Initial Therapy o Patient Optimization o Systemic Optimization o Patient Motivation o Patient Education Oral Cavity Optimization o Microbial Control

o Diet o Root Debridement o Extraction of Hopeless Teeth and Roots o Endodontic Therapy o Caries Control o Coronal Modification o Restorations o Occlusal Therapy Re-evaluation

Initital Therapy After completing a thorough examination, establishing a diagnosis and formulating a comprehensive treatment plan, the dental practitioner must explain these to the patient and obtain the patients agreement to proceed . The first phase of therapy of any treatment plan is most commonly referred to as initial therapy. The goal of initial therapy is to eliminate or control the etiologic and contributing factors that have resulted in breakdown of the masticatory system. Initial therapy is aimed at eliminating diseases by eliminating etiologic and contributing factors from the patient as a general entity and from the oral cavity as a specific entity.

Patient Optimization
Systemic Optimization In order to competently treat and fulfill our professional obligations to our patients, appropriate consultations with the patient's physician as well as other medical specialists are very important from both a therapeutic and legal point of view. The health questionnaire will identify systemic problems that require coordination between the dentist and the physician. Examples include the use of systemic antibiotics to protect patients with heart valve lesions from the bacteremias associated with periodontal therapy. The control of blood coagulation problems and diabetes prior to and during treatment will necessitate consultation with the patient's physician. In order to maximize the results of initial therapy, it is necessary to optimize the physical and mental status of the patient . Certain systemic conditions have a profoundly negative effect on the outcome of initial therapy and need to be controlled before even beginning certain procedures and may well moderate our expectations of initial therapy. The use and/or abuse of chemical substances (therapeutic and recreational) can complicate or contraindicate certain procedures. You should be familiar with what your patient is taking and what their effects are. The use of tobacco products may have a negative effect on a patient's response to

therapy. Thus the patient should be counseled to be involved in an appropriate smoking cessation or drug rehabilitation program as part of initial therapy. Psychological conditions (e.g. bulimia; stress) also require consideration during initial therapy. Patient Motivation One of the most important variables in initial therapy is patient compliance. Without patient compliance, initial therapy will have at best a limited and short term success. Patients need to show compliance with oral hygiene procedures, use of therapeutic agents, cessation of detrimental habits and attendance of appointments. The best way to obtain patient compliance is to motivate the patient. Motivating factors must include a desire for the final goal of treatment, a belief that it is attainable and an awareness of their pivotal role in achieving this. Motivation is best achieved by education. Motivation by Education In educating the patient, it is important to convey the following points: 1. That periodontal diseases are caused by microorganisms found in plaque. 2. That these microorganisms cause disease that can destroy healthy tissue and ultimately result in tooth loss. 3. That controlling the numbers of these microorganisms can provide an environment that leads to restoration of health to the tissues. 4. That a variety of factors such as a smoking habit or an overhanging restoration margin may have a negative effect on the outcome of initial therapy and that the patient may need to join a smoking cessation program or have a restoration replaced as part of initial therapy. 5. The patient should have their diagnosis explained to them, what their status is on the scale from health to tooth loss and what therapeutic measures are required to restore health and maintainability to their tissues. 6. Of crucial importance is the patient's awareness that they are ultimately responsible for improving and maintaining the health of their oral tissues. This is done using diagrams, charts, models, slides, videos, leaflets and all other means at our disposal.

Oral Cavity Optimization

Microbial Control Micro-organisms in the oral cavity have been shown to be the etiologic or causative factors in periodontal disease. Not all the oral microorganisms are periodontal pathogens and of those that are, not all are equally destructive. As a rule, a microbiota that is predominantly gram positive aerobic cocci is benign and a microbiota that is predominantly gram negative anaerobic rods and spirochetes is associated with periodontal breakdown. There are two methods by which we can control or eliminate microorganisms in the mouth. Mechanical plaque control using a variety of aids at our disposal is the most conventional and

widely used method. The use of antimicrobial chemotherapeutics is the other method and this is always used in conjunction with the mechanical plaque control. Oral Hygiene Instruction and Mechanical Plaque Control Oral hygiene instruction is part of the ongoing process of patient education. In order to promote plaque control by the patient we must help the patient understand what plaque is, where plaque is found and how to remove it. Then we develop a plaque control program for the patient and set a realistic goal for plaque control. After explaining what plaque is, we should disclose the plaque in the patient's own mouth using disclosing tablets or solutions. This will enable us to show the patient the presence and location of plaque in what they may have thought was a clean mouth. Using an oral hygiene progress form, we then chart the presence or absence of plaque on each tooth surface of each tooth present. The hygiene index is calculated as that percentage of tooth surfaces present that are plaque free. Using the oral hygiene index and progress form, we then set a goal of 80% or more plaque free surfaces. Methods of plaque removal should be demonstrated to the patient. This will include the use of manual toothbrushing techniques and dental floss. The use of any other plaque removal aids such as interproximal brushes, wooden toothpicks, irrigation devices, electric toothbrushes, floss threaders and gingival massage devices can be discussed and demonstrated now, or can be introduced at a later stage. The patient has to realize that although we (the oral health care professionals) can show the patient how to perform plaque control and can execute procedures to facilitate plaque control, the patients themselves are ultimately responsible for plaque control. It is imperative that plaque scores be recorded on the oral hygiene chart form so that a record of the patient's status is available. This can also be used to motivate the patient to achieve a lower level of plaque. Chemotherapeutics in Microbial Control The use of chemotherapeutics in miocrobial control is never as an alternative to conventional methods (mechanical plaque control, debridement, etc.) but rather as an adjunct to these methods. Chemotherapeutic anti-microbial agents are indicated in cases where conventional methods would fail to eliminate or control the infection, including cases of tissue or root surface invasion by bacteria or refractory cases. Another indication would be an inability of the patient's to perform adequate plaque control. Chemotherapeutics may be systemically or locally delivered. Mouthrinses are one of the most widely used forms of locally delivered chemotherapeutics (after dentifrices) and although they are useful in reducing gingivitis associated inflammation, they do not penetrate periodontal pockets well. At the present time the most effective anti-plaque mouthrinses are those containing chlorhexidine. The choice of systemic chemotherapeutic agents may be guided by the results of the culturing and sensitivity testing of a microbiological sample from the patients pockets. In some cases, combination or sequential (serial) administration of antibiotics is indicated. Judicious use of

chemotherapeutic agents is an effective adjunctive therapy, but never a replacement for good dental care both in the patients home and in your office. Diet Diet analysis and modification is another aspect of optimizing the status of the patients oral cavity. This is particularly relevant in relation to caries control. Although many foodstuffs can act as a substrate for the plaque forming microbes, our main concern would be diets high in refined forms of carbohydrates and sugars. The form in which these are ingested is significant. Sugars ingested in a tough sticky form (e.g. a toffee) take about four times as long or more to be cleared from the oral cavity than that ingested in a liquid form. This allows the oral microbiota that much longer to utilize these sugars as a substrate for their metabolism. This can lead to an increase in plaque byproduct formation and population growth, both undesirable sequelae. The erosive effect of excessive dietary acid (such as citric acid found in citrus fruit and juices) on dental tissues has been well documented. If erosion lesions are noted and dietary analysis can identify the etiology, counseling in this regard can help prevent or reduce further loss of tooth structure this way. It should always be remembered that, although rare in the United States, a number of dietary deficiency / malnutrition conditions exist that have oral manifestations (e.g. scurvy, beri-beri, pellagra). Root Debridement During the process of root debridement, all hard and soft deposits are removed from the radicular and coronal surfaces(scaling) as well as a thin layer of diseased cementum leaving the root surface healthy and smooth (root planing). Additionally, a thin layer of diseased pocket epithelium may be removed at the time of subgingival scaling and root planing (currettage). The soft deposits are materia alba and plaque and the hard deposits are sub and supragingival calculus. The inflammatory effect of calculus, once thought to be due to mechanical irritation of the tissue, is now known to be due to its endotoxin content and the layer of plaque retained around it. The importance of removing bacterial endotoxin from the oral cavity (plaque: calculus: diseased cementum and tissue) lies in its ability it initiate a host inflammatory response and prevent periodontal reattachment occurring. It goes without saying that calculus removal must be as thorough as possible and that the most important piece of calculus to remove is the last one.

According to the extent of the hard and soft deposits on the tooth surface as well as the degree of periodontal disease present, a number of appointments are scheduled to remove these deposits. The complete removal of subgingival calculus, however is not easily accomplished and becomes more difficult and less attainable as pocket depth increases. Increasing pocket depth, multi rooted teeth, furcation involvement, tooth crowding, root proximity and intra-bony defect morphology are all factors that complicate subgingival root debridement. A pocket probing up to 5mm is regarded by conventional wisdom as the maximum pocket depth in which an acceptable level of root debridement can be achieved by "closed" scaling and root planing techniques. Initial therapy debridement must be regarded as a vital and specialized field of our work requiring extensive skills, knowledge, manual dexterity, patience and persistance. Extraction of Hopeless Teeth and Roots All teeth deemed to have a hopeless prognosis due to periodontal and/or restorative considerations should be extracted during initial therapy This not only allows healing at these sites but removes deep pockets and/or carious lesions from the oral cavity which are inaccessible to oral hygiene measures and act as foci of infection which can reinfect other areas of the mouth. The strategic extraction of healthy teeth for orthodontics and/or restorative considerations should also be done at this stage so that the healing process can begin. For esthetic considerations, one or more teeth slated for extraction may be retained until an esthetic replacement can be provided. It is important to discuss the possible need for a transitional, removable partial denture with the patient. Endodontic Therapy Endodontically involved teeth should be appropriately treated during initial therapy to remove the infected pulpal tissue debride and obturate the canals and facilitate resolution of any periapical or "endo-perio" lesions. It is best to perform endodontic therapy early in the treatment plan as this allows for healing of bone defects associated with pulpal disease and often results in complete restoration of lost or demineralized bone. Any teeth requiring intentional endodontics for restorative needs may also be treated at this stage.

Any teeth requiring intentional endodontics for restorative needs may also be treated at this stage. Caries Control All carious lesions should be completely removed and the teeth restored with provisional or final restorations depending on the complexity of the case and what the situation allows. This will prevent progression of the caries to the pulpal tissues, eliminate an area of plaque retention and facilitate better plaque control. This therapy can be supplemented with fluoride treatment which will strengthen the mineralized tissues and decrease susceptibility to carious involvement. The application of fissure sealants can also be included as part of caries control. Coronal Modification There are a number of areas when dealing with the coronal aspect of the dentition that may be modified to produce an environment less favorable to plaque formation and retention and more amenable to plaque control. These include the removal of excessive contours on the buccal, lingual or interproximal surfaces that have shown themselves to be problematic, but should not be done prophylactically. Often the crown of a tooth may be modified to eliminate plaque retentive areas and provide better access for oral hygiene procedures. Grooves that extend subgingivally can be removed by recontouring the surrounding tooth to provide better plaque control access. Enamel pearls complicating furcation involvement can be similarly treated. These procedures require judicious use of the bur and any area of odontoplasty should be left smooth and confluent with the surrounding tooth structure. Restorations Inadequate restorations can create problem areas promoting plaque formation and retention and hampering plaque control. Examples of such problems are: 1. 2. 3. 4. 5. 6. 7. 8. 9. Overhanging margin Open margins Rough or pitted surfaces Open contacts Marginal ridge inadequacies Overcontoured restorations Inadequate embrasure spaces Poor framework, abutment and pontic design of partial dentures Ill fitting dentures

10. Overextended denture flanges

In many instances the existing restoration can be modified by trimming, smoothing, relining, polishing or a combination of these. In other cases, a new restoration will need to be provided, either provisional or permanent. Provisional restorations allows the restorative dentist the opportunity to "test" the compatibility of his proposed final restorative plan with the patient's oral health. Remember that by the time you reach your final provisional stage, the only difference between the provisional and permanent restorations should be the material from which they are made. Occlusal Therapy There is too often a lack of awareness and understanding of the need for occlusal therapy and it is subsequently neglected in diagnosis and treatment planning. The operator must be able to make the distinction between a physiological and a pathological occlusion. Basically stated, a physiological occlusion is one that is compatible with health and a pathological occlusion is one that is not compatible with health. Signs and symptoms of a pathological occlusion may include fremitus, mobility, flaring, drifting or tilting of teeth, radiographic evidence of widened periodontal ligament space, myofacial pain and clicking or popping sounds or

crepitus in the temporomandibular joint. The presence of one or more of the above is not, however, a definite indication of existing pathological condition. For example, not all tilted teeth are associated with pathosis. When occlusal pathology is identified it needs to be addressed. As the occlusion collapses, occlusal trauma increases. The initial approach to treating a pathological occlusion is controlling the occlusal trauma. This may include occlusal adjustment, temporary stabilization (splinting of teeth); bite plane therapy and tooth movements to align occlusal landmarks correctly. Much of this should be considered part of initial therapy. There has been much speculation as to the origins and effects of occlusal trauma. Today it is widely recognized that occlusal trauma alone does not lead to the loss of periodontal attachment. Superimposed on an existing inflammatory condition in the attachment apparatus, however, an accelerated loss of attachment loss will occur as opposed to that caused by the inflammation alone. Two types of occlusal trauma are recognized. Primary occlusal trauma is when larger than normal forces are applied to a tooth with adequate periodontal support (e.g., bruxing, clenching; orthodontic forces, high dental restorations). Secondary occlusal trauma is when the periodontal support is reduced to such an extent that even normal forces are not well tolerated.

Occlusal Therapy
A. Occlusal Adjustment This is the judicious grinding of certain aspects of the occlusal table, the aim of which is to create correct cusp fossa relationships in both centric and excentric positions. The first step is to achieve the desired jaw to jaw relationship in the retracted centric relation posterior. Cusp slopes are then judiciously adjusted, eliminating interferences to maximum intercuspation at this jaw to jaw relationship. Supporting cusp tips and fossae are not ground as this would lead to a loss of vertical dimension. Then, interferences to smooth excursive movements from this position are eliminated. Balancing interferences are modified first followed by interferences in working and protrusion It must be stressed that not all cases require occlusal therapy or occlusal adjustment and that this mode of therapy should only be embarked on when knowledgeable professional opinion deems it necessary. B. Temporary Stabilization This is achieved by splinting one or more mobile teeth to one another and to other more stable teeth in a position that facilitates a more axial and even distribution of occlusal forces. This is generally performed on teeth with reduced periodontal support. The rationale for this is improved patient comfort, function and plaque control, better distribution of occlusal forces and improved tooth stability during clinical procedures.

A variety of means may be utilized to achieve temporary stabilization. What ever means are used, special attention should be paid to making the splint amenable to oral hygiene procedures and instructing the patient on plaque control around the splint. C. Occlusal Splint This is achieved by the patient wearing an occlusal splint (orthotic appliance) appliance in one arch (usually the maxilla). The appliance is adjusted so that all teeth contact on a flat plane in centric relation with a long anterior contact to centric occlusion. When in position, the carefully fabricated and adjusted bite plane should allow all excursive movements to occur freely without any interarch tooth to tooth contacts taking place. By this method, occlusal trauma is controlled. Occlusal splint therapy may have the following additional uses and benefits: By preventing interarch contacts, "deprogramming" of masticatory neuromuscular reflexes may occur leading to muscular relaxation which could alleviate spasms and tenderness in the masticatory muscles. This would allow the positioning of the condyles in centric relation, widely accepted to be the best position to restore a case due to its reproducibility. Occlusal splints also allow us to test how well the patient can tolerate a proposed opening of the occlusal vertical dimension. Certain occlusal splints may also be modified and equipped to replace missing teeth and to perform or facilitate minor tooth movements.

Periodontally Oriented Tooth Orthodontic Movement This is tooth movement therapy to level and align periodontal support, improve direction and distribution of occlusal forces, modify periodontal defects and to create an environment more favorable to plaque control. Uprighting teeth, extrusion of teeth, retracting flared anteriors, de-rotating teeth, repositioning drifted teeth and separating crowded teeth and roots are examples of periodontally oriented tooth movement. It must always be borne in mind that tooth movement forces are equivalent to traumatic forces and should only be applied in the absence of inflammation. Otherwise, attachment loss can be expected and instead of attaining our goal, we will make matters worse. It is imperative that calculus is removed from all root surfaces prior to orthodontic movement. In some cases an open flap debridement is necessary to get access to deep calculus on furcation areas. Similarly plaque levels must be kept low throughout orthodontic movement.

Although occlusal therapy may be initiated during initial therapy, it is often carried over and completed in following phases of therapy.

Re-Evaluation
After completing this initial phase of therapy, an adequate period of time should be allowed for healing to occur. Four to six weeks from the last scaling and root planing appointment is the minimum time period required. Then a reevaluation must be carried out.

Clinical parameters are reexamined and remeasured. There should be considerable resolution of the inflammatory component of the disease with shrinkage of previously edematous tissue and a subsequent decrease in probing pocket depth. Active caries and periodontal breakdown should have been halted and tooth mobility should be decreasing. It is important to evaluate also the patients cooperation, motivation and commitment as well as their ability to perform plaque control procedures. All this provides information as to the success of initial therapy and the feasibility of proceeding with the next phase of the treatment plan or, if any modifications to it that are required.