Clinical Periodontology ( Irving Glickman)

Chapter 35

THE TREATMENT PLAN

THE TREATMENT PLAN –NOT AN HEROIC ATTEMPT TO SALVAGE LOOSE TEETH

After the diagnosis and prognosis have been established, the treatment is planned. The treatment
plan is the blueprint for case management. It includes all procedures required for the establishment
and maintenance of oral health, such as decisions as to teeth to be retained or extracted, whether
scaling and curettage or surgical techniques are to be used for pocket elimination, the need for
mucogingival or reconstructive surgical procedures and occlusal correction, the type of restorations
to be employed, which teeth are to be used for abutments, and the indications for splinting.

Unforeseen developments during treatment may necessitate modification of the initial treatment
plan. However, it is axiomatic that, except for emergencies, no treatment should be started until the
treatment plan has been established.

Periodontal treatment requires longrange planning. Its value to the patient is measured in years of
healthful functioning of the entire dentition, not by the number of teeth retained at the time of
treatment. It is directed to establishing and maintaining the health of the periodontium throughout
the mouth rather than to spectacular efforts to “tighten loose teeth”

The welfare of the dentition should not be jeopardized by an heroic attempt to retain questionable
teeth. The periodontal condition of teeth we decide to retain is more important than their number.
Teeth that can be retained with a minimum of doubt and a maximum margin of safety provide the
basis for the total treatment plan. Teeth on the borderline of hopelessness do not contribute to the
overall usefulness of the dentition, even if they can be saved in a somewhat precarious state. Such
teeth become sources of recurrent annoyance to the patient and detract from the value of the
greater service rendered in the remainder of the oral cavity.

THE MASTER PLAN FOR TOTAL TREATMENT

The aim of the treatment plan is total treatment-that is, the coordination of all treatment
procedures for the purpose of creating a well – functioning dentition in a healthy periodontal
environment. The following “master – plan” which divides total treatment into four phases is
prepared for each patient according to his needs.

THE TREATMENT OF GINGIVAL AND PERIODONTAL DISEASE

1. The soft tissue phase

This entails elimination of gingival inflammation, periodontal pockets and the factors which cause
them, the establishment of gingival contour and mucogingival relationships conducive to the
preservation of periodontal health, restoration of carious areas, correction of the margins of existing
restorations, and recontouring proximal, facial and lingual surface and occlusal marginal ridges of
existing restorations to provide proper proximal contact and food excursion pathways
 2. The Functional Phase

Anoptimal occlusal relationship is one that provides the functional stimulation necessary to preserve
periodontal health. To obtain it may require occlusal adjustment, restorative, prosthetic and
orthodontic procedures, splinting and the correction of bruxism, clamping and clenching habits.

3. The Systemic Phase

Systemic conditions may necessitate special precautions in the course of periodontal treatment,
affect the tissue response to treatment procedures or threaten the preservation of periodontal
health after treatment is completed. Such situations should be taken care of in conjuntion with the
patient’s physician.

4. The Maintenance Phase

This entails all procedures for maintaining periodontal health afterit has been attained. It consists of
instruction in oral hygiene, recall of the patient at regular intervals according to his needs, to check
on the condition of the periodontium, the status of the restorative dentistry and the need for further
occlusal adjustment, and follow up radiographs.

PLAQUE CONTROL IN PERIODONTAL TREATMENT

Plaque control is an integral part of periodontal treatment, no treatment, regardless of how expertly
it is performed, can succeed without it. Oral hygiene procedures performed by the patient to
prevent the accumulation of dental plaque and food debris in the course of periodontal treatment
are commonly referred to as “oral physiotherapy” All local irritants must be removed in the
treatment of periodontal disease. Irritation and infection from dental plaque are the most common
causes of delayed healing. They cause inflammatory and degenerative changes that not only retard
healing but may reverse it in the direction of recurrent disease.

Periodontal treatment is usually an entirely new experience for the patient. It is different from his
previous dental experience in that he becomes an active participant in the treatment process. The
patient must know what the dentist will do for him and what he will be expected to do for himself.
The various oral hygiene procedures should be explained so that he understands their purpose and
the effort they require. It should also be emphasized that these procedures are to be continued
afterperiodontal health has been attained in order to help prevent the recurrence of disease.

When discussing the treatment plan, it is not enough simply to tell a patient that his cooperation will
be required without explaining the effort it entails and the reasons for it. In his anxiety about his
problem, the patient willingly promises to cooperate and often adds: “ Doctor, I will do anything to
save my teeth. “ Such assurance may be well intentioned, but it is not very meaningful when given
without knowledge of the commitment involved.

Teaching Plaque Control As Part Of Periodontal Treatment

Teaching plaque control requires more chairside time with the patient than the total time required
for the other periodontal treatment procedures.The step by step procedure for teaching plaque
control is described on page 467. It many be started before or after the other treatment procedures
are performed.
It is a good idea to start the overall treatment with plaque control. Placing the patient on a one-
month oral hygiene regimen at the outset will help convince him of its high priority in the treatment
program and will familiarize him with what he must do to have a healthy mouth. It also gives the
dentist an idea of what he can expect from the patient and provides an opportunity to demonstrate
the benefits of plaque control in terms of improvement in the condition of the gingiva.

For all patients- those already started on a plaque control program and those who start after other
treatment procedures are performed-there are certain special guidelines. After scaling and curettage
or periodontal surgery, care should be taken not to injure the healing tissue. Cleansing should be
started as soon as possible, but it should be confined initially to the gentle removal of superficial
plaque and debris with a rubber tip or other interdental cleanser followed by light water irrigation.
Brushing should be introduced as soon as the tissues permit, gradually, but if it persists, it should be
treated.( See the treatment of sensiitive roots, page 660)

EXPLAINING THETREATMENT PLAN TO THE PATIENT

The following are suggestion for explaining the treatment plan to the patient : Be specific Tell your
patient :” you have gingivitis”, or “ you have periodontitis “. Then, explain exactly what these
conditions are, how they are treated and the future for the patients mouth after treatment. Avoid
vague statements such as : “ You have trouble with your gums “, or “ Something should be done
about your gums “. Patient do not understand the significance of such statements and disregard
them.

Start you discussion on a positive note. Talk about the teeth which can be retained and the long –
term service they can be expected to render. Do not start your discussion with the statement: “ The
following teeth have to be extracted “. This creates a negative impression which adds to the
erroneous attitude of hopelessness the patient already may have regarding his mouth.

Make it clear that every effort will be made to retain as many teeth as possible, but do not dwell on
the patient’s loose teeth. Emphasize the fact that the important purpose of thetreatment is to
prevent the other teeth from becoming as severely diseased as the loose teeth.

Present the entire treatment plan as a unit. Avoid creating the impression that treatment consists of
separate procedures, some or all of which may be selected by the patient. Make it clear that dental
restorations and prostheses contribute as much to the health of the gums as does the elimination of
inflammation and periodontal pockets. Do not speak in terms of “having the gums treated” and
“then taking care of the necessary restorations later” as if these were unrelated treatments.

Patient frequently seek guidance from the dentist with such question as: “Are my teeth worth
treating?” “Would you have them treated if you were I ?” “ Why dont I just go along the way I am
until the teeth really bother me, and then have them all extracted?”

If the condition is treable, make it clear that the best results are obtained by prompt treatment. If
the condition is not treable, the teeth should be extracted. Explain that “ doing nothing “ or holding
onto hopelessly diseased teeth as long as possible is in advisable for the following reasons.
In periodontal disease, proper mastication of food is impaired because of looseness of the teeth and
discomfort incurred by chewing. This leads to the “ bolting” of food, which complicates the digestive
process and may lead to gastrointestinal disturbances.

Exudate from periodontal pockets spoils the taste of food. In addition, the incorporation of purulent
material into the food may irritate the mucosa of the stomach and lead to gastritis. Infection in the
periodontal area is also a potential source of bacteremia. Inability to chew properly leads to habits of
food selection with preference for soft foods, which are for the most part carbohydrates.

It is not feasible to place restorations or “bridges” on teeth with untreated periodontal disease,
because the usefulness of the restoration is limited by the uncertain condition of the supporting
structures.

Failure to eliminate periodontal disease not only results in loss of teeth already hopelessly involved,
but also shortens the life span of other teeth which, with proper treatment,could serve as the
foundation for a healthy, functioning dentition.

It is the dentist’s responsibility to advise the patient of the importance of periodontal treatment.
However, if treatment is to be succesful, the patient must be sufficiently interested in retaining the
natural teeth to provide the necessary oral hygiene. Individuals who are not particularly perturbed
by the thought of losing their teeth are generally not good patient for periodontal treatment.