Periodontal Treatment Guide

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The treatment of patients with periodontal disease should involve the application of standard proce-dures based on commonly accepted guidelines. This “Periodontal Treatment Guide” aims to support local networks of general dentists, hygienists and perio-dontists 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 sys-tematic 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.

Teamwork for treating periodontal disease

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Prof. Dr. med. dent. Anton Sculean, Dr. h.c., M.S., Chairman of Department of Periodontology, School of Dental Medicine, University of Bern, Bern, SwitzerlandDr. Christina Tietmann, Certified periodontal specialist of the German Society of Periodontology, Private Practice for Periodontology, Aachen, GermanyDr. David Nisand, Lecturer of periodontics at the University of Paris, Private Practice limited to periodontology and implantology, Paris, FranceDr. Frank Bröseler, Certified periodontal specialist of the German Society of Periodontology, Private Practice for Periodontology, Aachen, GermanyDr. Holger Janssen, Specialist for periodontology, implantology and restorative dentistry, Private Practice, Berlin, Germany

The following authors have significantly contributed to the development of the “Periodontal Treatment Guide”

Dr. Mario Roccuzzo, Lecturer in Periodontics at University of Torino and Siena. Private Practice limited to Periodontics and Implantology, Torino, ItalyDr. Markus Schlee, Lecturer for periodontics and implantology at the Steinbeis University, Berlin and DIU, Dresden, Germany. Private practice limited to periodontology and implantology, Forchheim, GermanyProf. Dr. Nick Donos, DDS, MS, FHEA, FDSRCSEngl, PhD., Head & Chair of Periodontology, Director of Research, UCL-Eastman Dental Institute, Department of Periodontology, London, United Kingdom

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Periodontal treatment

BPE012

BPE34

BPE34

Periodontally healthy patientEVALUATION

Patient with periodontal diseaseHYGIENE

Patient with periodontal diseaseSURGERY

LegendBPE 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

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Periodontally healthy patient

ORAL CHECK

MAINTENANCE PHASE

Successful

PROPHYLAXISPreventive long-term care

Not successful

EVALUATION

PPD ≤ 4 mmFMPS ≤ 20%BOP ≤ 20%

TO CHECK● Oral hygiene● Tobacco consumption● Periodontal status● Furcation involvement● X-ray status● General health

TO DO● Oral hygiene motivation● Instruction● Disinfection

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Patient with periodontal disease

SYSTEMIC PHASE AND PERIODONTAL DIAGNOSIS

EVALUATION

PPD ≤ 4 mmFMPS ≤ 20%BOP ≤ 20%

TO CHECK

● Oral hygiene

● Tobacco consumption

● Periodontal status

● Furcation involvement

● X-ray status

● General health (systemic diseases, e.g. diabetes, circulatory problems, etc.)

● Stress

● Pregnancy

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.

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Moderate chronic periodontitisPPD ≤ 6 mm without

intrabony defect

Furcation involvement (class I)

Severe chronic periodontitis or aggressive periodontitis

PPD > 6 mm with intrabony defect

with furcation involvement (class II or class III)

Necrotizing periodontitisPeriodontitis with systemic disease

Special case of periodontitisPPD > 6 mm Profuse bleeding or pus

Optionally not via specialistPROPHYLAXISPreventive long-term care

Click here TO DO

Refer to a specialist

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Patient with periodontal disease

Successful

Not successful

RE-EVALUATION

PPD ≤ 4 mmFMPS ≤ 20%BOP ≤ 20%ATION

RE-EVALUATION (3 Month)

PPD ≤ 4 mmFMPS ≤ 20%BOP ≤ 20%ATION

TO DO● Motivation for oral hygiene● Instruction● Plaque control TO DO

Non-surgical periodontal treatment i.e. supragingival and subgingival SRP

Not successful

2nd Chance

Successful TO DO

Second non-surgical periodontal treatment

Click herePROPHYLAXISPreventive long-term care

PROPHYLAXISPreventive long-term care

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PERIODONTAL SURGERY OF MULTI-ROOTEDTEETH WITH FURCATION INVOLVEMENT

(Class II and III)

PERIODONTAL SURGERY OF SINGLE-ROOTEDTEETH OR MULTI-ROOTED TEETH WITHOUT

FURCATION INVOLVEMENT (PPD > 6 mm)

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Surgery – with furcation involvement(Class II and III)

MAXILLA¹

Class II Class IIClass III Class III

MANDIBLE²

Buccal: Straumann® Emdogain® or GTR

Mesial: Straumann® Emdogain®

Distal: Root resection or flap surgery with Straumann® Emdogain®

Straumann® Emdogain® or GTR either alone or in combination with graft (in buccal defects)

or resective approach

Resective approach or extraction

Tunneling, or resective approach or extraction

¹ Limited evidence for regeneration² Depending on the local soft and hard tissue characteristics

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Surgery – without furcation involvement(PPD > 6 mm)

HORIZONTAL BONE LOSS

SELF-CONTAINED DEFECT

NON-SELF-CONTAINED DEFECT

ANGULAR BONY DEFECT

Conventional periodontal flap surgeryConservative or resective approach according

to site characteristics

Site mapping for defect localization, e.g. bone soundingRegenerative surgical technique designed to maintain

the interdental soft tissueIntrabony component ≥ 3mm

Straumann® Emdogain® or GTR either alone or combined with graft

Straumann® Emdogain® or GTR combined with graft

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Re-evaluation

RE-EVALUATION (6 Month) TO DO

Post-operative care

Successful Not successful

TO DO

Reconsider diagnosis and treatment plan. Further non-surgical therapy, if necessary.

PPD ≤ 4 mmFMPS ≤ 20%BOP ≤ 20%

Closure or improvement to furcation class I Filling of the angular bony defect

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PROPHYLAXISPreventive long-term care

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Post-operative care (after periodontal surgery)

● Use of antiseptic oral rinse (e.g. 0.1-0.2% chlorhexidine solution) for 3-6 weeks

● Optional use of systemic antibiotics● Removal of sutures when they are no longer

necessary for wound stability (usually after 10-14 days)

● No brushing in the operated area for at least 2-3 weeks, professional post-operative care once a week (about 30 min)

● After 3 weeks gentle brushing of the buccal and lingual tooth surface with a “wiping technique”

● No sulcus or interproximal tooth cleaning for at least 3-4 weeks post-op/until stable or interproximal conditions are achieved

● Regular check-up by dentist – individual recall program

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The following publications have been consulted by the authors

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, 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, 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, Antimicro-bial therapy in periodontitis: the use of systemic antimicrobials against the subgingival biofilm. 6th European Workshop on Periodontology 2008, Feb, Ittingen, Thurgau, 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 Work-shop on Periodontology 2008, Feb, Ittingen, Thurgau, Switzerland. Claffey N, Nylund K, Kiger R, Garrett S, Egelberg J, Diagnostic predictability of scores of plaque, bleeding, suppuration and probing depth for probing attacment loss. 3.5 years of observation following initial periodon-tal 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-mouth debridement with and without antiseptics in patients with chronic periodontitis, J Clin Periodontol 2008, 35 (8) 8-21. Quirynen 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 fullmouth disinfection“ is explained 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.

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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 Periodontal 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 Periodontal 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 Periodontal Treatment Guide is therefore on the dentist’s responsibility. The statements and recommendations published in the Periodontal Treatment Guide are protected by copyright and may not be reused, in full or in part, without the express consent of the publisher.