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Failure of Periodontal Treatment

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									Failure of Periodontal Treatment
“Treatment failures appear to occur more frequently in periodontology
   than in other dental disciplines. A regular recall program can largely
   prevent such failures.”
                                                   Klaus H. Rateitschak
Treatment success
1.   Bleeding (inflammation) is stopped.
2.   Pocket activity is eliminated.
3.   Probing depth is significantly reduced.
4.   Gain of attachment is achieved.
5.   Tooth mobility is stabilized.
Treatment Failure
1.   Bleeding on probing is continued.
2.   Symptoms of activity in addition to bleeding (exudate or
     pus) are seen in response to probing.
3.   Probing depth is not reduced or continues to increase.
4.   Attachment loss is progressive.
5.   Tooth mobility is increased.
Causes of treatment failure
1.   Incorrect patient selection.
2.   Incomplete diagnostic procedures
3.   Improper diagnosis and incorrect prognosis.
4.   Treatment difficulties and obstacles.
5.   Poor/unsupervised healing.
6.   Absence of maintenance therapy.
Incorrect patient selection
 Patient cannot be motivated to maintain proper oral hygiene.
 Proper oral hygiene procedures is enormous and is
 underestimated by most dentists.
 The disease must be explained, follow by description of the
 bacterial cause of periodontitis, then oral hygiene measures.
Incorrect patient selection
 Patients who have a serious systemic disease that could
 promote periodontitis.
 The disease categories involved include metabolic diseases,
 blood dyscrasias, side effects of various drugs,
 immunodeficiency, genetic syndromes.
 The patients afflicted by such conditions require special
 attention and must be treated.
 Incomplete diagnostic procedure
It is important that we as clinician to follow the sequence of examination and
special investigation before we can make complete diagnosis.
When coming into a diagnosis, we can organizing it as “problem-oriented
In this method, the diagnostic data are organized into groups of problem (a
condition that differs from health, thus require further investigation or
With the information gathered from the history and from the clinical and
radiographic examinations, a problem list can be generated, so that, an
accurate diagnosis, prognosis, and treatment plan may be developed.
The seriousness of the disease must be established exactly through diagnostic
procedures, not only for the entire dentition, but also for each tooth
individually and for each side of a tooth.
Major problem categories for
periodontal disease
  a)        Gingival/periodontal problems
       i.    Bleeding on probing
       ii.   Tissue edema
       iii. Architectural tissue changes (e.g. cratering of papilla)
       iv. Probing pocket depth
       v.    Recession
       vi. Mucogingival defects
       vii. Furcation involvement
       viii. Tissue fibrosis
b)    Occlusion –related problems
     i.   Mobility
     ii. Interferences in movement
     iii. Fremitus
     iv. Excessive wear
     v. TMDS
     vi. Malocclusion, including position of the teeth in the maxilla and
     c) Other local etiologic problems
          i. Quantity, quality, and location of plaque and calculus
          ii. Oral hygiene status
          iii. Mouth-breathing
          iv. History of prior periodontal therapy
          v. Caries, abrasions and erosion of tooth
  Radiographically detectable problems
a) Horizontal/vertical bone resorption
b) Furcation involvement
c) Periapical radioluscency
d) Widening of the periodontal ligament space
e) Calculus, caries, overhanging/deficient restorations
f) Other pathologic findings (e.g. cysts)
Systemic problems
    •   Smoking
    •   Pregnancy and puberty
    •   Systemic disease (e.g. diabetes, HIV) and systemic medication (e.g.
Incorrect Prognosis
 Basically prognosis is defined as a forecast of the course of the
 disease. when applied to the dentition, prognosis usually refers to
 the anticipated period of time that the teeth will remain in the
 mouth as part of functional dentition
 Determination of prognosis is essential in treatment planning. The
 accurate prognosis will determine the success rate for periodontal
 Failure to include the factors that need to be considered in
 prognosis determination can lead to failure of periodontal therapy
Factors to be considered in
determining prognosis
 Patient factors
   Systemic health
   Patient motivation
   Financial concerns

 • Other aids to prognosis
     Nature of the infection
     Host response
Local factors
  Remaining natural teeth
  Probing pocket depth and existing attachment loss
  Presence of supragingival and subgingival plaque and calculus
  Tissue inflammation, suppuration, and abscess formation
  Tooth mobility
  Presence of furcation involvements
  Alveolar bone support
  Root length and root form (crown/root ratio)
  Harmful habits
  Malaligned teeth
  Caries, existing restorations
  Endodontics lesions, previous endodontic therapy
  Impacted teeth
  Other pathologic conditions
Treatment difficulties and obstacles
 Patient factors
   Lack of understanding among individuals about effective
   practices to prevent dental disease
   Patients with systemic diseases eg blood dyscrasias, diabetes
   Limited mouth opening – TMJ problems.
Local factors
  Difficulties in access – furcation area, posterior distal; affect
  cleaning effectiveness.
  Mobile teeth with good prognosis and extraction is avoided.
  Severely crowded dentition.
  Ill fitting dentures.

Operator factors
  Skill and knowledge – important in handling variety of cases and
Poor healing
The process of healing needs to be monitored
consistently to ensure its process is progressing well, e.g.
by follow up visits.
In the periodontium, as elsewhere in the body, healing is
affected by local and systemic factors.
Local factors
  Systemic conditions that impair healing may reduce the
  effectiveness of local periodontal treatment and should be
  corrected before or during local therapy.
  However, local factors, particularly plaque microorganisms are
  the most common deterrents to healing after periodontal
Healing also delayed by excessive tissue manipulation during
  trauma to the tissues
  the presence of foreign bodies
  repetitive treatment procedures that disrupt the orderly cellular activity in the
  healing process
An adequate blood supply is needed for the increased cellular
activity during healing. If this is impaired or insufficient, areas of
necrosis will develop and delay the healing process.
Systemic factors
  Healing capacity diminishes with age
    because of atherosclerotic vascular changes, which is common in aging and
    result in a reduction in blood circulation.
  Healing is delayed in patients with generalized infections and in
  those with diabetes and other debilitating disease.
  Healing is retarded by malnutrition (deficiencies in vitamin C,
  proteins, and other nutrients.) and condition that interfere with the
  utilization of nutrients.
  Systemically administered glucocorticoid eg cortisone , hinder repair
   depressing the inflammatory reaction or inhibiting the growth of
   reducing the production of collagen and
   disturbing the formation of endothelial cells.
 Systemic stress, thyroidectomy, testosterone, adrenocorticotropic
 hormone (ACTH), and large doses of estrogen suppress the formation
 of granulation tissue and retard healing.
 Progesterone increases and accelerates the vascularization of immature
 granulation tissue and appears to increase the susceptiblity of the
 gingiva to the mechanical injury by causing dilation of the marginal
 Current smokers do not respond as well to periodontal therapy as
 non-smokers or former smokers
   Reduced clinical response to scaling and root planing
   Less reduction in pocket depth
   Reduced gain in clinical attachment level ( especially in deep pockets >5mm)
 Toxic constituents of cigarette smoke-particularly nicotine,
 cotinine, carbon monoxide and hydrogen cyanide-are cytotoxic to a
 number of cells and inhibit wound repair.
Nicotine inhibits proliferation of fibroblasts and macrophages.
Fibroblasts exposed to nicotine have shown reduced migration and
attachment to root surfaces.
Fibroblasts have been shown to nonspecifically bind and internalize
nicotine, which could, in turn, result in an alteration of the cell
metabolism including collagen synthesis and protein secretion.
All these mechanisms could be in force in causing periodontitis in
smokers and ultimately be responsible for the reduced periodontal
healing observed in them.
Absence of maintenance therapy
 Rationale for maintenance therapy
   Subgingival scaling alters microflora of periodontal pockets (
   for 3-6 months)
   Incomplete subgingival plaque removal
   Treated periodontal patients are speculated to be predisposed to
   recurrent pocket formation because of its healing by long
   junctional epithelium
The maintenance visit may include:
  Discussing any changes in patient’s health history
  Examining mouth tissues for abnormal changes
  Measuring the depth of pockets around the teeth
  Assessing oral hygiene habits and providing instruction
  Removal of bacterial plaque and calculus
  taking necessary x-rays to evaluate the teeth and the bone supporting the
  examining teeth for decay and other dental problems
  checking the way teeth occlude when biting
  applying or prescribing medications to reduce tooth sensitivity or other
Absence from maintenance therapy could be due to
  Patient’s own motivation is lacking (possibly because of lack of
  communication with the operator)
  Patient may suffer from dentin hypersensitivity due to
  periodontal treatment
Attention to a few important points can improve the success rate
of periodontal treatment:
  Careful, comprehensive examination leads to a well-founded
  diagnosis and prognosis, thus a precise treatment plan.
  The limits of successful therapy must be recognized.
  Reinfection of pockets must be prevented through supervision of
  healing process.
  Long term success is possible only if patient, once treated is placed
  on regular recall schedule.
 Newman, Takei, Carranza, Clinical Periodontology, 9th edition;
 2002, Saunders
 Rateitschak, Failure of periodontal treatment, Quintessence Int
 1994; 25: 449-457
 Grossi, Zambon, Effects of smoking and smoking cessation after
 mechanical periodontal therapy, JADA, Vol. 128, May 1997

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