At the end of this lecture, you will be asked if you would like to take this course for continuing education units.
California Continuing Education Credits: 2 units
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 patient¹s 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.
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.
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.
In educating the patient, it is important to convey the following points:
This is done using diagrams, charts, models, slides, videos, leaflets and all other means at our disposal.
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 ³benign² 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.
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.