treatment planning in periodontics- dr harshavardhan patwal
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TREATMENT PLANNING IN PERIODONTICS Dr Harshavardhan PatwalDr Harshavardhan Patwal
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INTRODUCTIONAfter the diagnosis and prognosis is established, the treatment is planned.
The treatment plan is blueprint for case management.
It includes all procedures required for establishment and maintenance of oral health
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Treatment plan is based on Diagnosis Disease severity Desirable therapeutic end points
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AIM OF TREATMENT PLANNING To do total treatment that is coordinating of all treatment procedures for the purpose of creating a well-functioning dentition in a healthy periodontal environment .
The primary goal is to eliminate gingival inflammation and correction of conditions that cause and perpetuate it.
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For many years, dental treatment planning could be described as authoritarian.
Although at present dentist are still influenced by this approach, the climate is rapidly changing.
Thus the treatment planning becomes a discussion rather than a plan devised, directed and dispensed by the dentist.
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Notable attempts have been made to develop dental practice guidelines and protocols by specialty groups such as AAP
. Decision pathways.
provide direction in identifying the range of treatment options.
indicating some of the key decisions leading to appropriate treatment LIMITATION they tend to difficult for routine use, especially for experienced practitioner.
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DECISION TREES
Decision trees represent a more sophisticated expansion on this aspect.
These not only have key decision nodes but also include research- based success rates for each of these treatment options.
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SEQUENCE IN TREATMENT PLANNING
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TREATMENT PLANNING INCLUDES
Teeth to be retained or extracted.
Pocket therapy techniques surgical or non surgical that will be used.
The need for occlusal correction before, during or after pocket therapy.
The need for temporary restorations.The use of implant
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Final restorations that will be needed after therapy, and which teeth will be abutments if a fixed prosthesis is used.
The need for orthodontic consultations.Endodontic therapy.Decisions regarding esthetic considerations in periodontal therapy.
Sequence of therapy.
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EXPLAINING TREATMENT PLAN TO THE PATIENT
Understandable terms Informed of the disease process, Treatment options & expected results, Potential adverse events or complications. The consequences of not having treatment should also be explained to the patient .
Be specific Begin your discussion on positive note Present the entire treatment plan as whole unit
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UNREALISTIC WANTS OF PATIENT
Most often pt want to retain the hopelessly diseased teeth. But explain following reasons:
Periodontal disease is a microbial infection. Correcting the condition eliminates serious potential risk of systemic disease.
It is not feasible to place restorations or bridges on teeth with untreated periodontal condition.Periodontal disease also shortens the life span of other teeth.
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TREATMNET PLANNING IN PERIODONTICS
Ramfjord (1953). This plan included four phases: 1) systemic, 2) hygienic, 3) corrective 4) maintenance or supportive care
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LINDHE INTIAL CAUSE- RELATED THERAPY ADDITONAL THERAPEUTIC MEASURES SUPPORTIVE PERIODONTAL THERAPY
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In every patient with periodontitis, a treatment strategy should includes the elimination of the opportunistic infection
The treatment goal may be specified:
No sites with PPD >5mm but preferable less than 4 mm
No furcations involvement of degreeII or III.
<10% of sites Bop
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TREATMENT PLANNING
FERMIN CARRANZA, HENRY TAKEI
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PHASES OF PERIOODNTAL THERAPY
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CORRECT SEQUENCE OF PERIODONTAL TREATMENT
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EXTRACTING OR PRESERVING THE TOOTH
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PHASE I TREATMENT
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SEQUENCE OF PROCEDURESSTEP 1 Limited plaque control instruction:STEP 2 Supragingival removal of calculusSTEP3 Recontouring defective restorations
and crownsSTEP 4 Obturation of carious lesionsSTEP 5 Comprehensive plaque control instructions
STEP 6 Subgingival root treatment.STEP 7 Tissue revaluation
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ANTIMICROBIAL THERAPYSINGLE AGENT REGIMEN DOSAGE/DURATIONAMOXICILLIN 500 mg 3 times daily for 8 days
AZITHROMYCIN 500 mg Once daily for 4-7 days
CIPROFLOXACIN 500 mg Twice daily for 8 daysCLINDAMYCIN 300 mg 3times daily for 10 days
DOXYCYCLINE/MINOCYCLINE 100-200mg Once daily for 21 days
METRONIDAZOLE 500mg 3 times daily for 8 days
COMBINATION THERAPY REGIMEN DOSAGE / DURATION
METRONIDAZOLE+ AMOXICILLIN 250mg of each 3 times daily for 8 days
METRONIDAZOLE + CIPROFLOXACIN
500of each mg Twice daily for 8 days
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OCCLUSAL THERAPY
STEP1 Remove retrusive prematurities and eliminate the deflective shift from retruded contact position to intercuspal.
STEP 2 Adjust ICP to achieve stable, simultaneous multipointed widely distributed contacts
STEP 3 Test for excessive contact on incisor teeth
STEP 4 Remove posteriors protrusive supra contacts and establish contacts that are bilateraly distributed on anterior teeth
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Step 5 Remove or lessen mediotrusive interferences.
STEP 6 Remove excessive cusp steepness on laterotrusive contacts
STEP 7 Eliminate gross occlusal disharmoniesSTEP 8 recheck tooth contact relationshipSTEP 9 Polish all rough tooth surfaces
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SPLINTING Mobility of teeth that is increasing and impairs pt comfort
Migration of teeth Prosthetics where multiple abutments are necessary
Excessive occlusal forces from parafunction or deflective tooth contacts are frequent causes of mobility. Than occlusal therapy is performed.
Any inflammation should be reduced before splinting.
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REVALUATION AFTER PHASE I THERAPY
The assessment is generally made no less than 1 to 3 months as much as 9month s after therapy
REPROBE COBB in 1996
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SURGEY VERSUS ROOT PLANING
Surgery is an options : To control or eliminate periodontal disease.
Correct anatomic conditions which favor periodontal disease, impair esthetics or obstruct placement of prosthetic appliances. To place implant to replace an missing teeth.
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PERIODONTAL SURGERY
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SELECTION OF SURGICAL PROCEDURES
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PERIODONTAL SURGERY
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DRUG INDUCED GINGIVAL ENLARGEMENT
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PERIODONTAL SURGERY
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NO CRATER
CRATER
SHALLOW
WIDEMOD/ DEEP WIDE
NARROW
POCKET ELIMINATION RESECTION
PRICHARD FILL
TECHNIQUE
GTR/ RESECTION
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FURCATION
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ROOT COVERAGE GINGIVAL RECESION
APICAL CORONAL COMBINATION
FGG, FCTG SCTG, SEMILUNAR GTR , CTG APICAL DISPLACED LATERAL POSITIONED EMDOGAIN CORONAL POSITINING PRP, PRF DOUBLE PAPILLA
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INTER DENTAL PAPILLA RECONSTRUCTION
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PREPROSTHETIC SURGERYCROWN LENGHTENING PROCEDURES Indications Excessive gingival display when
smiling Inadequate amount of tooth structure for proper restorations.
Subgingival location of fracture lines and carious lesions
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RIDGE AUGMENTATION
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IMPLANT THERAPY
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ENDODONTIC THERAPYPrimary endodontic lesion = RCTPrimary periodontal lesion = PERIODONTAL THERAPY
Primary endodontic lesion with secondary periodontal involvement = RCT + PERIODONTAL THERAPY
Primary periodontal lesion with secondary endodontic involvement = RCT + PERIODONTAL THERAPY
True combined lesion =RCT+ PERIODONTAL THERAPY
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RESTORATIVE THERAPY
BIOLOGIC WIDTH It is defined as the physiologic dimension of the junctional epithelium and connective tissue attachment. The measurement is approximately 2mm
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GUIDELINES FOR PLACEMENT OF MARGINS
Rule 1) If the sulcus probes 1.5 mm or less, place the restoration margin 0.5 mm below the gingival tissue crest.
Rule 2) If the sulcus probes more than 1.5mm, place the margin half the depth of the sulcus below the tissue crest. This places the margin far enough below the tissue so that it will be covered when pt is at high risk of recession
Rule 3) If a sulcus is greater than sulcus. 2 mm is found esp on facial aspect gingivectomy should be done to lengthen the crown and create 1.5mm than pt can be treated using rule 1
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SUPPORTIVE PERIODONTAL THERAPYAfter phase I therapy the pt is placed on a schedule of periodic recall visits for maintenance care to prevent recurrence of the disease.
The pt must understand the importance of the program.
The dentist must also emphasize the importance of the program
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RATIONALE FOR SPT
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SPT SCHEDULING
ERD 10-15 MIN
MRI 30-40 MIN
TRS
PFD 5- 10 MIN
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SCHALHORN IN 1981
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CLASSIFICATION OF POSTOPERATIVE TREATMENT PATIENTS
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CUMULATIVE INTERCEPTIVE SUPPORTIVE THERAPY
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TREATMENT OF PLANNING
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CONCLUSION
An objective of the overall treatment plan is the creation and maintenance of oral health, function and esthetics. The outcome is thus long term. It requires coordination of several disciplines of dentistry. Apart from this a motivated patient is pre-requiste and overall success of this treatment plan will depend on this motivation
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