Periodontics

Failure of periodonta] treatmentKlaus H.Rateiischak'^

Treatment faihires appear to occur mare frequently in pcriodontology than in otherdental disciplinen, inappropriate patient selection, incomplete diagnostieprocedures,errors in diagnosis or prognosis, treatment difficulties, unsupervised healing, and theabsence of maintenance therapy may be causes of such failures. A regular recall program canlargely prevent .such failures. {Qwúzss&T\cel-ntl994;25:449-457.)

Introduction

Analysis of a periodontal treatment failure can contrib-ute more to practical understanding than can the de-scription of a "nice" success. Periodontal treatmentfailures seem to arise relatively frequently, possibly be-cause, among other reasons, the periodontist works in afield characterized by the presence of plaque, and themarginal periodontium remains more or less exposedto microorganisms—depending on the intensity andquality of oral hygiene — even after successful primarycare. Not only does the amount of plaque play a role,but the pathogenicity of the microorganisms and theimmune status of the patient, his or her "resistance,"are also factors.

Causes of treatment failure

To discuss treatment failures, the concept of successfulperiodontal treatment must be defined first. In thepast, treatment was only considered successful whenthere was radical elimination of pockets; today, theconcept of treatment success is defined more modestly:

1. Bleeding (inflammation) is stopped.2. Pocket activity is eliminated.3. Probing depth is significantly reduced.4. Gain ofattachment is achieved,5. Tooth mobility is stabilized.

Professor, Univertity of Basel, Dental Inslituie, Petersplülz 14.CH-4051 Basel, Switzerland.

According to this definition of successful treatment,the following clinical parameters must be classified astreatment failure:

1. Bleeding on probing is continued.2. Symptoms of activity in addition to bleeding (exú-

date or pus) are seen in response to probing,3. Probing depth is not reduced or continues to in-

crease.4. Attachment loss is progressive.5. looth mobility is increased.

The causes of failure are manifold. In addition to thefact that periodontal therapy always takes place in re-gions exposed to plaque formation, failures may be as-cribed to the following factors;

1. Incorrect patient selection2. Incomplete diagnostic procedures, improper diag-

nosis, and incorrect prognosis3. Difficult (or inappropriate} treatment4. Unsupervised heahng5. Absenceof maintenance therapy

Incorrect patient selection

A patient is inappropriately selected for comprehen-sive periodontal therapy if. despite repeated efforts, heor she cannot be motivated to maintain proper oral hy-giene. Such patients are programmed for treatmentfailure.

The effort required to train the patient in proper oralhygiene procedures is enormous and is underestimatedby most dentists. Just telling the patient repeatedly notto forget to brush, or giving a quick demonstration on a

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Periodontics

Fig 1 a A 27-year-old woman withDown's syndrome (Langdon-Downsyndrome, trisomy 21) and severeperiodontitis. Oral hygiene is ab-sent. She has an anterior open biteand her molars are in crossbite.Treatment makes sense only if goodcooperation vjill be provided by hercaregivers; otherwise, failure is cer-tain and radioal prosthetic treat-ment is indicated.

Fig 1 b Radiographs of the pa-tient's condition.

model, simply does not suffice. Rather, the diseasemust be explained, perhaps on the basis of a bleedingindex. The explanation proceeds to a description of thebacterial cause of periodontitis (plaque). Finally, oralhygiene measures, particularly interdental hygiene, aretaught and checked repeatedly.

Incorrectly selected patients also include those pa-tients who have a serious systemic disease that couldpromote periodontitis. The disease categories involvedinclude metabolic diseases, such as insulin-dependentjuvenile diabetes; blood dyscrasias,such as panmyelop-

athy, the various leukemias, cyclic neutropenia, drug-induced agranulocytosis. and erythroblastic anemia;side effects of various drugs, such as hydantoin. cyclo-sporine, and nifedipine; immunodeficiency, such as in-fection with human immunodeficiency virus; geneticsyndromes, such as Down's syndrome. Papillon-Lefèvre syndrome, Chédiak-Higashi syndrome, hypo-phosphatasia.

As an example of this group of patients, a 27-year-oldwoman with Down's syndrome (mongolism, trisomy21) is shown (Fig, 1). Of course, patients afflicted by

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Pehodontics

Fig 2a A 28-year-olci woman withrapidly progressive periodontitis,Flareups are frequently localizedand irregular in this condition.

Fig 2b Radiographs of the samepatient. In this case of generalizedmedium loss, deep losses of boneare visible (eg, at teeth 14 and 15).

such conditions require special attention and must betreated. The total treatment plan, however, is morelikely to be a radical one. Teeth with advanced loss ofattachment are extracted- The therapy uften can beonly symptomatic.

Incomplete diagnoscic procedures, improper diagnosis,and incorrec! prognosis

The seriousness of the disease must be established ex-actly through the diagnostic procedures, not only forthe entire dentition, but also for each tooth individually

and for each side of a tooth. In addition to this perio-dontal morphology, is also important to describe thepathobiology of the periodontal state: Is it a case ofadult periodontitis (AP), rapidly progressive periodon-titis of a young adult (RPP). or (rarely) localized juve-nile periodontitis (UP)?' Depending on the phase ofthe disease, and on the form of its course, treatmentplans and prognoses will vary. For example, therapy ofrapidly progressive periodontitis must be more radicalthan that of adult periodontitis, if failure is to be avoided.

As an example, Fig 2 depicts a case of well-advanced

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Pehodontics

Fig 3a A caries-free 20-year-oldwoman with serious postjuvenileperiodontitis. Cursory inspectionindicates oniy gingivitis.

Fig 3b Radiographsoftiiepatientcieariy show extensive loss of at-tachment, particularly in the an-terior maxillary region.

rapidly progressive periodontitis that is not recogniz-able through a diagnosis made by simple observation.Only the most careful probing of each tooth side, anal-ysis of radiographs, and determination of tooth mobil-ity will reveal the severity of the disease, which requiresa correspondingly extensive treatment.

Another case is that of a caries-free 20-year-old pa-tient (Fig 3). Initial observation indicates serious gingi-vitis caused by plaque. Again, only careful probing, de-termination of tooth mobility, and analysis of the radio-graphs make it clear that she has severe postjuvenile

periodontitis. If only gingivitis is diagnosed in such apatient, and treatment is limited to removal of supra-gingival plaque and calculus, tooth loss would result ina short time and thus there would be a failure of treat-ment.

Difficult (or inappropriaie) ireatment

The chief purpose of a causal periodontitis therapy isthe elimination of subgingival plaque, that is, cleaningthe root surface. Subgingival scaling can be performed

452 Quintessence Internationai Volume 25, Number 7/1994

Penodontícs

Fig 4 Untreated incisor with pro-found periodontitis and an extreme-ly irreguiar course of the floor of thepocket, (leñ) View from facial as-pect; (right) view from mesial as-pect. The remaining periodontal lig-ament structures are blue, plaqueand calculus are black. The pocketincludes undercut regions that wereinaceessibie to a curette.

conservatively (closed), or open debridemeni can beperformed after formation of a surgical flap. As simpleas scaling sounds, its application in practice may bequite difficult. Inconsistent treatment, however, inevi-tably leads to failure.

Several difficulties can stand in the way of subgingi-val scaling'̂ •': an uneven course of the pocket floor. Ihemicromorphology of the root surface, and the macro-morphology of the root.

Uneven course of the pockei floor. The extracted an-terior tooth in Fig 4 clearly illustrates the extraordinar-ily uneven course of the pocket floor. This is a case ofseverely advanced periodontitis, and the tooth was ex-tracted. The course of the pocket floor can be irregular,however, even in the eariy and middle stages of the dis-ease. Although a very deep pocket may exist on oneside of the tooth, there may be little loss of attachmenton another surface. The course of the pocket floor evenmay have undercut regions, so that it is very difficult—particularly during a closed procedure—to reach thepocket floor with the curette and thus to achievethorough root cleaning. If large masses of bacteria re-main deep in the pocket, failure is certain.

Micromorphology of rhe root surface. Occasionallysmall resorptive regions (lacunae) are present on theroot surface {Fig 5). These may be up to 80 \x.m deepand cannot be reached by curettes or other instru-ments, whether used in closed or open debridementprocedures. Microorganisms that promote recurrencesremain in these niches.''

Macromorphology of the root. In practice, almost nosingle-rooted teeth have round or oval cross sections.Roots usually have hourglasslike depressions. Occa-sionally, teeth have fused roots that often run togetherin a deep groove (Fig 6). Such grooves act as a "guideplane" for bacteria. They are largely inaccessible tocurettes. It may be possible to open the grooves slightlyand to pohsh them with diamonds in an open proce-dure during the early stages of periodontitis, but fail-ures are frequent in teeth with such unfavorable mac-romorphology.

Tns matter becomes even more complicated in themolar region. Cleaning the roots when open furcationsexist is particularly difficuh. The variety in macromor-phology of these teeth is shown in Fig 7. As a rule, fur-cations must be treated with open debridement proce-dures. Despite treatment, these sites remain as minorsites of resistance that can lead to failure. Only hemi-sectionandapicoectomyof such teeth may lead to suc-cess.

Unsupervised healing

Many failures arising soon after completion of treat-ment can be traced to the absence of supervision of thehealing process. When the closed or open root cleaningis finished, removal of the dressing or the stitches doesnot mark the end of treatment. Rather, the treated re-gion must be professionally cleaned supragingivally atintervals of about 2 weeks. The oral hygiene status of

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Periodontics

Fig 5a Electron micrograph ot a root surface after planingwith a 15-tJ,m Perio-diamond (Intensiv SA). The root surfaceis clean on the smooth surfaces. It shows fine scrafches fol-iowing the treatment, ¡arrow) A résorption lacuna, approxi-mately 0.15 X 0.50 mm, is present. The cracks on the rootsurface are artificial, arising from the preparation of thespecimen for electron microscopy.

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Fig 5b Enlargement of Fig 5a. The lacuna is thoroughlyfilled with bacteria.

Fig 5c Bacteria in the iacuna depicted in Figs 5a and 5b.The bacteria were inaccessible to tbe finest Perio-dia-monds.

Fig 6a A bony pocket reaching almost to the apex becomes visible during a flapoperation on the maxillary right centrai incisor. This tootb has two fused roots.Periodontaily, it is no longer treatable.

Fig 6b Same tooth after extraction.Two fused roots end in a groove inwhich the infection is borne apicaily.

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Periodontics

Fig 7 (left) Mandibular and (right) maxillary molars. Approximately two thirds of the roots viiere separated apically. Note thelarge variety of root fusions and furcations. If periodontal disease reaches these sites, treatment, whether open or closed, ishardly possible. As a rule, only parts of such teeth can be retained after amputation of single roots or hemisection.

the patient must be assessed repeatedly at short inter-vals. Westfelt et aF demonstrated that a large variety ofperiodontal treatment procedures are successful whensupplemented with consistent supervision of healing(treatment as required at 2-week intervals for 6months). Their study revealed that the treatment pro-cedure itself (closed scaling, modified Widman flap, api-cally repositioned flap, etc) is not as important for suc-cess as is optimal cleaning of the treated sections of thedentition during the first few weeks and months afterthe procedures. Such extensive follow-up treatment isnot identical with maintenance therapy at recall ap-pointments.

Absence of maintenance thenipy

Maintenance therapy is decisive for long-term success.Without regular recall examinations of the patient, newinfections can arise over the course of time. The fre-quency of recall is not the same for all patients. It de-pends on a variety of factors: the primary diagnosis{course and severity of the disease), the success of pri-mary treatment following the period of supervisedhealing, and the extent to which the patient can be mo-tivated to cooperate. Depending on the case, the inter-val between recall appointments can vary from 2months to a year. Specific examinations are necessaryat each recall appointment to determine whether theresults of therapy have remained stable or whether re-

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currences or new infections are present. Il is not neces-sary, however, Ihat a complete diagnostic process takeplace at each recall appointment.

Some findings must be recorded at each recall ap-pointment, hut other assessments must be made atgreater intervals. At each recall appointment, the gingi-val status, and the amount of plaque should he deter-mined, by calculation of the indices il' appropriate. Atlonger intervals, perhaps annually, pocket depth andthe presence of symptoms of activity in single pocketsshould be recorded.

Occlusion, need for reconstruction, condition of res-torations, tooth vitality, and existence of new cariouslesions are checked at still greater intervals. New radio-graphs are made at approximately 4-year intervals. Ifpockets are found to recur or new pocket activity isnoted, radiographs are prepared as indicated.

Nor are the preventive and therapeutic measurestaken by the dentist and the dental hygicnist the sameat all recall appointments. As ii rule, remotivation ofthe patient, assessment of oral hygiene and reinforce-ment of patient instruction, and removal of plaque andcalculus at indicated sites are undertaken at each recall.The last of these appears to be particularly important.Scaling should not be done on all teeth. Teeth free ofdeposits need not be touched with a sealer. Long- andshort-term studies have shown ihat frequently re-peated scaling ofsound teeth can lead to loss of attach-ment.''"" However, all teeth should be cleaned and pol-ished with low-abrasion paste and rubber tips.

At longer intervals, if pockets or pocket activity isfound, subgingival scaling and new stirgery (rarely,only for extensive recurrences) should be carried out.

The chairside time required for regular recall ap-pointments intended to prevent periodontal treatmentfailures is. in most instances, severely underestimated.Ineluding the time required for disinfection of the op-eratory and for bringing in a different patient, an houris not an excessive amount of time to schedule for a re-call appointment. After the patient is greeted, the ap-pointment begins with the more or less extensive diag-nostic measures described previously (5 to 10 minutes).Abriefconversationwith the patient about the presentstatus of the oral cavity, together with the associated re-motivation efforts, requires about 5 minutes. Tliis is fol-lowed by plaque disclosure and reinstruction aboutoral hygiene (approximately 5 minutes).

Only after these preliminary steps are finished is in-strumental removal of supragingival plaque and calcu-lus completed at the indicated sites (20 minutes). As arule, this includes subgingival procedures, performed

without anesthesia, in pockets up to 4 mm deep. In ad-dition to plaque, discoloration, from chlorhexidine orsmoking, for example, is removed (3 minutes) and allteeth are polished with a low-ahrasion paste (5 min-utes). After the teeth are dried, the entire dentitionshould be treated with topical Ouoridc (5 minutes). Fi-nally, the dentist checks everything (5 minutes). Afterthe patient is discharged, the operatory is disinfectedand fresh instruments are placed (5 minutes).

The great expenditure of time for diagnosis, motiva-tion, instruction, and actual treatment of patients withperiodontitis has been noted. Maintenance therapyalso takes time. Twenty-minute recall appointmentsare at besl "alibi exercises."

Summary

Because of numerous failures, periodontal treatment isfrequently discredited. Careful attention to a few im-portant points can improve the success rate of perio-dontal therapy;

1. Only those patients prepared for long-term cooper-ation should be treated. Patients with certain serioussystemic diseases tend to have recurrences. Treat-ment planning should be rather more radical andthe therapy perhaps should be provided by a spe-cialist or in a clinic.

2. Time cannot be saved in diagnostic procedures.Only a careful, comprehensive examination leads toa well-founded diagnosis and prognosis, and thus toa precise treatment plan.

3. The limits of successful therapy must be recognized.Far advanced periodontitis, Class III furcation in-volvement, and rapidly advancing disease are diffi-cult to control over the longer term. A radical plan,including multiple extractions, is indicated.

4. Reinfection of the pockets must be preventedthrough supervision of the healing process hy re-peated cleaning of the teeth and checking of oral hy-giene immediately following each active interven-tion (closed root planing or flap operation).

5. Long-term treatment success is possible only if thepatient, once treated, is placed on a regular recallschedule.

6. Consistent periodontal therapy requires a great dealof time. That time is usually underestimated. In-forming the patient about the disease (case presen-tation), instruction in and repeated checking of oralhygiene, supervision of the healing process and re-call all are enormously time consuming. The actual

456 Quintessence International Volume 25, Number 7/1994

closed or open treatment is only a part—perhapsthe smaller part—of the total treatment.

References

1. Raieilichak KH, Raieitschak EM, Wolf HF. Hassell TM, ColorAlias of Denial Medicine, Vol. J, Pedodoniology ed 2 NewYork. Stuttgart'Thieme. 1989.

2. Schwarz JR Guggenheim R. DUggelJn M, Hefli AF, Rateil-schak-Plüss EM. Raieitschak KH. The effectiveness of rool de-bridement in open flap procedures by means of a comparisonbetween hand instruments and diamond burs. A SEM sludy.J Clin Periodontol 1989;t6:510-518.

3. Rateitschak-Plüss EM, Schwarz JP, Guggenheim R. DüggílinM, Rateitschak KH. Non-surgical periodontal Ireatment —Where are the limits'," J Clin Periodontol 1992; 19:240-244.

4. Schrocder HE, Rateitschak-Plüss EM. Fotal root résorption la-cunae causing retention of subgingival plaque in periudontalpockets. Acta Parodontologica. Schweiz Monats sehr Zahn-heilkd 1983:93:1033/179-1041/187.

5. Westfell E. Bragd L, Socransky SS, Haffajee AD. Nynian S,Lindhe 1 Improved periodontal conditions following therapy.J Clin Periodontol 1985; 12:283-293.

t. Knowles JW. Burgett FG, Nissie RR. Shick RA, Morrison EC,Ramfjord SP Resuhs of periodontal treatment related to pock-et deth and attachment level. Eight years. J Periodontol:979;50:2Z5-233-

7. Lindhe J, Westfelt E, Nyman S, Socransky SS, HeijI L, BratthallG. Healing following surgical/non-surgical treatment of perio-dontal disease, A clinical study, J Clin Periodontol 1982;9:115-128,

8. Pihistrom BL, McHugh RB, Oliphant TH, Ortiz-Campos C.Comparison of surgical and nonsurgical treatment of periodon-tal disease. A review of cunent studies and additional restjits af-ter6' / , years. J Chn Periodontol 1983; 10:524-541,

9. Lindhe J. Nyman S. Scaling and granulation tissue removal inperiodontal therapy, J Clin Periodontol 1985;12:374-388.

10. Ramfjord SP Caffesse RG, Morrison EC, Hill RW, Kerry GJ,Appleberry EAet al. Four modalities of periodontal treatmentcompared over 5 years. J Clin Periodontol 1987;14;445-452.

11. Kaldah! WB. Kalkwarf KL. Patil KD. Molvar ME Responses offour tooth and site groupings to periodontal therapy. J Peri-odontol 1990;61:]73-179. G

Rubber Dam in Clinical PracticeJ. S. Reid, P, D. Callis, and C. J, W. Patterson

Although the rubber dam was first introduced intodentistry more than lOO years ago. il is still not widelyaccepted in general dental practice. Yet this technique isbasically simple to use once it has been mastered and hasmany advantages both for the patient and the dentist.

The authors have set out to provide a clear text thatexplains how and why the technique should be used; thisis supplemented hy excellent photograph.^ illustratingdetails of the technique iti practice.

All dentists will benefit from having this handbook readilyat hand so that they can put this technique to regular useand benefit from its advLintages of safety, better workingconditions in the mouth, and better patient management.

Quintessence International Volume 25, Number 7/1994

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