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Progressive Treatment Planning
By Kimberly R. Miller, RDH, BSDH
January 2011

Gone are the days of fitting a patient into a pre-existing treatment plan. Soft tissue management programs that promote one treatment plan for a case type I, and one treatment plan for a case type II etc. put the clinician in the dilemma of trying to fit a square peg into a round hole. One size does not fit all regardless of case type because when it comes to the treatment of periodontal disease, there are just too many variables.

According to a new study, the prevalence of periodontal disease in the adult US population has been underestimated by up to 50%. Based on this study conducted by the Centers for Disease Control and Prevention (CDC) and the American Academy of Periodontology (AAP) (1) more adults are suffering with moderate to severe periodontal disease than was previously thought. One might conclude that we haven’t done a very good job of the diagnosis and treatment of periodontal disease.

Samuel Low, DDS, MS and Paul Eke, MPH, PhD, say the two key take aways from this study are: Annual comprehensive periodontal charting for every patient and crucial patient education regarding periodontal risk factors and medical systemic links.

Patient education begins with risk assessment. The clinician should begin a new patient exam or a routine hygiene visit by having a candid discussion with the patient about the importance of risk assessment. It should be a priority for each patient to be evaluated for their level of risk for the development and progression of gum disease and the presence of oral systemic links.

Once risk level has been determined, the patient should then be case typed according to the ADA’s Periodontal Case Types after collecting comprehensive periodontal information. Now that we know the level of risk, the medical systemic considerations and the case type, the real work begins. Periodontal treatment planning requires a combination of the professional’s clinical care, skill and judgment.

The greater the level of risk the more progressive the treatment plan should be regardless of case type. Unfortunately, most clinicians still treatment plan according to pocket depth and calculus deposits.

Instead the clinician should choose appropriate diagnostic and treatment recommendations from each of the following categories:

Laboratory Testing: Systemic Options:
DNA-PCR Systemic Antibiotics
HPV Collagenase Inhibitors
PST Nutritional Supplementation
CRP Clinical Procedures:
  Hand Instumentation
Behavior Modification: Ultrasonic Instrumentation
Oral Hygiene Supra & Sub-g air polishing
Smoking Cessation LAA
Nutrition/Diet/Exercise Pocket Irrigation
Specialist Referral Laser Therapy
  Supra & Sub-g air polishing

The misconception about the prevalence of periodontal disease should be a call to action for all clinicians to provide customized progressive treatment planning based on each individual patient’s need.

1. Eke PI, Thornton-Evans GO, Wei L, et al. Accuracy of NHANES periodontal examination protocols. J Dent Res 2010 Nov;89(11):1208-1213.

©2011 Richard Nagelberg, DDS & Kim Miller, RDH, BSDH, RDHMP