My patient did not respond to periodontal therapy. Now what?

Feb. 1, 2011
It is a virtual certainty that every clinician has treatment successes and failures - every clinician, not just dental professionals.

Richard H. Nagelberg, DDS

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It is a virtual certainty that every clinician has treatment successes and failures - every clinician, not just dental professionals. The patients' underlying biology, behaviors, environmental factors, and genetics, among others, contribute to clinical disease development and progression.

In the general dental office setting, a common approach to periodontal disease includes a comprehensive periodontal and radiographic evaluation and recording. A nonsurgical treatment plan is developed and executed. Some patients respond well, and others do not. One patient comes back for reevaluation and significant disease resolution has occurred. This patient is put on three-month maintenance, signaling the end of the active phase of therapy.

Another patient with the same clinical disease presentation comes in for reeval and no appreciable improvement has occurred. The question then becomes, what do we do now? We scaled thoroughly, irrigated, used antibiotics, and the pockets did not improve appreciably and BOP is still occurring in most sites. Why did the same treatment plan work for the first patient and not for the second?

When we look at each patient's clinical presentation -pocket depths, bone loss, swelling, bleeding, mobility, attachment loss, etc. - we are merely observing the history of the disease process. Our comprehensive evaluation is essentially a damage report.

A variety of processes and events from the past resulted in the clinical presentation we see the day we perform the initial perio evaluation. When we only address the clinical manifestations of the disease we see, we are not taking into account those prior processes and events that got the patient to this point.

Treatment failures occur for many reasons, but deciding how to proceed is central to ultimately achieving disease resolution. A reexamination of the patients' risk factors is a good place to start. They include diabetes, smoking, heredity, medications, nutrition, stress, poor biofilm control, connective tissue disorders, faulty restorations, previous history of gum disease, hormonal variations, immunocompromise, and occlusal problems.

Risk factors really address the underlying biology and behaviors that may hold the keys to less-than-ideal treatment results. Perhaps the patient has a family history of diabetes, and is then possibly prediabetic. She might have an elevated stress level that is suppressing the immune system. His home care may need improvement, including the use of a power brush such as the Philips Sonicare or a mouth rinse or specific interdental devices. We might have to address occlusal disharmony, faulty restorations, and medication-driven xerostomia.

Sometimes another round of scaling is necessary. There are countless examples in every health-care field of modified or repetitive treatments prior to reaching the endpoint of therapy. One and done does not happen all the time. Perio disease development is the result of the interplay between the bacteria and the host response.

Expecting the immune system of each patient to respond favorably to the same therapy is unrealistic. Utilizing low-dose doxycycline may be indicated to reduce the release of the tissue-degrading collagenases. This is a true host response medication.

Another important piece of the puzzle is to understand what it is we are treating, meaning the specific bugs causing this patient's perio disease. Identifying the specific causative pathogens by OralDNA salivary testing provides crucial information regarding the number and virulence of the bugs we are trying to eradicate or reduce to nonpathogenic levels.

Postop testing tells us whether or not we knocked down the number of perio pathogens. If not, further scaling with antibiotics, such as Arestin, may be indicated.

Considering how to address unfavorable results when we develop the initial treatment plan gives us a head start should that occur. Planning how we may proceed with nonresponding sites in advance will reassure the patient and ultimately help us achieve healing.

There is no cookbook approach or flowchart to address unfavorable treatment outcomes, because each patient's biology is unique. We will achieve favorable treatment outcomes more frequently when we use all the tools in our toolbox, exercise our clinical judgment, consult with our periodontist colleagues, and consider the various factors and events that previously occurred resulting in the damage we see today. We will also gain insight as to how we should proceed with less-than-ideal outcomes. As always, all of our efforts are directed to help patients regain their health.

Dr. Richard Nagelberg has practiced general dentistry in suburban Philadelphia for more than 28 years. He is a speaker, advisory board member, consultant, and key opinion leader for several dental companies and organizations. He lectures extensively on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. In-office consultations are available. Contact him at [email protected].

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