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HERRERA ET AL .
6 | CLINICAL RECOMMENDATIONS: CASE TYPE 1
(Continued) Additional question raised by the WG
R5.3: Expert consensus-based recommendation Quality of evidence Not applicable Grade of recommendation GradeB — " Strength of consensus Consensus (0% of the group abstained due to potential CoI)
Case type 1: the patient with tooth hypermobility due to secondary occlusal trauma that can be corrected without tooth replacement.
6.1 | Intervention: Tooth splinting and occlusal adjustment in patients with periodontitis stage IV
Background
In cases with an intact dental arch (no missing teeth apart from the molar area), the possibility to preserve all teeth, and thus avoid the need for tooth replacement, through periodontal and/or restorative treatment provides a strategic advantage. It may simplify treatment and reduce costs. A careful diagnosis of the possibility to preserve “ hopeless ” or severely compromised teeth by advanced periodontal therapy, combined with management of hypermobility and/or addressing patient concerns, should be performed before deciding to extract teeth in such cases.
A systematic review (Dommisch et al., 2021) assessed the efficacy of tooth splinting (TS) and occlusal adjustment (OA), compared with no- TS or OA in patients with periodontitis exhibiting masticatory dys- function. Both treatment modalities are especially relevant in fully dentate patients with stage IV periodontitis. In this context, TS reduces tooth mobility due to advanced attachment loss to facilitate biting and chewing abilities (patient's comfort), and OA addresses sec- ondary occlusal trauma in the management of occlusal dysfunction. In the systematic review (Dommisch et al., 2021), no study specifically focused on patients with stage IV periodontitis, and thus, the efficacy of TS and OA was evaluated for patients with all stages of periodontitis. The primary outcome criterion was tooth loss, and the secondary outcome parameters were change in PPD, change in clinical attach- ment level (CAL), tooth mobility (TM) and PROMs (Dommisch et al., 2021). For TS, two studies were included considering a follow- up time range between 3 – 15 and 2 – 32.4 years, respectively. Three studies addressed OA with a follow-up of 2 – 8 years. As explained in Section 4, a degree of overlap between stage III periodontitis and case type 1 of periodontitis in stage IV exist. R6.1. In fully dentate patients with periodontitis stage IV with increased tooth mobility due to advanced periodontal attachment loss, what is the effectiveness of tooth splinting and/or limited occlusal adjustment of hypermobile teeth?
R5.4. Can acceptability of tooth preservation be improved with simple measures?
Additional question raised by the WG
R5.4: Expert consensus-based recommendation In patients with stage IV periodontitis requesting improvement of aesthetics , phonetics , masticatory function and/or patient well-being , direct and indirect tooth restorations and/or epitheses may be considered . Supporting literature Expert opinion Quality of evidence Not applicable Grade of recommendation GradeO — $ Strength of consensus Consensus (0% of the group abstained due to potential CoI)
Background
(Common question for Recommendations R6 . 1 , R6 . 2)
In many stage IV periodontitis cases, the aesthetic, phonetic and functional sequelae of periodontal breakdown severely affect patient well-being and quality of life. Once correctly identified, such concerns may raise questions on tooth-retention-based choices, unless costly approaches are considered, and may provide barriers to the acceptability of periodontal therapy and tooth retention. Simple approaches such as the use of gingival epitheses (custom-made removable silicone masks to replace missing gingiva that hide black triangles or correct the presence of uneven gingival margins) and/or direct/indirect adhesive restoration that re-shape teeth (and some- times provide a splinting effect) may mitigate patient concerns and increase the acceptability of periodontal treatment in stage IV peri- odontitis patients.
PICOS question addressed by a SR
R6.1: Evidence-based recommendation In patients with stage IV periodontitis , temporary splinting and/or limited selective occlusal adjustment of hypermobile teeth may be considered during all steps of periodontal therapy (but particularly during step 1 treatment) to increase patient comfort and enable/facilitate periodontal therapy . Supporting literature (Dommisch et al., 2021; Sonnenschein, Ciardo, et al., 2021; Sonnenschein, Ziegler, et al., 2021) Quality of evidence Very low Grade of recommendation GradeO — $
(Continues)
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