19
HERRERA ET AL .
patient preferences, clinical findings and changes to the patient's overall state of health. It must be recognized that in stage IV peri- odontitis, a “ no treatment ” option must be discouraged, given the expected high risk of loss of the dentition. Key to the care of these patients is: • The need to combine periodontal therapy, which is modelled in line with the recent guidelines for the treatment of stage I – III periodon- titis (Sanz, Herrera, et al., 2020), with rehabilitation. • Identification of the appropriate timing/sequence of implementa- tion of the adjunctive orthodontic/restorative treatment and the periodontal treatment (Figure 1). For details of recommended approaches to periodontal therapy, readers are referred to the guideline for periodontal therapy for stage I – III peri- odontitis (Sanz, Herrera, et al., 2020), since that guideline also applies to the periodontal treatment of stage IV periodontitis patients. Of particu- lar importance are the frequent re-evaluations to assess adherence to oral hygiene instructions for supragingival biofilm control and adherence to risk factor control interventions, and the two periodontal re- evaluation assessments following step 2, and later after step 3 ( “ final re- evaluation ” ), since achieving the desired treatment outcomes is particu- larly important in stage IV cases to be suitable to proceed with the planned restorative or orthodontic therapy, as well as to justify the sig- nificant resources required to proceed with the case. In stage IV peri- odontitis patients, re-evaluation following steps 2 and 3 treatment requires additional planning over and above purely periodontal mainte- nance. Restorative factors need to be adequately assessed. For example, the ability of a tooth to act as an abutment for a restoration needs to be assessed in terms of periodontal maintainability, but also residual peri- odontal support and restorative parameters such as the presence of adequate tooth structure. Similarly, dental implants that have been placed to assist in the restoration should present with healthy, maintain- able soft- and hard-tissue interfaces. When evaluating periodontal outcomes at the end of active peri- odontal treatment (control of periodontal inflammation, achievement of shallow maintainable pockets, management of furcation lesions), it is important to consider whether a specific tooth will be incorporated as an abutment for a fixed or removable prosthesis. Specific criteria must be considered to assess the ability of the tooth to function as a restor- ative abutment. While it has been shown that teeth with a reduced but healthy periodontium can function well as prosthetic abutments, a mini- mal threshold of residual periodontal support (10% – 20%) may be con- troversial and dependent upon the design of the restoration (e.g., fixed vs. removable), the number and distribution of the abutments and the stability of the definitive prosthesis (Nyman & Lang, 1994).
commissioned and have been used as the basis for development of this clinical guideline. Several treatment tools are available for the rehabilitation of the different case types, besides the treatment of periodontitis according to the guideline for the treatment of periodontitis in stages I – III (Sanz, Herrera, et al., 2020): • Temporary control of secondary occlusal trauma (e.g., extra- coronal splinting and/or relief of fremitus by limited selective occlusal adjustment). • Prosthetic splinting with a fixed dental prosthesis. • Orthodontic therapy. • Tooth-supported/retained removable or fixed partial dental prostheses. • Implant-supported/retained removable or fixed partial dental prostheses. • Tooth-supported/retained cross-arch dental prostheses, conven- tional full dental prostheses, implant-retained or -supported full dental prostheses.
The following key messages should be highlighted:
• Most cases of stage IV periodontitis can be successfully treated, maintaining the natural dentition in a state of adequate health and function. • Before treatment planning for people with stage IV periodontitis, it is recommended undertaking a full diagnosis and case study, including a tooth-by-tooth prognosis to identify the number, distri- bution, residual support, periodontal maintainability and res- torability of the remaining natural dentition.
4.2
| Sequence for the treatment of stage IV
periodontitis
The treatment plan for the management of stage IV periodontitis should include a successful outcome after completing the interventions in steps 1, 2 and 3, according to the EFP S3 Level clinical practice guideline for treatment of stage I – III periodontitis (Sanz, Herrera, et al., 2020). The sequence of the different steps, however, requires the introduction of specific additional treatment measures to meet the spe- cific demands of stage IV periodontitis. In these cases, rehabilitation of function, restoration of masticatory comfort and treatment of second- ary occlusal trauma and, sometimes, restoration of the vertical dimen- sion of the occlusion are also necessary and need to be planned from the beginning, and even implemented simultaneously with steps 1 – 3. As is the case for the treatment of periodontitis in stages I – III, an essential pre-requisite to therapy is to inform the patient of the diag- nosis, including aetiology of the condition, risk factors, treatment alternatives and expected risks and benefits, including the option of no treatment. This discussion should be followed by agreement on a personalized care plan. The plan might need to be modified during the course of treatment, depending upon initial treatment outcomes,
4.2.1 | Specific treatment pathways according to the different stage IV periodontitis case types
Common to all clinical case types is the need to perform a careful diagnosis and a case study that includes both periodontal and
Made with FlippingBook Annual report