severe perio treatment sequence

[oyasumi]

Hi,
I wanted to ask any practicing dentists what the proper treatment sequence is for a new pt that presents to the office with advanced perio disease. I am a new graduate from dental school and I will start associating soon, and I just wanted to make sure I have the correct understanding. My questions are highlighted in bold.

Here's how we learned it in school:

New patient comes in, new patient exam, etc., complete perio charting.

Deep probing depths/attachment loss, bleeding on every site, terrible OH, abundant plaque/calculus, furcation involvement, etc.

Lets say my diagnosis for this pt comes to be generalized severe periodontitis.

So my initial treatment would be 1 round of scaling then a re-eval appointment in 4-6 weeks.
At the re-eval I will do a complete perio charting again, assess hygiene levels, disease activity, home care, etc.
How do I determine if at the re-eval appointment that my initial round of scaling was a success and the patient can be placed on recall 3-4 months?

If disease activity is still present, I assume I would offer another round of scaling. Is this correct?
Would I do another re-eval appointment in 4-6 weeks for my second round of scaling?

At what point do I decide my treatments are not resolving the disease and refer to a specialist for more advanced treatment such as open flap debridement?

Also, if a patient that had severe periodontitis in the past is on recall getting regular scalings from a hygienist every 3-4 months and is getting complete perio chartings done yearly, at the recall exam how would I decide if the patient's disease is back and his diagnosis should be changed from "stable on reduced periodontium" to "active generalized severe periodontitis". Is the only way to compare the probing depths from the yearly perio charting?


I realize that these may be really obvious questions I am asking. I am a new grad and just making sure I have the proper understanding of everything I've learned in school before I start treating my own patients. I have asked another associate at the clinic I plan on associating at, but she wasn't really able to give me a straight answer/I don't think she knew. Also, sorry if this is not the proper place to post this, as I am new to this forum and not entirely familiar with posting rules.

Thank you!

---

Members don't see this ad.

 

[charlestweed]

If you see no attachment gain, no reduction in the pocket depth 4-6 weeks after the initial therapy of scaling and root planning, then there's no reason to do another round of sc/rp. To control the active perio disease and to prevent further bone loss , you need to bring the pocket depth to a normal maintainable level of 2-3mm so the patient can brush his/her teeth properly. The toothbrush cannot reach the pocket greater than 2-3mm. You have to refer the pt to a periodontist for pocket reduction surgeries, for extractions of perio hopeless teeth and implant placements. Or you can perform these surgical procedures yourself if you are confident in your surgical skills.

Patient's motivation and cooperation are very important in controlling the perio disease. It's is a silent painless chronic disease. Pocket reduction surgeries basically give the patient the second chance to maintain and to keep his/her teeth longer. There's nothing much you can do, if he/she refuses to brush/floss daily or continues to smoke. Patient education is very important.

 

[oyasumi]

If you see no attachment gain, no reduction in the pocket depth 4-6 weeks after the initial therapy of scaling and root planning, then there's no reason to do another round of sc/rp. To control the active perio disease and to prevent further bone loss , you need to bring the pocket depth to a normal maintainable level of 2-3mm so the patient can brush his/her teeth properly. The toothbrush cannot reach the pocket greater than 2-3mm. You have to refer the pt to a periodontist for pocket reduction surgeries, for extractions of perio hopeless teeth and implant placements. Or you can perform these surgical procedures yourself if you are confident in your surgical skills.

Patient's motivation and cooperation are very important in controlling the perio disease. It's is a silent painless chronic disease. Pocket reduction surgeries basically give the patient the second chance to maintain and to keep his/her teeth longer. There's nothing much you can do, if he/she refuses to brush/floss daily or continues to smoke. Patient education is very important.

Thanks charlestweed for the very informative response. I have a few follow up questions if you don't mind.

At the re-eval appointment, I see that the patient's oral hygiene and home care has improved dramatically. I see attachment gain and reduction in pockets depths in most sites, but still, others show no change. Would this be reason enough to do another round of scaling at the re-evaluation appointment? Or would it be best to still refer to a periodontist to perform some kind of periodontal surgery?

If I do decide to do another round of scaling at the re-eval, do I book another re-eval appointment in 4-6 weeks to follow up on those deep sites?

What is the difference from a "deep cleaning" and a scaling and root planing? Or are these the same things? The term "deep cleaning" is something I am unfamiliar with having graduated from a Canadian dental school, and I don't see how it differs from a traditional SRP. Is local anaesthesia always needed for a "deep cleaning"?

Using local anaesthetic during SRP, so far I haven't had to do this yet, but when would you personally considering doing it?

Please let me know if you need any clarification for my questions. I greatly appreciate your help!

 

[charlestweed]

Thanks charlestweed for the very informative response. I have a few follow up questions if you don't mind.

At the re-eval appointment, I see that the patient's oral hygiene and home care has improved dramatically. I see attachment gain and reduction in pockets depths in most sites, but still, others show no change. Would this be reason enough to do another round of scaling at the re-evaluation appointment? Or would it be best to still refer to a periodontist to perform some kind of periodontal surgery?

If I do decide to do another round of scaling at the re-eval, do I book another re-eval appointment in 4-6 weeks to follow up on those deep sites?

What is the difference from a "deep cleaning" and a scaling and root planing? Or are these the same things? The term "deep cleaning" is something I am unfamiliar with having graduated from a Canadian dental school, and I don't see how it differs from a traditional SRP. Is local anaesthesia always needed for a "deep cleaning"?

Using local anaesthetic during SRP, so far I haven't had to do this yet, but when would you personally considering doing it?

Please let me know if you need any clarification for my questions. I greatly appreciate your help!

First, you should praise the patient for making an effort to take better care of his teeth. IMO, patient’s own effort is the key in stopping the perio disease from progressing. Sure, you can do another round of scaling on those deep pocket sites but you should inform the patient that these deep pockets won’t go away on their own and it will be hard to maintain even with good daily brushing/flossing. The patient needs to be on a 3-month perio maintenance schedule if he/she refuses surgery. The problem with doing scaling on those deep pocket areas is you can’t effectively remove the subgingival calculus because you can’t see. When the subgingival anaerobic bacterial matrices are not removed, patient continues to get more bone loss.

The benefit of doing an open flap surgery is you can see and effectively remove the calculus deposit on the cementum. The infected cementum can also be smoothed out with a bur. Another benefit is you can re-contour the osseous defects and reduce the deep pocket to a normal level so the patient can easily maintain with daily brushing. Certain defects (3-walled or 4-walled defects) can be repaired with bone graft. The disadvantages of surgery are: cost, pain, root sensitivity, teeth may look worse than before because of the ugly exposed root surfaces.

I think it’s very uncomfortable for the patient, when you try to scale off the subgingival calculus without using local anesthesia. It’s your call. If you think the calculus is mostly supragingival and can easily be removed with the cavitron, then you don’t need to numb the patient.