Resident Doctor. Department Periodontology & Oral Implantology, Kathmandu, Nepal

2. Introduction
Rationale for Perio Treatment
Local & Systemic Therapy
Treatment Goals
Master plan for total treatment
Extracting or preserving tooth
Therapeutic procedures
2

3. Phases of Perio Therapy
Explaining TP to Patient
Summary
Conclusion
References
3

4. TP is blueprint for case management
Treatment is planned after diagnosis & prognosis
established
Includes all procedures required for establishment
& maintenance of oral health
4

5. Involves following decisions:
Teeth to be retained/ extracted
Pocket therapy techniques – surgical/
nonsurgical
Need for occlusal correction – before/ during/
after pocket therapy
Use of implant therapy
Need for temporary restorations
5

6. Final restorations that will be needed after
therapy & which teeth will be abutments if fixed
prosthesis used
Need for orthodontic consultation
Endodontic therapy
Decisions regarding esthetic considerations in
perio therapy
Sequence of therapy
6

7. Unforeseen developments during treatment may
necessitate modification of initial treatment plan
except for emergencies, no treatment should be
started until TP established
7

8. Perio therapy can restore chronically inflamed
gingiva – clinical & structural view - is almost
identical with gingiva never exposed to excessive
plaque accumulation
8

9.  Eliminate pain,
 Exudate, gingival inflammation & bleeding,
 Reduce perio pockets & eliminate infection,
 Stop pus formation,
 Arrest destruction of soft tissue & bone,
 Reduce abnormal tooth mobility,
 Establish optimal occlusal function,
 Restore tissue destroyed by disease,
 Reestablish physiologic gingival contour,
 Prevent recurrence of disease &
 Reduce tooth loss 9

10. 10

11.  Removal of plaque & all factors that favor its
accumulation
 Elimination of trauma – chances of bone
regeneration & gain of attachment
 Creating occlusal relations that are more
tolerable to perio tissues – reduce tooth mobility
& increases margin of safety of periodontium to
minor buildup of plaque
11

12.  Employed as adjunct to local measures & for
specific purposes:
Control of systemic complications from acute
infections
Chemotherapy to prevent harmful effects of
posttreatment bacteremia
Supportive nutritional therapy &
Control of systemic diseases that aggravate
patient’s perio status/ necessitate special
precautions during T/t
12

13. Systemic antibiotics – to completely eliminate
mo’s that invade gingival tissues & can
repopulate pocket after SRP
NSAIDs – flurbiprofen & ibuprofen – slow down
development of gingivitis, loss of alveolar bone
(Heasman & Seymour 1989, Howell & Williams 1993)
Alendronate, bisphosphonate – studies in monkey
– reduce bone loss asso with periodontitis (Brunsvold,
Chaves, Kornman et al 1992, Weinreb et al 1994)
13

14. Reduction/ resolution of gingivitis – full mouth
mean BoP ≤ 25 %
Reduction in probing pocket depth (PPD) – no
residual pockets with PPD > 5 mm
Elimination of open furcation – initial furcation
involvement should not exceed 3 mm
Absence of pain
Individually satisfactory esthetics & function
16

15. Aim of TP is Total Treatment - coordination of all
treatment procedures for purpose of creating
well–functioning dentition in healthy perio
environment
Primary goal is elimination of gingival
inflammation & correction of conditions that
cause & perpetuate it
17

16. Includes not only elimination of root irritants, but
also pocket eradication & reduction,
establishment of gingival contours &
mucogingival relationships conducive to
preservation of perio health, restoration of carious
areas & correction of existing restorations
19

17. Perio T/t requires long range planning
Its value to patient is measured in years of healthy
functioning of entire dentition, not by no. of
teeth retained at time of treatment
Treatment is directed to establishing &
maintaining health of periodontium throughout
mouth rather than to spectacular efforts to
“tighten loose teeth”
20

18. Welfare of dentition should not be jeopardized by
heroic attempt to retain questionable teeth
Perio condition of teeth to be retained is more
important than no. of such teeth
21

19. Teeth on borderline of hopelessness do not
contribute to overall usefulness of dentition, even
if they can be saved
become sources of recurrent annoyance to
patient & detract from value of greater service
rendered by establishment of perio health in
remainder of oral cavity
22

20. Tooth should be extracted when any of following
occurs:
It is so mobile that function becomes painful
It can cause acute abscesses during therapy
There is no use for it in overall TP
23

21. Tooth can be retained temporarily, postponing
decision to extract it until after treatment, when
any of following occurs:
It maintains posterior stops - removed after T/t
when it can be replaced by prosthesis
24

22. It maintains posterior stops & may be functional
after implant placement in adjacent areas –
When implant is exposed, these teeth can be
extracted
In anterior esthetic areas, tooth can be retained
during perio therapy & removed when T/t is
completed, & permanent restorative procedure
can be performed
avoids need for temporary appliances
25

23. Removal of hopeless teeth can also be
performed during perio surgery of neighboring
teeth - reduces appointments for surgery in same
area
In formulation of TP  in addition to proper
function of dentition, esthetic considerations play
increasingly important role in many cases
26

24. According to their age, gender, profession, social
status & other reasons
Different patients value esthetics differently
Clinician should carefully evaluate & consider
final outcome of T/t that will be acceptable to
patient without jeopardizing basic consideration
of attaining health
27

25. In complex cases, interdisciplinary consultation
with other specialty areas is necessary before
final plan made
29

26. May necessitate:
Occlusal adjustment
Restorative, prosthetic, & orthodontic procedures
Splinting &
Correction of bruxism & clamping & clenching
habits
30

27. Carefully evaluated
May require special precautions during course of
perio T/t
May also affect tissue response to T/t
procedures/ threaten preservation of perio
health after treatment is completed
Patient’s physician
31

28. Paramount importance for case maintenance
Entails all procedures for maintaining perio health
after it has been attained
Consists of instruction in oral hygiene & checkups
at regular intervals, acc to patient’s needs
To examine condition of periodontium & status of
restoration as it affects periodontium
32

29. Periodontal therapy is inseparable part of dental
therapy
Includes perio procedures & other procedures
not considered within province of periodontist
They are listed together to emphasize close
relationship of perio therapy with other phases of
therapy performed by general dentists/ other
specialists
33

30. 34

31. 35

32. Preliminary phase
Non surgical phase (Phase I Therapy)
Evaluation of response to Nonsurgical Phase
Surgical Phase (Phase II Therapy)
Restorative Phase (Phase III Therapy)
Maintenance Phase (Phase IV Therapy)
36

33. A. Preliminary Phase
Treatment of emergencies:
Dental/ periapical
Periodontal
Other
Extraction of hopeless teeth and provisional
replacement if needed (may be postponed to
more convenient time)
37

34. B. Nonsurgical Phase (Phase I Therapy)
Plaque control and patient education:
Diet control (in patients with rampant caries)
Removal of calculus & root planing
Correction of restorative & prosthetic irritational
factors
Excavation of caries & restoration (temporary/
final, depending on whether a definitive
prognosis for tooth has been determined & on
location of caries)
38

35. Antimicrobial therapy (local/ systemic)
Occlusal therapy
Minor orthodontic movement
Provisional splinting & prosthesis
C. Evaluation of response to Nonsurgical phase
Rechecking:
Pocket depth & gingival inflammation
Plaque & calculus, caries
39

36. D. Surgical Phase (Phase II Therapy)
Perio therapy, including placement of implants
Endodontic therapy
E. Restorative Phase (Phase III Therapy)
Final restorations
Fixed & removable prosthodontic appliances
Evaluation of response to restorative procedures
Periodontal examination
40

37. F. Maintenance Phase (Phase IV Therapy)
Periodic rechecking:
Plaque & calculus
Gingival condition (pockets, inflammation)
Occlusion, tooth mobility
Other pathologic changes
41

38. Preferred sequence of periodontal therapy
43

39. Although phases of T/t have been numbered,
recommended sequence does not follow nos.
Phase I/ Nonsurgical phase - directed to
elimination of etiologic factors of gingival & perio
diseases
When successfully performed, this phase stops
progression of dental & perio disease
44

40. Immediately after completion of Phase I therapy,
- patient should be placed on Maintenance
phase (Phase IV)
To preserve results obtained & prevent any further
deterioration & recurrence of disease
45

41. While on maintenance phase, with its periodic
checkups & controls, patient enters into Surgical
phase (Phase II) & Restorative (reparative) phase
(Phase III) of T/t
Include perio surgery to repair & improve
condition of perio & surrounding tissues & their
esthetics, rebuilding of lost structures, placement
of implants & construction of necessary
restorative work
46

42. Systemic phase of therapy including smoking
counseling
Initial (or hygiene) phase of periodontal therapy
– cause related therapy
Corrective phase of therapy – surgery, endo
therapy, implant, restorative, ortho/ prosthetic T/t
Maintenance phase (care) – SPT
• Salvi, Lindhe & Lang 2008 47

43. Goal :
To eliminate/ decrease influence of systemic
conditions on outcome of therapy
To protect patient & dental care providers
against infectious hazards
Efforts – to enroll smokers into cessation program
48

44. Represents cause related therapy
Objective:
Clean & infection free oral cavity
Motivating patients to perform optimal plaque
control
Phase concluded by – reevaluation & planning of
both additional & supportive measures
49

45. Addresses sequelae of opportunistic infections &
includes therapeutic measures:
Perio & implant surgery
Endodontic therapy
Restorative &/ prosthetic T/t
Amount of corrective therapy required –
determined only when degree of success of
cause related therapy – properly evaluated
50

46. Patient’s willingness & ability to cooperate in
overall therapy – determine type of corrective T/t
If inadequate – permanent improvement of oral
health, function & esthetics not achieved – may
not be worth initiating rest of perio procedures
(Lindhe & Nyman 1975, Rosling et al 1976, Nyman
et al 1975, 1977, 1979)
51

47. Aim:
Prevention of reinfection & disease recurrence
For each patient – recall system designed:
1. Assessment of deepened sites with bleeding on
probing
2. Instrumentation of such sites
3. Fluoride application for prevention of dental
caries
52

48. Additionally – phase involve regular control of
prosthetic restorations incorporated during
corrective phase
Tooth sensitivity testing – be applied to abutment
teeth as loss of vitality is frequently encountered
complication
(Bergenholtz & Nyman 1984; Lang et al 2004, Lulic
et al 2007)
53

49. 54

50. Be specific
Tell our patient, “You have gingivitis,” or “You
have periodontitis,” then explain exactly what
these conditions are, how they are treated, &
prognosis for patient after treatment
Avoid vague statements - “You have trouble with
your gums,” or “Something should be done about
your gums”  Patients do not understand
significance of such statements & disregard them
55

51. Begin our discussion on positive note
Talk about teeth that can be retained & long
term service expected to render
Not begin our discussion with statement,
“Following teeth have to be extracted” - creates
negative impression - adds to hopelessness
patient already may have regarding their mouth
56

52. Make it clear that every effort - to retain as many
teeth as possible, but do not dwell on patient’s
loose teeth
Emphasize that important purpose T/t is to
prevent other teeth from becoming as severely
diseased as loose teeth
57

53. Present entire treatment plan as unit
Avoid creating impression that T/t consists of
separate procedures
Do not speak in terms of “having gums treated &
then taking care of necessary restorations later”
as if these were unrelated treatments
58

54. Explain that “doing nothing” or holding onto
hopelessly diseased teeth as long as possible is
inadvisable for following reasons:
1. Periodontal disease is microbial infection, &
research - important risk factor for severe life-
threatening diseases - stroke, cardiovascular
disease, pulmonary disease, & diabetes, as well
as for premature low-birth-weight babies
60

55. 2. It is not feasible to place restorations/ bridges
on teeth with untreated perio disease because
usefulness of restoration would be limited by
uncertain condition of supporting structures
3. Failure to eliminate perio disease not only results
in loss of teeth already severely involved, but
also shortens life span of other teeth that, with
proper treatment, could serve as foundation for
healthy, functioning dentition
61

56. Therefore dentist should make it clear to patient
that:
If perio condition is treatable, best results are
obtained by prompt treatment
If condition is not treatable, teeth should be just
as promptly extracted
62

57. It is dentist’s responsibility to advise patient of
importance of perio T/t
if treatment is to be successful - patient must be
sufficiently interested in retaining natural teeth to
maintain necessary oral hygiene
Individuals who are not particularly perturbed by
thought of losing their teeth are generally not
good candidates for perio T/t
63

58. Objective of overall TP is creation & maintenance
of oral health, function, & esthetics
Outcome is long term & in most cases requires
coordination of several disciplines of dentistry
A motivated patient is prerequisite, & success will
depend on this motivation being sustained
through maintenance care
64

59. TP should focus on list of diagnoses for patient
T/t should be planned in phases
At completion of each phase, patient should be
reevaluated to assess response to treatment, & TP
may be modified based on this assessment
66

60. Treatment plan is guiding map for perio
treatment – no treatment should be initiated
without forming a solid TP &
Although Its clinician’s responsibility to make
individual patient realize the value of Treatment –
motivated patient is a prerequisite for optimum
outcome of perio therapy
69

61. Carranza’s Clinical Periodontology 8th, 9th, 10th &
11th edition
Clinical periodontology & Implant dentistry 5th
edition – Jan Lindhe
Bruce L. Philstrom. Periodontal risk assessment,
diagnosis & treatment planning. Perio 2000.
2001;25:37-58.
Renz & Newton. Changing the behavior of
patients with periodontitis. Perio 2000.
2009;51:252-68. 70

62. Schuz B, Sniehotta FF, Wiedemann A, Seemann R.
Adherence to a daily flossing regimen in
university students: effects of planning when,
where, how and what to do in the face of
barriers. J Clin Periodontol 2006; 33: 612–619.
Kwok, Caton, Polson & Hunter. Application of
evidence-based dentistry: from research to
clinical periodontal practice. Perio 2000.
2012;59:61-74.
Heasman PA, Seymour RA. The effect of a
systemically administered non-steroidal anti-
inflammatory drug (flurbiprofen) on experimental
gingivitis in humans. J Clin Periodontol.
1989;16:551.
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