, low

plaque and gingivitis scores (5-10%) and no active

carious lesions. The corrective treatment therefore in-

cluded the following components:

Periodontal surgery

at sites which bled on probing

and with probing depths > 4 mm.

Root separation

37 and extraction of the distal root.

Root separation

26 and extraction of the buccal roots.

Extraction

36, 25 and 27.

4. Preparation and installation of

fixed bridges

24, 25,

26 (palatal root) and 35, 36, 37 (mesial root).

The result of the overall treatment is shown in Figs.

19-5a-c & 19-6.

SUPPORTIVE PERIODONTAL

THERAPY

Following completion of initial,

cause-related and addi-

tional therapy

the patient must be enrolled in a recall

system which aims to prevent the recurrence of dis-

ease. The time interval between the recall appoint-

ments must be related to the ability of the patient to

maintain a proper oral hygiene standard. Findings

reported from several long-term clinical trials have

suggested that a maintenance program based on recall

appointments once every 3 months is, for most pa-

tients, effective in preventing disease recurrence.

It is

important to emphasize, however, that the recall program

must be designed to meet the individual patient's need. Some

patients must be recalled every month, while other patients

may have to be checked only once a year.

At the various recall visits the following procedures

should be carried out:

Evaluation of the oral hygiene standard

Scaling and polishing of the teeth (if indicated).

At least once a year a comprehensive examination

should be performed including assessments of (1)

caries, (2) gingivitis, (3) pathologically deepened

pockets, (4) furcation involvements, (5) tooth mobility

and (6) alterations of the alveolar bone level.

The patient (Mr. U.N.) used in this chapter to de-

scribe the guiding principles of treatment planning

was, during the first 6 months after the active treat-

ment, recalled once every 2 months, during the next 6

months once every 3 months, and subsequently only

once every 6 months. The clinical and radiographic

status 11 years after active treatment is shown in Figs.

19-7 & 19-8. In the course of this 11-year period there

were no signs of recurrence of caries or periodontal

disease. The buccal cusp of the crown of 15 was frac-

tured approximately 5 years after active therapy and

the tooth was restored with a gold crown with a

porcelain facing.

The large variety of treatment problems that differ-

ent patients present may obviously require that devia

tions are made from the sequence of treatment steps

(initial cause-related therapy, corrective therapy, etc.)

discussed above. Such deviations may be accepted as

long as the fundamental principles regarding the

overall therapy are understood (Fig. 19-9: flow chart).

Three patients will be presented below together

with a brief description of their specific dental prob-

lems and the treatment delivered in order to demon-

strate the rationale behind such variations in the se-

quence of therapy.

CASE REPORTS

Patient K.A. (female, 29 years old)

Initial examination

The periodontal status (pocket depths, furcation in-

volvements, tooth mobility, radiographs and diagno-

ses) from the initial examination of patient K.A. is

shown in Fig. 19-10a,b. The data obtained from this

examination disclosed the presence of an advanced

destruction of the supporting tissues in most parts of

the dentition and the presence of a large number of

angular bony defects. The teeth 14, 12, 11, 21, 22, 23,

24, 25, 43, 42, 41, 31, 32, 33, 37 exhibited increased

mobility. The plaque and gingivitis scores were 75 and

70%, respectively.

Treatment planning

In the planning of the treatment of this case, it seemed

reasonable to anticipate the extraction of some teeth

in this severely compromised dentition, namely 14,11,

21 and 31 (see radiograph: Fig. 19-10a). The extraction

of these teeth, however, calls for extensive prosthetic

therapy. Should additional teeth be scheduled for

extraction in order to facilitate or make the outcome

of prosthetic therapy more predictable? The neighbor-

ing teeth of 11, 21, 31, also exhibited advanced loss of

supporting structures and showed signs of increased

mobility. It could be questioned, therefore, if these

teeth (i.e. 12, 22, 41, 32) could serve as proper abut-

ments for a fixed bridge. The extraction of tooth 31

would most likely enforce the additional extraction of

TREATMENT PLANNING • 4

Fig. 19-10a. Case K.A. (29-year-old female patient). Radiographs prior to therapy

the remaining three mandibular incisors, and conse-

quently a therapy could be anticipated which in-

cluded the preparation and installation of a fixed

bridge extending from tooth 44 to tooth 34. Extraction

of 11 and 21 would motivate the extraction of 12, 22,

14 and 24 as well, and call for a bridge construction

that extended from tooth 16 to 25 or 26. The prerequi

sites for a proper prognosis for the prosthetic therapy

described above are (1) optimal self-performed oral

hygiene, (2) proper healing of the periodontal tissues

following cause-related and corrective therapy, and (

3) a carefully monitored maintenance care program.

these prerequisites can be met, it may, on the other

hand, be possible to avoid all anticipated tooth extrac

tions in this patient and the prosthetic therapy

avoided. As stated above most of the teeth had in-

creased mobility. This mobility, however, did not dis-

turb the chewing comfort of this patient. The tooth

mobility

per se,

therefore, was not regarded as an

indication for splinting.

Conclusions:

In a case of this character extensive efforts

should be made to properly treat inflammatory peri-

odontal disease in the entire dentition

before

decisions

are made to extract one or several teeth. Decisions

regarding tooth extraction should, if possible, not be

made until after healing following periodontal sur-

gery.

Treatment

Subsequent to initial examination, the patient was

given a detailed "case presentation" and information

regarding alternative goals of and prerequisites for the

overall treatment. This information included a de-

scription of the role of dental plaque in the etiology of

periodontal disease and the significance of optimal

plaque control for a successful outcome of therapy. A

treatment program was subsequently planned which

aimed at maintaining all teeth, thereby avoiding ex-

tensive prosthetic therapy. The overall treatment was

performed in the following sequence:

Fig. 19-10b. Periodontal chart relating to case K.A. (Fig.

19-10a).

424 • CHAPTER 19

Fig. 19-11a-c. Case K.A. Clinical status 5 years after initial treatment.

Fig. 19-12. Case K.A. Radiographs obtained 8 years after treatment.

Initial

therapy

Oral hyiene instruction and plaque control evalu

ation.

Scaling and root planing. Adjustment of im

proper

amalgam restorations.

Additional therapy (following evaluation at

re-examination)

Periodontal surgery involving careful removal of sub-

gingival soft and hard deposits and root planing. All

teeth in the dentition could be maintained and the

furcation involvements in the premolar and molar

areas could be treated successfully with furcation

plasty (see Chapter 29). After healing, a fixed bridge

(

16, 15, 14) was fabricated and inserted on esthetic

indications.

Supportive therapy

During the first 6 months after completion of the initial

and corrective therapy, the patient was recalled for

maintenance care every 3 weeks. This interval be-

tween the recall appointments was then gradually

extended to 3 months.