PERIODONTAL TREATMENT GUIDE

TEAMWORK FOR TREATING PERIODONTAL DISEASE

The treatment of patients with periodontal disease should involve the application of standard procedures based on commonly accepted gui-delines. This “Periodontal Treatment Guide” aims to support local net-works of general dentists, hygienists and periodontists by providing evi-dence-based guidelines for diagnosis, referral and treatment options.

The “Periodontal Treatment Guide” is the result of a consensus estab-lished by a group of experienced and highly renowned periodontists who based their recommendations for these guidelines on the syste-matic 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.

2

THE FOLLOWING AUTHORS HAVE SIGNIFICANTLY CON-TRIBUTED TO THE DEVELOPMENT OF THE “PERIODONTAL TREATMENT GUIDE”

Prof. Dr. med. dent. Anton Sculean, Dr. h.c., M.S., Chairman of Department of Periodontology – School of Dental Medicine – University of Bern – Bern, Switzerland. Dr. Christina Tietmann, Certified periodontal specialist of the German Society of Peri-odontology – Private Practice for Periodontology – Aachen, Germany. Dr. David Nisand, Lecturer of periodontics at the University of Paris – Private Practice limited to periodontology and implantology – Paris, France. Dr. Frank Bröseler, Certified periodontal specialist of the German Society of Periodontol-ogy – Private Practice for Periodontology – Aachen, Germany. Dr. Holger Janssen, Specialist for periodontology, implantology and restorative dentistry – Private Practice – Berlin, Germany. Dr. Mario Roccuzzo, Lecturer in Periodontics at University of Torino and Siena. Private Practice limited to Periodontics and Implantology – Torino, Italy. Dr. Markus Schlee, Lecturer for periodontics and implantology at the Steinbeis University, Berlin and DIU, Dresden, Germany. Private practice limited to periodon-tology and implantology – Forchheim, Germany. Prof. Dr. Nick Donos, DDS, MS, FHEA, FDSRCSEngl, PhD., Head & Chair of Periodontology, Director of Research, UCL-Eastman Dental Insti-tute – Department of Periodontology – London, United Kingdom.

3

Legend BPE: 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

PERIODONTALLY HEALTHY PATIENT Evaluation

BPE012

BPE34

PATIENT WITH PERIODONTAL DISEASEHygiene

BPE34

PATIENT WITH PERIODONTAL DISEASESurgery

CLICK HERE

CLICK HERE

CLICK HERE

PERIODONTAL TREATMENT

4

PPD ≤ 4mmFMPS ≤ 20%BOP ≤ 20%

Oral hygiene, tobacco consump-tion, periodontal status, furcation involvement, X-ray status, general

health

Oral hygiene motivationInstruction

Disinfection

PROPHYLAXISPreventive long-term care

ORAL CHECK

MAINTENANCE PHASE

NOT SUCCESSFUL

EVALUATION

TO CHECK

TO DO

SUCCESSFUL

PERIODONTALLY HEALTHY PATIENT

CLICK HERE

5

Moderate chronicperiodontitisPPD ≤ 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 periodontitis

Periodontitis with systemic diseaseSpecial case of periodontitis

PPD > 6 mm Profuse bleeding or pus

PROPHYLAXISPreventive long-term care

SYSTEMIC PHASE AND PERIODONTAL DIAGNOSIS

Oral hygiene, tabacco consumption, periodi-ontal status, furcation involvement, X-ray status, general health (systemic diseases, e.g. diabe-tes, circulatory problems, etc), stress, pregnancy

Consider also the removal of inadequate restorations,optional splinting before surgery, use of microbiologic tests, involvement of gen-eral physician and extraction of hopeless teeth.

Regarding hopeless teeth the following factors should be considered: bone loss, clinical attach-ment loss, degree of mobility, endodontic factors, restorative factors, anatomy and tooth position.

TO CHECK

PATIENT WITH PERIODONTAL DISEASE

PPD ≤ 4mmFMPS ≤ 20%BOP ≤ 20%

EVALUATION

Refer to a specialist

TO DO

Optionally not via specialistCLICK HERE

6

PATIENT WITH PERIODONTAL DISEASE

Motivation for oral hygieneInstruction

Plaque control

TO DO

PPD ≤ 4mmFMPS ≤ 20%BOP ≤ 20%

PPD ≤ 4mmFMPS ≤ 20%BOP ≤ 20%

PROPHYLAXISPreventive long-term care

PROPHYLAXISPreventive long-term care

NOT SUCCESSFUL

NOT SUCCESSFUL

2ND CHANCE

RE-EVALUATION

RE-EVALUATION (3 MONTHS)

SUCCESSFUL

SUCCESSFUL

Non-surgical periodontal treatment i.e. supragingval and subgingval SRP

Second non-surgical periodontal treatment

TO DO

TO DOCLICK HERE

7

PERIODONTAL SURGERY OF MULTI-ROOTED TEETH WITH FURCATION INVOLVEMENT

(CLASS II AND III)

CLICK HERE CLICK HERE

PERIODONTAL SURGERY OF SINGLE-ROOTED TEETH OR MULTI-ROOTED TEETH WITHOUT FURCATION INVOLVEMENT (PPD > 6MM)

8

SURGERY – WITH FURCATION INVOLVEMENT (CLASS II AND III)

Buccal:STRAUMANN®

EMDOGAIN or GTR

Mesial:STRAUMANN® EMDOGAIN

Distal:Root resectionor flap surgery

with STRAUMANN® EMDOGAIN

STRAUMANN® EMDOGAIN

or GTReither alone or in combination with

graft (in buccal defects) or resective approach

Tunneling, or resective approach

or extraction

Resective approach or extraction

MAXILLA1

CLASS II CLASS IICLASS III

MANDIBLE2

CLASS III

CLICK HERE1 Limited evidence for regeneration2 Depending on the local soft and hard tissue characteristics

9

SURGERY – WITHOUT FURCATION INVOLVEMENT (PPD>6MM)

Conventional periodontal flap surgery

Conservative or resective approach according to site characteristics

Site mapping for defect localization, e.g. bone sounding

Regenerative surgical technique designed to maintain the interdental soft tissue

Intrabony component ≥ 3mm

STRAUMANN® EMDOGAIN or GTR

either alone or combind-ed with graft

STRAUMANN® EMDOGAIN or GTR

combinded with graft

HORIZONTAL BONE LOSS ANGULAR BONY DEFECT

SELF-CONTAINED DEFECT

NON-SELF-CONTAINED DEFECT

CLICK HERE

10

Post-operative care

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

TO DO

TO DO

PPD ≤ 4mmFMPS ≤ 20%BOP ≤ 20%

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

PROPHYLAXISPreventive long-term care

NOT SUCCESSFUL

RE-EVALUATION (6 MONTHS)

SUCCESSFUL

CLICK HERE

RE-EVALUATION

11

POST-OPERATIVE CARE (AFTER PERIODONTAL SURGERY)

Use of antispetic 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

12

THE FOLLOWING PUBLICATIONS HAVE BEEN CONSULTED BY THE AUTHORS:

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 de-fects. 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, Evalua-tion of Human recession defect treated with coronally advanced flaps and either Enamel Ma-trix 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 Cue-va MA, Boltchi FE, Nunn ME, Rivera-Hidalgo F, Rees T, A comparatitive study of coronally ad-vanced 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 fur-cation 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 pro-teins on tissue formation along the roots of human teeth. J Periodontol. Res 2004, 40, 158 Cor-tellini 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, Bac-terial 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 Data-base Syst Rev 2005, CD003875.

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 sys-tematic 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 treat-ment of chronic periodontitis. J Clin Periodontol 2002, 29 (3) 92-102 Herrera D, Alonso B, Leon R, Roldan S, Sanz M, Antimicrobial therapy in periodontitis: the use of systemic antimi-crobials 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 pa-tients with chronic periodontitis. 6th European Workshop on Periodontology 2008, Feb, Ittin-gen, Thurgau, Switzerland Schwarz F, Aoki A, Becker J, Sculean A, Laser application in non-surgical periodontal therapy: a systematic review. 6th European Workshop on Periodontol-ogy 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 periodontal 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 periodon-titis, J Clin Periodontol 2008, 35 (8) 8-21 Quirinen 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 plan-ing, J Clin Periodontol 2009, 36, (3) 240-249 Quirinen M et al., Benefit of „one-stage full-mouth 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 sin-gle-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,

13

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 opin-ion 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 state-ments and recommendations published in the Periodontal Treatment Guide. The information given in the Periodontal Treatment Guide cannot replace a dental assessment by an appro-priately 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 ex-press consent of the publisher.

© Institut Straumann AG, 2011. All rights reserved.Straumann® and/or other trademarks and logos from Straumann® mentioned herein are the trademarks or registered trademarks of Straumann Holding AG and/or its affiliates. All rights reserved.

www.straumann.com