Establishing a treatment plan
Establishing a treatment plan
The management of periodontal disease is a continuous process of assessment, treatment and re-assessment. As a result, treatment plans may be adapted depending on the response to treatment and the wishes of the patient.
The BSP implementation of European S3 – level evidence-based treatment guidelines for stage I-III periodontitis in UK clinical practice (BSP-S3) guideline6 advises a stepwise approach to periodontal therapy in patients with a diagnosis of periodontal health, gingivitis or periodontitis. The various treatment elements are organised into steps 1-4 in a structured manner (see Stepwise approach); some or all of these steps may be employed throughout treatment depending on the disease status of the patient.
Patients with a diagnosis of periodontal health will require Step 1 of therapy as part of the prevention and early detection of periodontal diseases (see table: Planning periodontal care), with recall intervals based on an assessment of their risk and ongoing treatment need.
Patients with a diagnosis of gingivitis will require Step 1 of therapy to address risk factors which increase their susceptibility to periodontal diseases and professional mechanical plaque removal (PMPR) to control inflammation (see table: Planning periodontal care), with recall intervals based on an assessment of their risk and ongoing treatment need.
Patients with a diagnosis of periodontitis require lifelong periodontal treatment and maintenance care (see table: Planning periodontal care). In addition to Step 1 of therapy to address risk factors and remove supragingival calculus, patients with periodontitis will require subgingival PMPR (Step 2 of therapy) to control inflammation at deeper sites. They may in addition require further treatment at sites that fail to respond to Steps 1 and 2 of therapy (Step 3 of therapy) before entering a programme of maintenance (Step 4 of therapy), with recall intervals based on an assessment of their risk and ongoing treatment need.
Planning periodontal care
| Diagnosis | Treatment need |
| Periodontal health |
Step 1 of therapy.
|
| Gingivitis |
Step 1 of therapy. As for Periodontal Health with additional consideration of:
|
| Periodontitis | Stepwise approach to periodontal therapy as described in Stepwise approach to periodontal therapy. |
When planning treatment for an individual patient:
Take into account the findings of the patient history, the basic periodontal examination, any further in-depth periodontal examination and patient-specific risk factors when planning treatment (see Periodontal assessment).
Make a periodontal diagnosis and inform the patient of the diagnosis and any relevant risk factors. Record the diagnostic statement in the patient’s clinical record (see Diagnosis).
Explain to the patient what treatment options are available, what these involve and the potential benefits and risks of treatment, for example stabilisation of the disease and reduced risk of tooth loss but potential post treatment recession. Also explain what the consequences of no treatment may be, for example progression of disease and increased risk of tooth loss.
Make a personalised treatment plan with defined therapeutic goals that addresses the causes of disease and includes:
- holistic assessment of the prognosis of individual teeth and the dentition as a whole;
- control of systemic and local risk factors;
- encouraging effective home care and oral hygiene behaviour change;
- removal of plaque biofilm and calculus deposits from the tooth and root surface to allow healing of inflamed tissues;
- reassessment to arrange further active treatment or ongoing maintenance care.
N.B. the treatment plan may need to be revisited depending on patient motivation and response to treatment.
Ensure consent from patient is obtained to either proceed with treatment or decline treatment.
N.B. The SDCEP Practice Support Manual15 includes information on obtaining consent.
For patients with complex disease, consider consulting a colleague or a specialist for advice to assist with diagnosis and treatment planning.
When planning the schedule for professional mechanical plaque removal (PMPR), assess the level of deposits, extent of disease along with patient preference and operator preference and skill to determine the number and length of appointments required for thorough debridement.
If treatment involves referral to specialist or enhanced care:
- carry out Steps 1 and 2 of therapy;
- encourage and support the patient to maintain effective plaque removal;
- ensure that if the patient smokes you have discussed this with them and offered referral to smoking cessation support services (see Smoking cessation);
- where appropriate, discuss the impact of periodontitis on systemic disease (e.g. diabetes) and consider whether early liaison with the medical team is needed (see Control of diabetes).
See Referral for further information.
Where possible, identify occlusal trauma during diagnosis (see Occlusal examination).
Where periodontally compromised teeth may be affected by occlusal trauma:
- check the occlusion for the presence of fremitus or occlusal interference;
- consider occlusal management as part of the periodontal treatment plan.
Manage tooth mobility associated with periodontitis by non-surgical periodontal treatment in the first instance as part of an overall plan for the dentition.
Ensure that periodontal disease is controlled before any advanced or complex procedures are planned (e.g. implant placement).
Ensure that patients with a history of periodontitis who are considering dental implants are fully informed about the increased risk of peri-implantitis and implant loss due to their oral health history (see Management of patients with dental implants).