Chapter 19 - Problem/Evidence-based treatment planning
Problem based learning
Designed to develop individual plans for patients. It identifies problems from the patient's medical/dental history from which a differential dental hygiene diagnosis will be made
The American Academy of periodontology has developed practice parametes on the diagnosis and treatment of periodontal diseases
Research is showing that there are microbial species whose presence tends to signal a greater likelihood of progressive periodontal destruction
The goal of periodontal therapy is to restore the periodontium to a comfortable and functional state of health for the balance of the patient;s life
Ongoing care - periodontal maintenance is the usual course of treatment for patients with disease. There is no specific end point. "once a perio patient always a perio patient" mentality
The advancement of periodontal disease is halted through regular perio appointments and good oral home care
Diagnostic tests: PSR, gingival assessment, periodontal probing, radiographic assessment, microbial testing
We do most of this in our clinic, except for the microbial testing. This is a large part of the dental hygienists job, identifing periodontal disease and these diagnostic tests are important in identifing that disease
Non-surgical treatment choices
Periodontal debridement: Scaling and root planning
Adjunctive therapy with antimicrobials: chlorhexidine in conjunction with debridement
Controlled-release drug delivery.: Arrestin and atridox
Antibiotics
Surgical options: patient would be seen by periodontist at this point. When pocket depths are too deep for the hygienists instruments to reach
Open flap debridement
Gingivectomy/gingivoplasty
Guideed tissue regeneration
Root coverage
Dental implants
Problem list: setup for individual periodontal patients. In our clinic it is the treatment plan with the unmet needs section. Identify patients unmet needs and come up with solutions and how to evaluate the patient
Risk assessment for periodontal diseases: increased age, male gender, lower socioeconomic status, and genetics. Other modifiable risk factors include plaque biofilm, poor oral hygiene, and tobacco use. Risk assessments are usually identified at first appointment through medical history and oral evaluation
Note the patient's self-control methods and what they try on his or her own. This can be a valuable in assessing what motivates the patient and maybe what the patient will be likely to do on his or her own to accomplish better oral heatlh
Soft tissue risks: gingival inflammation, lack of attachemd gingiva, probing depths
Hard tissue: ridge defects
Teeth: missing teeth, mobility, fremitus, occlusal wear, abfractions, parafunctional habits
Pathology: mucosal lesions, TMD/Pain
Guidelines for treatment
Level 3: patients who should be treatment by a periodontist: severe chronic periodontitis, furcation involvement, vertical bone defects, aggressive periodontitis
Level 2: patient who whould likely benefit from co-management by the referring dentist and the periodontist: those with risk factors and who will may likely progress in the future
Level 1: patients who may benefit from co-management by the referring dentist and the periodontist: those with risk factors
Phases of treatment
Phase I: relief of acute symtoms, nutritional counseling, periodontal debridement, antibiotics, smoking cessation and other modifiable risk factor control methods
Phase II: Therapy, surgical access
Phase III: Restorative/prosthetic care
Phase IV therapy: maintenance care: evaluate patients oral hygiene, smoking cessation, treatment depends of the condition of the periodontium
Informed consent: advise the patient on what the procedure is, what the expected outcome will be, the benefits and risks associated. Be honest about what you can do and what may happen if treatment is not successful
Stages of periodontitis and treatment planning
Slight chronic periodontitis (4-5mm depths): plan the first appointment to be at least an hour; time enough for a complete periodontal assessment, diagnostic tests, patient history and patient education of periodontitis. SEcond and third appointments maybe about 45 minutes and continue care and conseling
Moderate chronic periodontitis: 6-7mm depths, CAL of 3-4mm: First appointment 1 hour, same as above. Most of the treatment is similar how may require more time and closer monitoring. The use of antibiotics and more push for contol of modifiable risk factors. Patient education on what peridontitis is and how it will effect overall health is critical and management with periodontist may be necessary
Severe chronic periodontitis: depths of more than 8mm and CAL >5mm: First appointment similar to other stages of disease. Patient needs to be seen by periodontist and close monitoring and co-management is critical in order to prevent further loss.
Refractory periodontitis: Does not respond to convention therapy: These patients are best treated by a periodontist and co-management necessary
Prognosis: prediction of the future course of malady with or without treatment
Usually reported on a graded scale: good, guarded, or poor; or from good, fair, poor, questionable, or hopeless
Devloping a prognosis is important in treatment planning so that the practioner and patient can agree on a plan that best satisfies the patient's overall goals while minimizing disappointments if setbacks occur