1. C HAPTER 10 Treatment Planning for the Periodontal Patient Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

2. I NTRODUCTION Defining a treatment plan for the patient with periodontal disease is a process that requires assessment, preventive, therapeutic, and evaluative skills of the dental hygienist and dentist. The treatment plan is the blueprint for the management of the dental patient and is an essential aspect of successful therapy. 2 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

3. G OALS OF T REATMENT The treatment plan defines the methods and sequence of delivering appropriate treatment. The dental hygiene treatment plan consists of services that are performed by the dental hygienist within the total treatment plan. Treatment planning occurs after the assessment of all clinical data is complete and reflects the diagnosis and the prognosis of the patient. 3 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

4. G OALS OF T REATMENT (C ONT.) Goals of the treatment plan are to eliminate and control the etiologic and predisposing factors of disease, maintain health, and prevent the recurrence of disease. The problems and the treatment goals must be explained to the patient in understandable terms. The patient’s perceived needs, as well as the disease identified by the clinician, need to be addressed. 4 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

5. P HASES OF T REATMENT The treatment sequence begins with a preliminary phase that addresses the immediate treatment needs of the patient such as extractions or endodontic treatment. This preliminary phase is followed by: Phase I –etiologic treatment Phase II –surgical treatment Phase III –restorative treatment Phase IV –maintenance treatment 5 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

6. P HASES OF T REATMENT (C ONT.) The purpose of the preliminary phase is to bring all emergency and other critical situations under control. Phase I therapy is the etiologic phase of treatment and includes the procedures that control or eliminate the etiologic factors of the disease process. Providing patient education and plaque control instruction Scaling and root planing Administering antimicrobial agents 6 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

7. P HASES OF T REATMENT (C ONT.) Phase II therapy is the surgical phase of treatment and includes the procedures that reduce the effects of disease. Performing techniques designed to restore periodontal tissues that have been lost as a result of disease Phase III therapy is the restorative phase of treatment and involves the restoration and replacement of missing teeth. Providing restorative dentistry, orthodontics, or any needed occlusal therapy 7 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

8. P HASES OF T REATMENT (C ONT.) Phase IV therapy is the maintenance phase of treatment. Patients remain in this phase for a lifetime. The accepted term for phase IV therapy is periodontal maintenance or periodontal recall. The periodontal condition and the plaque control that the patient is able to attain and maintain determine the interval of maintenance visits. Most patients who have been treated for moderate-to- advanced periodontal disease require maintenance visits every 3 months. 8 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

9. R OLE OF THE D ENTAL H YGIENIST The dental hygienist is often responsible for the treatment of the patient with periodontal disease in phases I, II, and IV. Slides 10 through 13 are examples of successful therapeutic results achieved by the dental hygienist provided in phase I therapy. 9 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

10. 10 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

11. 11 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

12. R OLE OF THE D ENTAL H YGIENIST (C ONT.) 12 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

13. 13 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

14. R OLE OF THE D ENTAL H YGIENIST (C ONT.) Disease classifications are useful for diagnosis, prognosis, and treatment planning. Various periodontal classification systems have been used over the years and have been modified to reflect advances in knowledge and research. A classification system is simply a method for comparing treatment approaches and the likely results. 14 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

15. R OLE OF THE D ENTAL H YGIENIST (C ONT.) The American Academy of Periodontology (AAP) approved a classification system that is based on the clinical manifestations of diseases and conditions. This system separates gingival diseases from the periodontal diseases and conditions that affect the periodontium. 15 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

16. R OLE OF THE D ENTAL H YGIENIST (C ONT.) The case type classification system includes: Case Type I–Gingivitis Case Type II–Slight Chronic Periodontitis Case Type III–Moderate Chronic or Aggressive Periodontitis Case Type IV–Advanced Chronic or Aggressive Periodontitis Case Type V–Refractory Chronic or Aggressive Periodontitis 16 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

17. R OLE OF THE D ENTAL H YGIENIST (C ONT.) Severity of disease is described in terms of clinical attachment loss (CAL) and is generally defined as follows: 1 to 2 mm of CAL characterizes slight periodontal disease. 3 to 4 mm of CAL characterizes moderate periodontal disease. 5 mm or more of CAL characterizes severe periodontal disease. 17 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

18. R OLE OF THE D ENTAL H YGIENIST (C ONT.) Disease is also characterized as generalized or localized, depending on the extent of the dentition that is affected. The severity of disease, the extent of disease, the amount of calculus, and the patient education process will influence the number of visits required to treat the patient appropriately. 18 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

19. R OLE OF THE D ENTAL H YGIENIST (C ONT.) Patient education to attain plaque biofilm control is a critical element of treatment and is often the responsibility of the dental hygienist. Plaque control and prevention instruction makes a significant difference in the overall success of periodontal treatment. The patient education process continues throughout the treatment sessions and during all phases of care. 19 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

20. T REATMENT P LANNING FOR P ERIODONTAL D ISEASE The systemic and periodontal condition of the patient dictates how the dental hygienist sequences either a single session or a series of nonsurgical treatment sessions. The patient may have systemic conditions that alter the number and length of treatment appointments. Patients with physical or mental disabilities can also present challenges that require a modification of the treatment plans. 20 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

21. T REATMENT P LANNING FOR P ERIODONTAL D ISEASE (C ONT.) The currently accepted scaling technique is to completely scale a sextant, quadrant, or more teeth during a single session. This practice often requires that local anesthesia be administered to permit the treatment to be painlessly completed for the patient. The immediate goal of each session of instrumentation is the complete removal of all adherent bacterial plaque biofilm and calculus deposits. 21 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

22. I NFORMED C ONSENT Informed consent is permission to proceed with treatment granted by the patient to the health care provider. All treatment plans must be understood by the patient and reflect the patient’s wishes and preferences. The patient must be fully aware of the extent of his or her disease and the treatment options that are being considered. 22 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

23. I NFORMED C ONSENT (C ONT.) Informed consent can be verbal or written. Verbal consent is often called implied consent and is used in routine clinical situations in which little or no apparent risk exists. Written or expressed consent is the common practice with most periodontal therapy in which invasive and surgical care is rendered and the risks are greater than those expected during a routine clinical visit. 23 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

24. I NFORMED C ONSENT (C ONT.) The patient should always be informed of the disease process that is present in his or her mouth, as well as the treatment proposed and any alternatives to that treatment. This presentation must also include the consequences of providing no treatment or partial treatment, which is termed informed refusal. A patient has the right to refuse any treatment, even if it is not in his or her best interest or even if no treatment might contribute to further health-related problems. The patient must have the opportunity to ask questions and understand the answers before signing any document or before proceeding with any treatment option. 24 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

25. D OCUMENTATION Documentation is essential in all aspects of dental hygiene and periodontal care. The dental hygienist must be careful to document treatment at every visit in the patient’s record, which is referred to as chart notes or progress notes. 25 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

26. D OCUMENTATION (C ONT.) All entries in the patient’s clinical chart should be complete and clear. In a written record, if an error is made while entering information in the patient’s chart, then a line should be drawn through the incorrect information, ensuring that the incorrect information is still legible; the correct information should then be entered next to it. Electronic notes entered after the original date should reflect the actual date entered and the reason for the correction. 26 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

27. D OCUMENTATION (C ONT.) Confidential handling of a patient’s record is important. Unauthorized disclosure to other patients or providers is considered negligence. Careful documentation is the foundation of sound risk management practice. 27 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

28. D OCUMENTATION (C ONT.) The two universally accepted strategies for minimizing the risks associated with providing dental and dental hygiene services are: 1.Good documentation 2.Careful communication with the patient 28 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

29. T REATMENT P LANNING IN D ENTAL H YGIENE The dental hygiene care plan is an individualized approach to treatment that details the care to be provided by the dental hygienist. The plan is adapted to the needs of the patient and is presented in an orderly sequence to allow for thoroughness in completing each procedure. 29 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

30. T REATMENT P LANNING IN D ENTAL H YGIENE (C ONT.) Determining the débridement sequences is influenced by a number of factors, including the location and extent of infection, the presence of pain, or any medical or physical limitations of the patient. All aspects of the patient’s condition must be considered in choosing which area to begin treatment, the length of the appointment time, and homecare recommendations. 30 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

31. T REATMENT P LANNING IN D ENTAL H YGIENE (C ONT.) The patient with periodontal disease requires a follow-up visit to evaluate the response of the tissues to the scaling and débridement procedures. This appointment is often called the re-evaluation or s ometimes simply a tissue check. Tissue healing and the patient’s progress toward effective plaque control can be observed and evaluated approximately 4 weeks after débridement. Pockets will re-epithelialize in approximately 1 week, but connective tissue healing will not have occurred. 31 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

32. T REATMENT P LANNING IN D ENTAL H YGIENE (C ONT.) At the re-evaluation appointment, the dental hygienist assesses and determines the appropriate interval for periodontal maintenance. In many practices, the re-evaluation visit is also the logical and convenient time for the periodontist or dentist to examine the patient and initiate the next step in the total treatment plan. 32 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

33. T REATMENT P LANNING IN D ENTAL H YGIENE (C ONT.) Treatment planning is considered part of the dental hygiene process of care. The components of dental hygiene care are divided into five categories: assessment, diagnosis, planning, implementation, and evaluation. Treatment planning incorporates both assessment and diagnosis in defining a set of procedures to restore the patient to a state of health. 33 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

34. T REATMENT P LANNING IN D ENTAL H YGIENE (C ONT.) The treatment plan is the guideline for the management of comprehensive care and is an essential part of successful therapy for every dental patient. A series of sample treatment plans are presented in slides 35 and 36 to assist the dental hygienist in applying a variety of treatment options to specific patients. 34 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

35. T REATMENT P LANNING IN D ENTAL H YGIENE (C ONT.) 35 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

36. T REATMENT P LANNING IN D ENTAL H YGIENE (C ONT.) 36 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.