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Decision-making for residual periodontal pockets after aetiological treatment Amal Bouziane Latifa Benrachadi Oumkeltoum Ennibi Dental Update 2024 42:5, 707-709.
Authors
AmalBouziane
DMD Specialist in Periodontology, Associate Professor, Department of Periodontology, Faculty of Dental Medicine, Biostatistical, Clinical and Epidemiological Research Laboratory. Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
The practitioner may have difficulties making decisions regarding the most appropriate therapeutic approach in the case of the persistence of periodontal pockets after initial periodontal treatment. Several options may be considered: aetiologic retreatment, maintenance, surgery of the pocket or extraction of the tooth for strategic reasons or when the conservation of the tooth is impossible. There are no clear guidelines for the treatment decision. The aim of this article is to present the main factors involved in making a treatment decision. An algorithm and its background rationale are presented to help the practitioner make a decision about residual periodontal pockets after aetiological treatment.
CPD/Clinical Relevance: Many factors need to be considered in making a treatment decision for residual periodontal pockets: depth of the pocket, presence of signs of infection, difficulty of access to deposits and the type of periodontal lesion.
Article
Non-surgical mechanical debridement is the first therapeutic option of periodontal pockets during the initial phase to eliminate local aetiological factors of periodontitis, namely the bacterial biofilm (plaque) and calculus. In many cases, the aetiological periodontal treatment alone is a sufficient treatment for the improvement of clinical parameters.1
There is no consensus on the clinical criteria to guide therapeutic decisions in the case of residual periodontal pockets after initial periodontal treatment. Decision-making is an important aspect of everyday clinical practice. Definition of therapeutic goals is an important step in this process:
Maintenance or pocket surgery?;
Open flap debridement?;
Regenerative therapy?; or
Resective surgery?
The aim of this article is to present the criteria that can guide the clinician in his/her decision when dealing with residual periodontal pockets.
Phase of decision-making
There must be a proper time interval between initial treatment and re-evaluation of residual periodontal pockets. Different periods have been reported to reassess the pocket depth after initial treatment. Based on the rate of healing, 3 months after treatment is a proper interval for evaluation of initial non-surgical treatment. Healing seems to be complete 3–6 months after non-surgical treatment.2 A limited and gradual healing can even occur over 9 months or more after treatment.3 Too short a time interval can lead to an overtreatment.4
It is important to programme control visits before the time of re-evaluation. If a case of periodontitis has not been subject to periodic controls between the end of the initial or surgical treatment and reassessment, the case may have an unfavourable prognosis and this is especially true if the time between sessions is extended.
Criteria of positive therapeutic outcome are:
Absence or significant reduction of plaque deposits;
Elimination or significant reduction of signs of inflammation (gingival aspect, bleeding, suppuration);
Reduction of tooth mobility;
Reduction or elimination of the pocket depth;
Radiographic signs of stability;
Conservation of the tooth.
The main positive result of periodontal treatment is the prevention of tooth loss. Tooth preservation, which is the real purpose of periodontal treatment, is the most appropriate parameter for assessing the effectiveness of treatment.5,6
The evaluation of periodontal treatment results was listed according to standards defined by Swiss authors (Table 1).7 These standards determine the clinical criteria of periodontal therapy success (pocket depth, bleeding, suppuration, pain, aesthetics). A patient belongs to any class when responding to four criteria from each category.7
Quality Standard
Criteria
A+
No probing depth >4 mmMinimal bleeding on probing (<10%)No visible hard and soft bacterial depositsAesthetically satisfactory periodontal situationAbsence of painIndividually optimal function
A
No persisting pockets >5 mmNo suppurationOccasional bleeding on probing (<25%)Low plaque index (<30%)Minimally impaired aesthetics (minimal impaired tooth position or impairment of speech by tooth position or root surfaces visible when speaking)Absence of painSatisfactory function
B
Attachment loss with persisting pockets >5 mmSuppuration from few persisting pocketsBleeding on probing (>25%)Insufficient oral hygiene (>30%)Adjustable impairment of aesthetics (more than one criterion listed under A present)Occasional painMinimally impaired, adjustable function
C
Multiple sites with suppurationRecurrent abscessesSeverely neglected oral hygieneGeneralized bleeding on probingMassive attachment loss without adequate treatmentSignificant attachment loss with pocketing in adolescentsIncapability to chew due to periodontitis
Factors influencing the decision
Persistence of residual pockets after a sufficient healing period raises the question of the therapeutic approach to follow. Depending on the clinical situation, surgical and non-surgical treatment can be combined.
There is evidence that chronic periodontitis can be successfully controlled by conservative treatment based on repetitive non-surgical debridement of residual pockets.8,9,10 However, this debridement should not be repeated more than twice according to some authors.11
In the particular case when the plaque control is effective but the tissue response to initial treatment is generally unsatisfactory, the practitioner must exclude the possibility of a patient who brushes his/her teeth well just before visits to the dentist. Therefore, we can mention the following assumptions:11
It is a refractory periodontitis. In this case, bacterial test and antibiotherapy may be indicated;
The patient has a general disease or a risk factor initially undiagnosed, eg smoking;
A diagnostic error is possible (chronic periodontitis instead of aggressive periodontitis). Thus the diagnosis should be reviewed.
If periodontal pockets persist, the therapeutic approach may vary between initial retreatment, pocket surgery or maintenance. Factors influencing the decision are:
Deposits of plaque and calculus;
Signs of inflammation (gingival aspect, bleeding, suppuration);
Dental mobility;
Pocket depth;
Radiographic signs of disease stability;
Furcation defect.
Discussion: therapeutic decision
The pocket can be maintained if:
It shows no signs of inflammation;
The patient has a satisfactory individual plaque control;
The pocket depth was reduced by half compared to the initial measurement11 or at least 2 mm.12
This treatment option requires regular and frequent maintenance checks (Figures 1,2–3). Matuliene et al13 studied the influence of residual pockets ≥5 mm and bleeding on probing after active periodontal treatment on the progression of periodontitis and tooth loss. They concluded that a residual pocket ≥6 mm is an insufficient therapeutic outcome and requires adjuvant therapy. The decision depends on the therapeutic goals. The higher the residual pocket depth and clinical attachment loss, the more surgery will be recommended. In addition, the type of the tooth (mono- or multi-rooted), age and plaque index are factors that have an impact on decision-making.14
Figure 1.
(a, b) Initial state: severe generalized aggressive periodontitis. Probing values of UR4 initially with unfavourable prognosis. B: above buccal probing values; P: below palatal values.Figure 2.
(a, b) Improved pocket depth 2 years after the aetiological treatment. Values: buccal: recessions 4 4 5, probing depth 3 3 5; palatal: recessions 3 3 5, probing depth 4 3 5.Figure 3.
(a, b) Stability of the lesion and maintenance. Values 6 years after the aetiological treatment: buccal: recessions 3 5 5, probing depth 3 1 3; palatal: recessions 3 4 3, probing depth 3 2 2.
Following the re-evaluation of aetiologic treatment, open flap debridement may be indicated to complete debridement in difficult areas (Figure 4,5,6–7, Tables 2,3–4). If the indication is that access surgery is required due to difficulty of access (furcation, root concavities, deep pockets), this surgery will be programmed after the patient has achieved good plaque control. Pocket surgery should be avoided in non-compliant patients.15
Figure 4. Initial radiograph in a context of severe generalized aggressive periodontitis.Figure 5. Clinical case at re-evaluation.Figure 6. Access periodontal surgery for debridement of the lesions.Figure 7. Improvement of the lesions (result 4 years after surgery). There was an amalgam filling of the cavity following caries in the mesial of the tooth.
B 3.2.7
7.1.2
6.5.2
12.3.8
L 3.3.7
7.5.3
5.5.5
1.2.8
LR7
LR6
LR5
LR4
B 3.2.5
5.2.2
6.2.2
11.1.5
L 2.2.3
6.1.2
2.1.2
2.1.5
LR7
LR6
LR5
LR4
B 3.2.3
5.2.3
3.2.2
12.1.2
L 1.1.5
5.2.3
3.2.3
3.2.3
LR7
LR6
LR5
LR4
Results of a meta-analysis have indicated that the surgical access flap improves the reduction of pocket depth and the clinical attachment gain at deep sites (≥7 mm probing depth) compared with non-surgical debridement.16,17 This result is, however, not clinically relevant because the reduction of pocket depth is only 0.6 mm and gain in clinical attachment is only 0.2 mm. Therefore, the superiority of surgical debridement by a simple access flap, compared to non-surgical debridement, is limited clinically. A more recent meta-analysis18 was conducted to investigate the clinical performance of conservative surgery in the treatment of intrabony defects caused by periodontal disease. The treatment of intrabony defect with conservative surgery was associated with improvement of periodontal clinical parameters. Better outcomes seemed to be associated with papilla-preservation flaps. The objective of this review was not to compare conservative surgical treatment with other treatments, such as regenerative. However, clinicians should bear in mind that, in intrabony defects, conservative surgery may represent a viable therapeutic option when regenerative treatment is not feasible.
When the aim of the treatment is to improve periodontal architecture (eg in the case of craters), and to create favourable local conditions for facilitating hygiene and maintenance, the access surgery can be associated with resective surgery.1,19 This is especially important for long-term results because periodontal maintenance is the most critical phase of treatment. Resective techniques consist of gingivectomy or apically positioned flap with or without bone resection (osteoplasty). However, adverse effects of these techniques, sensitivity and aesthetic inconvenience should be evaluated before making a decision.
When the objective is the reconstruction and regeneration of lost periodontal structures, surgical treatment by a regenerative technique is an adequate therapeutic option. The condition is positive bone architecture (2 or 3 intraosseous walls, Cl II furcation lesions). This treatment allows for the correction of anatomical defects and completion of the reduction of the pocket, partial or total root coverage and tissue regeneration (Figures 8,9,10,11–12).
Figure 8. Initial state: chronic periodontitis with probing values at UL5: buccal, 6 3 3; palatal, 9 3 2.Figure 9. Indication of surgery at residual pocket (8 mm at mesiopalatal of UL5).Figure 10. Angular bone resorption of 50% on mesial of UL5. The lesion is of three walls apically and two walls coronally.Figure 11. Use of tricalcium phosphate as regenerative material and suturing.Figure 12. Stability of the lesion 7 years after surgery. Probing values: buccal, 3 2 2; palatal, 5 2 2.
In the case of an orthodontic multidisciplinary treatment, surgery of the pocket can be recommended to maintain teeth with advanced tissue destruction, prior to initiation of orthodontic movement.20 However, regenerative techniques should be delayed until the end of orthodontic treatment, because the orthodontic movements can modify the bone lesion and transform an angular lesion to a horizontal one.21 Only cases of severe lesions that threaten the conservation of involved teeth should be treated prior to orthodontic treatment.
The decision to extract a tooth with residual pockets can be made for strategic reasons or if the periodontally compromised tooth is of definitive poor prognosis.
Therapeutic options for residual periodontal pockets after aetiological treatment are presented in Figure 13.
Figure 13. Decision-making for residual periodontal pockets.
Conclusion
As in many other disciplines, decision-making in periodontics is complex because of several factors influencing the clinical decision. Any decision should be guided by the therapeutic objectives, the patient's demands and co-operation, and the complexity of the case.
Despite the description of clinical factors that may influence the surgical decision-making in the case of residual periodontal pockets, there is no consensus on the criteria that can serve as a guide. Treatment planning should select the best treatment option to achieve specific objectives. In the management of periodontal disease, the periodontist must find the best compromise to avoid overtreatment to the patient.
