The Ortho-Perio Patient

Clinical Evidence & Therapeutic Guidelines

Theodore Eliades, Christos Katsaros

• Publisher: Quintessence Publishing Co, Inc
• Year: 2019
• ISBN:
  9780867158458
• Topic: Medicine
• Subtopic: Dentistry

Although most orthodontic curricula provide courses on interdisciplinary orthodontic-periodontic treatment, there are still surprisingly few resources on the topic. Written by leading scholars in the field, this book provides a broad analysis of the topic from both the periodontal and orthodontic perspectives. The authors systematically analyze the scientific and clinical interactions of these specialties by reviewing all the available evidence and using case studies to demonstrate principles discussed in theory. The result is a text that outlines the treatment fundamentals and shows how to improve the therapeutic outcomes involving orthodontic-periodontic interventions. 346 illus.

Periodontal Examination of the Orthodontic Patient

Giovanni E. Salvi
Christoph A. Ramseier

Periodontal diseases represent inflammatory conditions initiated by oral biofilms. From a clinical point of view, redness and swelling of the gingiva as well as increased probing depths with tendency to bleeding on probing (BoP) are common characteristics of patients suffering from periodontitis. Advanced periodontitis may also be associated with gingival recessions, increased tooth mobility, and flaring of teeth. Moreover, periodontitis may be recognized in radiographs by moderate to severe loss of alveolar bone. Based on the fact that periodontitis includes gingival inflammation and progressive loss of periodontal attachment and alveolar bone, a comprehensive examination must include assessments describing such pathologic changes.

Outcomes from studies in humans have indicated that elimination of the biofilm infection and institution of plaque-control regimens result in periodontal health in most, if not all, cases. This condition forms the basis for further correction, including orthodontic therapy.

Comprehensive planning and treatment of patients with periodontal diseases and problems such as tooth malpositioning and migration should include the following:

1.A systemic phase with a smoking cessation program, if necessary

2.An initial phase of periodontal therapy

3.A corrective phase of therapy including orthodontic therapy

4.A maintenance phase including supportive periodontal care

Treatment Goals

A treatment strategy including elimination of the bacterial infection must be defined and followed. In this context, the following clinical parameters should be reached at the end of active periodontal therapy:

•Reduction of periodontal tissue inflammation as measured by BoP. A full-mouth mean BoP ≤ 25 % should be achieved.¹

•Reduction in probing pocket depth (PPD) measured in millimeters. Absence of residual pockets with PPD > 5 mm should be achieved.¹

•Control of furcation involvement of multirooted teeth not exceeding grade 1.²

•Absence of pain and discomfort.

Following active periodontal therapy, the patient has to be enrolled in a regular supportive periodontal therapy program.³

Patient History and Systemic Phase

Assessment of the patient’s periodontal and orthodontic problems requires an evaluation of the following aspects: chief complaint, medical history with concomitant medication(s), social and family history, dental history, oral hygiene habits, and smoking history and counseling. Prior to the initial periodontal examination, a health questionnaire should be filled out by the patient in order to immediately capture medical risk factors affecting treatment. The four major categories of medical complications encountered in patients undergoing dental treatment may be prevented by checking the medical history with respect to cardiovascular diseases, bleeding disorders, infective risks, and allergic reactions. If indicated, referral to a physician or specialist should be made to take appropriate preventive measures.

Assessment of the family history with respect to periodontal problems may also be important in order to diagnose aggressive forms of periodontitis with a hereditary component. However, based on current knowledge, it is premature to recommend a systematic genetic screening of patients with periodontal diseases and candidates for orthodontic therapy.

With respect to dental history, symptoms of periodontitis noticed by the patient such as tooth migration, increasing tooth mobility, bleeding gingiva while eating or brushing, and impaired chewing function have to be explored. Information on the patient’s oral hygiene routine should also be collected, including frequency and duration of daily brushing with a manual or electric toothbrush as well as the use of interproximal cleansing devices or additional chemical agents.

Second to inadequate oral hygiene, cigarette smoking has been identified as the most important risk factor in the etiology and pathogenesis of periodontal diseases.^4,5 Therefore, in every patient, the history of tobacco use (eg, the current smoking status) must be recorded. For patients with regular tobacco use, brief interventions have to be provided in order to encourage smokers to enroll in a smoking cessation program.

Initial Phase

Following completion of a comprehensive periodontal examination, an initial phase of periodontal therapy should be conducted. This initial phase is also called cause-related therapy. The goal of this phase is to achieve infection-free conditions in the oral cavity through removal of all supra- and subgingival soft and hard deposits and their retentive factors (eg, root remnants, caries lesions, overhanging fillings, and reconstructions). Moreover, following individualized instructions, the patient should be motivated to perform optimal plaque control.

Repeated plaque score recordings are indicated during the initial phase of periodontal therapy (ie, infection control) and are used for the improvement of self-performed plaque control.⁶

At the end of the healing time following the initial phase (ie, 3 to 6 months), re-evaluation with a periodontal chart helps to determine the needs for additional and supportive therapies.

Corrective Phase

The need for additional therapy in the corrective phase is assessed following evaluation of the success of the initial phase. The main goal of the corrective phase is to address the sequelae of periodontal tissue destruction, and this phase includes therapies such as periodontal and implant surgery and prosthetic reconstruction.

If patient compliance is unsatisfactory, it may not be worth initiating corrective treatment procedures as they will not lead to a final improvement of periodontal health. This is supported by the outcomes of studies indicating that surgical periodontal procedures performed in patients with proper plaque control result in gain of periodontal attachment and alveolar bone, whereas periodontal surgery performed in plaque-infected dentitions may yield additional periodontal tissue destruction.^7–11

Moreover, in patients who are candidates for dental implants, implant placement should be initiated only following the completion of successful periodontal therapy.¹²

Maintenance Phase

The aim of this phase of periodontal treatment is the prevention of reinfection and disease recurrence. During the maintenance phase, repeated assessments of clinical periodontal parameters have to be conducted. These include the assessment of residual PPD ≥ 5 mm, BoP and suppuration around teeth and implants, and the evaluation of furcation involvement. Repeated BoP recordings are recommended during the maintenance phase in order to assess periodontal stability.^13,14 It is established that self-performed plaque control combined with regular attendance of maintenance care visits following active periodontal treatment represented an effective means of controlling gingivitis and ...