6: Initial treatment planning

Chapter 6

Initial treatment planning

Introduction

In order to plan any kind of therapy for a patient, we need information about the patient and his or her condition. Previous chapters discussed the assessment and diagnosis of patients with periodontal disease. For patients other than those with gingivitis or mild periodontitis, when treatment is simple and prevention oriented, by the time we are ready to plan initial treatment for our patient, we should have a wealth of information to facilitate this process. The aim of this chapter is to describe the planning of treatment for a patient with periodontal disease.

The treatment planning process

At this stage, the following should have been undertaken to inform the treatment planning process:

Assessment of the patient’s concerns, symptoms, expectations, and aspirations for treatment

Identification of any problems such as pain that may require immediate intervention

A general diagnosis of the periodontal condition

A tooth-by-tooth assessment of the periodontal condition, including pocket depths, recession, mobility, furcations, and radiographic findings

Identification of any other associated pathologies, such as caries or endodontic problems

An assessment of the patient’s disease susceptibility and identification of risk factors that may influence this, such as smoking or diabetes

Identification of other factors that might influence treatment or treatment outcomes

Identification of local factors that might influence plaque retention and also a functional occlusal assessment to consider possible effects on mobility, etc.

Initial periodontal treatment has sometimes also been referred to as “cause-related therapy,” emphasizing the fact that the primary aim of this treatment is to eliminate or control the aetiological factors associated with the disease, to allow stabilization of the disease, and to promote healing of the tissues. Thus, at this stage, much of initial treatment planning is a relatively simple task in that initial treatment relates to the removal of the primary causative agent of periodontitis—plaque—and the correction of those factors that serve to retain plaque (calculus, overhanging restorations, etc.). Add to this smoking cessation for patients who smoke, and then the previously discussed plan would be an initial treatment plan that would serve for many periodontal patients. However, although it is common to make some of the important long-term decisions about management at reassessment following completion of initial treatment (see < ?xml:namespace prefix = "mbp" />Chapters 9 and 15), an initial treatment plan should also consider the long-term goals of treatment, and it should be clearly explained to the patient how these will aim to address the patient’s concerns and aspirations. Without this, patients often do not clearly understand the objectives of treatment, which can be demotivating at a time when motivation is most important.

Thus, the initial treatment plan will include the following:

The immediate management of symptoms (e.g., pain and active caries)

Achieving adequate plaque control measures by the patient

Correction of plaque retentive factors

Subgingival debridement

Management of modifiable risk factors

Reassessment, to include the definitive decision on long-term management objectives, which may include the need for extractions, restorative needs, and management of aesthetics and function

Assessing prognosis

Assessing the prognosis for specific teeth, and for individual patients overall, is inevitably an inexact exercise because it involves the assessment of a wide range of different factors that will affect the risk of tooth loss in the future. However, a judgement of likely prognosis may influence treatment planning decisions (1) by trying to control any adverse prognostic factors that are identified, (2) by affecting decisions to carry out extensive (and expensive) complex treatments, and (3) by informing decisions about extractions that may be required. As also discussed elsewhere, a wide range of different factors at both the patient level and the tooth level will affect prognosis. A judgement of prognosis is thus made by the clinician by weighing all of these factors. Studies suggest that, in general, clinicians tend to underestimate the adverse effects of patient-level factors such as smoking on prognosis while overestimating the effects of tooth-level factors.

A list of many of the factors that may influence prognosis is given in Table 6.1. Some teeth may be judged to have such a poor prognosis that they are deemed “hopeless.” A hopeless tooth would generally be considered to be untreatable and may be particularly associated with grade 3 mobility, perio/endo lesions, and other pathologies such as advanced caries.

Table 6.1 Patient-level and tooth-specific factors influencing long-term prognosis

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Better prognosis Worse prognosis
Nonsmoker Smokers
Medically fit Medically compromised
Low susceptibility High disease susceptibility
Good response to initial therapy Poor response to initial therapy
Good OH Poor compliance/OH
Shallower pockets Deeper pockets
Horizontal-type bone loss Vertical bone loss
Simple root anatomy; anterior teeth Furcations and other anatomical factors (root grooves, etc.); posterior teeth
  Mobility
Jan 5, 2015 | Posted by in Implantology | Comments Off on 6: Initial treatment planning
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