Getting Patients Off the 3-Month Merry-Go-Round: Part II Nancy Adair

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Getting Patients Off the 3-Month Merry-Go-Round: Part II


[Editor's note: This is the second part of a series by the author.
Check out the first installment here.]

 

Do you feel like you're on a merry-go-round with your patient care and getting nowhere? Have you taken your patients as far as possible with conservative nonsurgical periodontal care, also known as Phase I? Can you objectively look at the acquired patient data over a period of time and determine if they'd benefit from surgical intervention, Phase II? Often, the merry-go-round syndrome can be seen in our patients of record, also known as Phase III, supportive periodontal therapy.

For most patients with a history of periodontitis, visits at three-month intervals have proven effective in maintaining the established gingival health. However, with our aging population retaining teeth or dental implants, periodontal intervention is becoming more common. Based on evaluation of clinical findings and assessment of disease status, periodontal maintenance frequency may be modified, or the patient may be returned to active treatment.1 

Getting Patients Off the 3-Month Merry-Go-Round: Part II

 

Dentistry his definitely become more complex and challenging. For the most part, the past has consisted of checkups and cleanings, but today we are contending with chronic periodontal disease, management of the elderly and incorporating dental implant departments into our practices. We are uncovering many undiagnosed dental conditions because of the aging population and advancements in technology. Technology has enabled dentistry to be more accurate, and much more of an exact science-based profession than ever before. With that, our diagnosis and treatment plans need to expand and evolve.

In the fast-paced world of dentistry, we are often making knee-jerk reactions on patients and defaulting to a “checkup and cleaning.” Perhaps by applying the new American Academy of Periodontology guidelines (See previous article) and the benefits of surgical intervention, a different path may open for your patient.

Periodontics has been the least-developed dental discipline in dentistry, and yet many patients require periodontal surgery to address conditions and diseases.  If our goal is truly teeth for life, periodontal surgery can improve the success rate of patients in retaining their dentition for a lifetime. Periodontal surgery can be thought of as resective, or regenerative in nature.

Resective procedures aim to reduce or eliminate periodontal pockets and create acceptable gingival health that facilitates good oral hygiene and periodontal maintenance. Periodontal regenerative procedures include bone replacement grafts, use of biologics, root biomodifications, guided tissue regeneration, and combinations of these procedures for osseous, furcation and gingival recession defects.2

Expanding the continuum of care for new patients and patients of record to include surgical intervention will be beneficial.  


Getting Patients Off the 3-Month Merry-Go-Round: Part II

 

Do any of the following conditions exist in your patients?

  • Constant inflammation
  • Periodontal pockets ≥ 5mm
  • A lack of attachment and/or mucogingival involvement
  • Mobile teeth
  • Class II furcations
  • Vertical bony defects or overgrowth of tissue

If the answer is yes, consider the following procedures:

 

Comprehension of procedure

 

Resective or regenerative

procedure

OFD (open flap debridement) with or without osseous surgery.

 

Flapping the area of concern and removing tissue and/or bone

Alternatively, flapping and adding tissue and/or bone

Can be both

Proximal wedges

Correcting the height of tissue and bone; often this procedure is done on the distal of the maxillary second molars

Resective

Bone grafting

 

Adding bone to a bony defect; can be autograft, allograft or xenograft

 

Regenerative

Soft tissue grafting

Adding tissue to an area to enhance the amount of tissue and/or provide more keratinized tissue; possible in some cases to achieve root coverage

 

Regenerative

Periodontal splinting

When foreshortened roots and/or mobile teeth exist, splinting teeth can help to stabilize teeth; can be seen more commonly in anterior than posterior

 

Regenerative

Gingivectomy/gingivoplasty

This procedure has been relegated to a lesser role as more sophisticated techniques are available

 

Resective

Implants

In many situations, implants are more ideal than bridges; however, the patient has to be selected as a candidate and meet criteria

 

Regenerative

 

 

It is important to have a “working model” approach and generalized guidelines. However, each case needs to be assessed individually. Review common clinical situations and expand the scope of practice to include possible periodontal surgical procedures, such as:

Persistent pocketing. Monitor pocket depths (PD) up to 12–18 months after Phase I active definitive SRP. If PD of 4mm or greater in the anterior and/or 5mm or greater in the posterior remain, consider referring for pocket reduction. Pocket reduction may be resective or regenerative procedure. Possible procedures are open flap debridement with or without osseous recontouring, bone grafting and/or proximal wedges.

  • Probing depths greater than 5mm were difficult to maintain as healthy and had more residual plaque and calculus.3

     

    Deep restorative margins. Evaluate the current restorative margin and/or where the new margin will be placed. Does adequate distance exist between margin and bone? If an adequate distance does not exist between bone and tissue, constant inflammation will likely persist. Possible procedure is crown lengthening. (Note: Crown lengthening often includes osseous surgery.)

  • Clinicians should establish the level of the subgingival restorative margin and then remove bone so it’s 2–3mm apical to the margin.4

     

    Lack of attached gingivae/mucogingival involvement. During an intraoral exam, evaluate the attachment level of tissues around teeth and implants as well as the frenum pulls. The use of a probe can help determine if adequate tissue exists by rolling the unattached tissues. Possible procedure is soft tissue grating, often known as connective tissue grafting (CTG) or free gingival grafting (FGG).

  • In general, at least 1mm of attached gingiva is sufficient for general health.5

     

    Mobile teeth. Use a combination of full periodontal records and quality and quantity of radiographs to determine the mobility in teeth. For shortened roots and/or bone loss, especially in the anterior regions, periodontally splinting teeth together is a viable option. If the case is Class II/Class II+ or a plus-or-minus moderate-to-advanced bone loss, a possible procedure may be periodontally splinting teeth, occlusal adjustment or a night guard.

  • Although the relationship between mobility and periodontal prognosis is still unclear, studies suggested that mobility was associated with increased periodontal breakdown and a poorer long-term prognosis.6

     

    Unresolved periodontal conditions. If a resolution cannot be achieved conservatively and the diagnosis cannot be clearly determined, sometimes flapping an area for exploratory purposes can benefit the case. With direct visual inspection of the area, a more definitive diagnosis and treatment plan is possible. Possible procedure: exploratory surgery.

  • If a stable periodontium cannot be achieved, pursue options. Note: A successfully treated periodontitis case would have ≤ 4mm PD and < 10% BOP.7

     

    Isolated areas of recession and/or furcations. Using a furcation probe, evaluate all furcations. Often, furcation involvements are not detected at an early stage. If a Class II furcation exists (3mm or greater horizontally in furcation), that patient may be a candidate for bone and/or soft tissue grafting. Isolated areas of recession with or without furcation involvement may mean occlusal trauma. Possible procedures are bone grafting, soft tissue grafting, occlusal adjustment or night guard.

  • Early surgical intervention with flap and osseous surgery or flaps with regenerative materials should be implemented. 8

     

    Unresponsive to conservative or surgical treatment. Patients may require a second session of Phase I active definitive SRP before surgery. Some periodontists prefer that compromised teeth have some SRP before surgery to reduce the inflammation and provide a better quality of tissue to work with during surgery. However, if teeth are hopeless and patients refuse additional Phase I, referral or surgery, the procedure here would be to extract teeth and preserve bone for potential future implants.

  • If a stable periodontium cannot be achieved, pursue options. Note: A successfully treated periodontitis case would have ≤ 4mm PD and < 10% BOP.7

 

Advanced periodontal cases. Many moderate and mostly all advanced cases require monitoring indefinitely by a periodontist. According to many periodontists, a very high percentage of patients with advanced periodontal disease do require some form of periodontal surgery.

Example 1
Getting Patients Off the 3-Month Merry-Go-Round: Part II
Persistent pocketing situation whereby a horizontal bitewing and vertical bitewings never identified the extent of bone loss; a periapical radiograph clearly shows the extent of bone loss and Class III furcation. Conservative SRP with antimicrobial agents is not enough; referral was executed to a periodontist for evaluation. Possible procedure: OFD, osseous recontouring and apically reposition of tissue.

Example 2 
Getting Patients Off the 3-Month Merry-Go-Round: Part II
Deep restorative margins and/or redundant tissue should be identified before new restorative procedures are completed. Note the probing depths and amount of inflammation in area of maxillary central. At exam time, a suggestion was for possible crown lengthening before new crowns are fabricated. A common healing period is six weeks after many surgical procedures.

Example 3 
Getting Patients Off the 3-Month Merry-Go-Round: Part II
Lack of attached keratinized gingivae may mean a soft tissue graft is ideally required; that is, a connective tissue graft (CTG) or free gingival graft (FGG). As a clinician, gather data and imaging, and test the amount of keratinized tissue with the side of a probe. In this case we referred to a periodontist to evaluate whether the patient would benefit from grafting before replacing the old restoration.

Example 4
Getting Patients Off the 3-Month Merry-Go-Round: Part II      Getting Patients Off the 3-Month Merry-Go-Round: Part II
Mobile teeth and unresolved periodontal case occurred in an older individual, whereby after active definitive SRP, pocketing and inflammation remained, so OFD was executed, some minor osseous recontouring was completed, and then the teeth were periodontally splinted. In the older population we are trying a conservative approach to include surgery versus extractions and implants whenever possible.

Example 5
Getting Patients Off the 3-Month Merry-Go-Round: Part II        Getting Patients Off the 3-Month Merry-Go-Round: Part II      Getting Patients Off the 3-Month Merry-Go-Round: Part II

All three of these images can be seen in many of our patients of record; that is, furcation involvement, bone loss, larger interproximal spacing, and continual loss of tissue and/or bone. For the first time in history, our population is growing old with their natural dentition and/or implants. Dentistry has become much more complex and challenging. My preference is to collaborate with a periodontist on these cases to ensure the patient is receiving comprehensive care.

Conclusion
Use the new criteria guidelines to help get your patients off the three-month merry-go-round! Ensure all patients have a complete periodontal exam and quality and quantity of radiographs, then go through the periodontal process of Phase I, Phase II and Phase III. The phases are dynamic and will need to be adjusted constantly as your patients retain their teeth for a lifetime.

References
1. Parameter on Periodontal Maintenance; J Periodontol 2000;71:849-850.
2. Comprehensive Periodontal Therapy: A Statement by the American Academy of Periodontology; doi: 10.1902/jop.2011.117001.
3. Prognosis Revisited: A System for Assigning Periodontal Prognosis. doi:10.1902/jop.2007.070210.
4. Newman et at. Clinical Periodontology. Periodontal Restorative Interrelationships. 2012; 609.
5. Darby M. Walsh M. Dental Hygiene Theory and Practice. Periodontal Risk and Assessment. 2015; 319.
6. Prognosis Revisited: A System for Assigning Periodontal Prognosis. doi: 10.1902/jop.2007.070210.
7. Fritz P. Ward W. The New Global Classification System for Periodontal and Peri-Implant Diseases. Oral Health, October 2018.
8. Newman et al. Clinical Periodontology. Periodontal Restorative Interrelationships. 2012: 593.
Lending a Helping Hand

Getting Patients Off the 3-Month Merry-Go-Round: Part IINancy Adair's journey in dentistry and dental hygiene have enabled her to be a source of knowledge on the evolution of dentistry. Adair is a motivational international speaker, a dental educator, a past CE chairperson, a transition leader, a clinical supervisor, a research team member on implants, a periodontal hygienist and the founder and owner of the CE company Hygiene Excellence.

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