periodontal treatment guide
Teamwork for treating periodontal disease The treatment of patients with periodontal disease should involve the application of standard procedures based on commonly accepted guidelines. This “Periodontal Treatment Guide” aims to support local networks of general dentists, hygienists and periodontists by providing evidence-based guidelines for diagnosis, referral and treatment options. The “Periodontal Treatment Guide” is the result of a consensus established by a group of experienced and highly renowned periodontists who based their recommendations for these guidelines on the systematic assessment of the available literature. The final goal of these activities is to help you to improve periodontal therapies in order to restore oral health and help preserve the teeth of the patient.
periodontal treatment
We are thankful to the following authors for their significant support in developing this “Periodontal Treatment Guide”
BPE
Prof. Dr. med. dent. Anton Sculean, Dr. h.c., M.S., Chairman of Department of Periodontology – School
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PERIODONTALLY HEALTHY PATIENT
BPE
PATIENT with PERIODONTAL disease
Evaluation
of Dental Medicine – University of Bern – Bern, Switzerland. Dr. Christina Tietmann, Certified periodontal specialist of the German Society of Periodontology – Private Practice for Periodontology – Aachen, Germany. Dr. David Nisand, Lecturer of periodontics at the University of Paris – Private Practice limited to periodontology and implantology – Paris, France. Dr. Frank Bröseler, Certified periodontal specialist of the German Society of Periodontology – Private Practice for Periodontology – Aachen, Germany. Dr. Holger Janssen, Specialist for periodontology, implantology and restorative dentistry – Private Practice – Berlin, Germany. Dr. Mario Roccuzzo, Lecturer in Periodontics at University of Torino and Siena. Private Practice limited to Periodontics and Implantology – Torino, Italy. Dr. Markus Schlee, Lecturer for periodontics and implantology at the Steinbeis University, Berlin and DIU, Dresden, Germany. Private practice limited to periodontology and implantology – Forchheim, Germany. Prof. Dr. Nick Donos, DDS, MS, FHEA, FDSRCSEngl, PhD., Head & Chair of Periodontology, Director of Research, UCL-Eastman Dental
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Institute – Department of Periodontology – London, United Kingdom.
BPE 3 4
Hygiene
PATIENT with PERIODONTAL disease Surgery
Legend BPE: Basic Periodontal Examination PPD: Probing Pocket Depth FMPS: Full Mouth Plaque Score BOP: Bleeding on Probing GTR: Guided Tissue Regeneration SRP: Scaling and Root Planing
PERIODONTALLY HEALTHY PATIENT
to check
ORAL CHECK
Oral hygiene, tobacco consumption, periodontal status, furcation involvement, X-ray status, general health
MAINTENANCE PHASE
to do Oral hygiene motivation Instruction Disinfection
evaluation PPD ≤ 4 mm FMPS ≤ 20 % BOP ≤ 20 % Successful
PROPHYLAXIS Preventive long-term care
NOT SUCCESSFUL
PATIENT WITH PERIODONTAL DISEASE
to check
Systemic phase and Periodontal diagnosis
Oral hygiene, tabacco consumption, periodiontal status, furcation involvement, X-ray status, general health (systemic diseases, e.g. diabetes, circulatory problems, etc), stress, pregnancy
evaluation Moderate chronic
Severe chronic periodontitis or
periodontitis
aggressive periodontitis
PPD ≤ 4 mm
PPD ≤ 6 mm
PPD > 6 mm with intrabony defect
FMPS ≤ 20 %
without intrabony defect
Consider also the removal of inadequate restorations, optional splinting before surgery, use of microbiologic tests, involvement of general physician and extraction of hopeless teeth. Regarding hopeless teeth the following factors should be considered: bone loss, clinical attachment loss, degree of mobility, endodontic factors, restorative factors, anatomy and tooth position.
BOP ≤ 20 %
with furcation involvement (class II or class III) Furcation involvement (class I)
Necrotizing periodontitis Periodontitis with systemic disease
PROPHYLAXIS Preventive long-term care
Special case of periodontitis
to do
PPD > 6 mm Profuse bleeding or pus
Refer to a specialist
Optionally not via specialist
PATIENT WITH PERIODONTAL DISEASE
to do Motivation for oral hygiene Instruction Plaque control
to do Non-surgical periodontal treatment i.e. supragingival and subgingival SRP
re-evaluation
NOT SUCCESSFUL
PPD ≤ 4 mm FMPS ≤ 20 % BOP ≤ 20 %
2nD chance
re-evaluation (3 months) PPD ≤ 4 mm
Successful
FMPS ≤ 20 % BOP ≤ 20 % Successful
to do Second non-surgical periodontal treatment
PROPHYLAXIS
PROPHYLAXIS
Preventive long-term care
Preventive long-term care
NOT SUCCESSFUL
PERIODONTAL SURGERY OF MULTI-ROOTED TEETH WITH FURCATION INVOLVEMENT (CLASS II AND III)
SURGERY – WITH FURCATION INVOLVEMENT (CLASS II AND III)
MAXILLA 1
RE-evaluation
MANDIBLE 2
SURGERY – WITHOUT FURCATION INVOLVEMENT (PPD > 6 MM)
to do Post-operative care
horizontal bone loss Conventional periodontal flap surgery Conservative or resective approach
class II
class III
class II
Buccal:
Resective approach
STRAUMANN ®
Tunneling, or
STRAUMANN ®
or extraction
EMDOGAIN
resective approach
or GTR
or extraction
EMDOGAIN or GTR Mesial: STRAUMANN ® EMDOGAIN
according to site characteristics
class III
Site mapping for defect localization, e.g. bone sounding Regenerative surgical technique designed to maintain the interdental soft tissue
re-evaluation (6 MONTHS)
either alone or in
PPD ≤ 4 mm
combination with
FMPS ≤ 20 %
graft (in buccal
BOP ≤ 20 %
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Intrabony component ≥ 3 mm
defects) or resective
Distal:
approach
Closure or improvement to furcation class I Filling of the angular bony defect
Root resection
SELFCONTAINED defect
NON-SELFCONTAINED defect
STRAUMANN ®
STRAUMANN ®
EMDOGAIN or GTR
EMDOGAIN or GTR
Reconsider diagnosis and treatment plan.
either alone or com-
combined with
Further non-surgical therapy, if necessary.
bined with graft
graft
or flap surgery with STRAUMANN
angular bony defect
®
Successful
NOT SUCCESSFUL
EMDOGAIN
to do
PROPHYLAXIS Preventive long-term care 1
Limited evidence for regeneration
2
Depending on the local soft and hard tissue characteristics
NON-SELF-CON
Post-operative care (after PERIODONTAL Surgery) The following publications have been consulted by the authors: Use of antispetic oral rinse (e.g. 0.1– 0.2 % chlorhexidine solution) for 3– 6 weeks
Lang, Lindhe, Clinical Periodontology and Implant Dentistry (5th ed.) 2008(2) 655-673. Lang et al., Qualitätssicherung in der Parodontologie. Interdisziplinäre Fortbildungswoche IWF zur Qualitätssicherung in der Zahnmedizin der Schweizerischen Zahnärzte-Gesellschaft SSO,
Optional use of systemic antibiotics
1999 Saxer UP, Muhlemann HR, Motivation and education. SSO Schweiz Monatsschr Zahnheilkd 1975, 85, 905-919 Lang N, Tan WC, Krähenmann MA, Zwahlen M, A systematic review of the effects of full-mouth debridement with and without antiseptics in patients with chronic periodontitis. 6th European Workshop on Periodontology 2008, Feb, Ittingen, Thurgau, Switzerland Heitz Mayfield LJA, Trombelli L, Heitz F,
Removal of sutures when they are no longer necessary for wound stability (usually after 10 –14 days)
Needleman I, Moles D, A systematic review of the effect of surgical debridement vs. non-surgical debridement for the treatment of chronic periodontitis. J Clin Periodontol 2002, 29 (3) 92-102 Herrera D, Alonso B, Leon R, Roldan S, Sanz M, Antimicrobial therapy in periodontitis: the use of systemic antimicrobials against the subgingival biofilm. 6th European Workshop on Periodontology 2008, Feb, Ittingen, Thurgau,
No brushing in the operated area for at least 2–3 weeks, professional post-operative care once a week (about 30 min)
Switzerland Gaunt F, Devine M, Pennington M, Vernazza C, Gwynett E, Steen N, Heasman P, The cost-effectiveness of supportive periodontal care for patients with chronic periodontitis. 6th European Workshop on Periodontology 2008, Feb, Ittingen, Thurgau, Switzerland Schwarz F, Aoki A, Becker J, Sculean A, Laser application in non-surgical periodontal therapy: a systematic review. 6th European Workshop on Periodontology 2008, Feb, Ittingen, Thurgau, Switzerland Claffey N, Nylund K, Kiger R, Garrett S, Egelberg J, Diagnostic predictability of scores of
After 3 weeks gentle brushing of the buccal and lingual tooth surface with a “wiping technique”
plaque, bleeding, suppuration and probing depth for probing attacment loss. 3.5 years of observation following initial periodontal therapy. J Clin Periodontol 1990, 17 (2) 108-114 Eberhard J, Jervoe-Storm PM, Needleman I, Worthington H, Jepsen S, Full-mouth treatment concepts for chronic periodontitis: a systematic review, J Clin Periodontol 2008, 35 (7) 591-604 Lang N et al., A systematic review of the effects of full-
No sulcus or interproximal tooth cleaning for at least 3– 4 weeks post-op/until stable or interproximal
PERIODONTAL SURGERY OF SINGLE-ROOTED TEETH OR MULTI-ROOTED TEETH WITHOUT FURCATION INVOLVEMENT (PPD > 6 MM)
conditions are achieved
mouth debridement with and without antiseptics in patients with chronic periodontitis, J Clin Periodontol 2008, 35 (8) 8-21 Quirinen M, Mongardini C, de Soete M, The role of chlorhexidine in the one-stage full-mouth disinfection treatment of patients with advanced adult periodontitis. J Clin Periodontol 2000, 27 (8) 578-589 Swierkot K, Flores de Jacoby L, Mengel R et al., One-stage full-mouth disinfection versus quadrant and full-mouth root planing, J Clin Periodontol 2009, 36, (3) 240-249 Quirinen M et al., Benefit of „one-stage full-mouth disinfection“ is explained
Regular check-up by dentist – individual recall program
by disinfection and root planing within 24 hours: a randomized controlled trial. J Periodontol, 33, (9) 639-647 Wang D et al., Antibody response after single-visit full-mouth ultrasonic debridement versus quadrant-wise therapy. J Clin Periodontol 2006, 9, 632-638 Lindhe J et al., Special issue of the Journal of Clinical Periodontology on Enamel Matrix Proteins. J Clin Periodontol 1997 Sep. 24(9) Bosshardt D et al., Effects of enamel matrix proteins on tissue formation along the roots of human teeth. J Periodontol. Res 2004, 40, 158 Heijl, Heden et al., Enamel matrix derivative (Straumann® Emdogain) in the treatment of intrabony periodontal defects. J Clin Periodontology 1997; 24; 705-714 Pontoriero et al., The use of barrier membranes and enamel matrix proteins in the treatment of angular bone defects. J Clin Periodontol. 1999; 26(12): 833-40 Heden, Wennström et al., Five-Year Follow-Up of Regenerative Periodontal Therapy with Enamel Matrix Derivative at Sites with Angular Bone Defects. J Periodontol 2006; 295-301 Sculean et al., Treatment of Intrabony Defects With an Enamel Matrix Protein Derivative or Bioabsorbable Membrane: A 8-Year Follow-Up Split-Mouth Study. J Periodontol 2006; 77(11), 1879-1886 McGuire MK, Nunn M, Evaluation of Human recession defect treated with coronally advanced flaps and either Enamel Matrix Derivative or Connective Tissue. J Periodontol 2003; 74: 1110-1125 McGuire MK, Cochran DL, Evaluation of Human recession defect treated with coronally advanced flaps and either Enamel Matrix Derivative or Connective Tissue. J Periodontol 2003; 74; 1126-1135 Cueva MA, Boltchi FE, Nunn ME, Rivera-Hidalgo F, Rees T, A comparatitive study of coronally advanced flaps with and without the addition of enamel matrix derivative in the treatment of marginal tissue recession. J Periodontol 2004 Jul; 75(7):949-56 Castellanos A, de la Rosa M, de la Garza M, Caffesse RG, Enamel matrix derivative and coronal flaps to cover marginal tissue recessions. J Periodontol. 2006 Jan. 77(1):7-14 Jepsen, Meyle et al., A randomized clinical trial comparing enamel matrix derivative and membrane treatment of buccal Class II furcation involvement in mandibular molars. Part I: Study design and results for primary outcomes. Part II: secondary outcomes. J Periodontol. 2004, Aug; 75(8): 1150-60 Meyle, Jepsen et al., A randomized clinical trial comparing enamel matrix derivative and membrane treatment of buccal Class II furcation involvement in mandibular molars. Part I: Study design and results for primary outcomes. Part II: secondary outcomes. J Periodontol. 2004, Sep; 75(9): 1188-95 Lindhe J et al., Special issue of the Journal of Clinical Periodontology on Enamel Matrix Proteins. J Clin Periodontol 1997 Sep; 24(9) Bosshardt D et al., Effects of enamel matrix proteins on tissue formation along the roots of human teeth. J Periodontol. Res 2004, 40, 158 Cortellini P, Tonetti MS, Microsurgical approach to periodontal regeneration. Initial evaluation in a case cohort. J Periodontol 2001,72, 559-569 De Sanctis M, Zucchelli G, Clauser C, Bacterial colonization of barrier material and periodontal regeneration. J Clin Periodontol 1996, 23, 1039-1046 Esposito M, Grusovin MG, Coulthard P, Worthington HV, Enamel matrix derivative (Emdogain) for periodontal tissue regeneration in intrabony defects. Cochrane Database Syst Rev 2005, CD003875
Exclusion of liability for statements and recommendations of the authors: The statements and recommendations published in this Periodontal Treatment Guide have been systematically assessed and carefully selected by the publisher of the Perio Treatment Guide (Institut Straumann AG, Basel). The statements and recommendations in every case reflect the opinion of the authors and therefore do not necessarily coincide with the publisher’s opinion. Nor does the publisher guarantee the completeness or accuracy and correctness of the statements and recommendations published in the Periodontal Treatment Guide. The information given in the Perio Treatment Guide cannot replace a dental assessment by an appropriately qualified dental specialist in an individual case. Any orientation to statements and recommendations published in the Perio Treatment Guide is therefore on the dentist’s responsibility. The statements and recommendations published in the Perio Treatment Guide
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