Periodontal diagnosis and periodontal treatment planning are critical steps in the process of periodontal disease management. Diagnosis and treatment planning are the direct outcomes of a periodontal assessment. An accurate diagnosis and an effective periodontal treatment planning should be based upon a compressive assessment of periodontal signs and patient symptoms.
The art of decision making in periodontal treatment planning therapy involves a synthesis of
1) clinical experience of the therapist,
2) the technical ability of the therapist,
4) the experience of others as recorded in texts or presented in texts or presented in professional forum and
5) evidence-based thinking.
What is a Working Diagnosis? How Does a Working Diagnosis Differ From a Differential Diagnosis?
Working diagnosis is the “pencil” diagnosis generated by the cindan that is based upon the scientific significance of the signs and symptoms recorded during the comprehensive examination. It is the clinician’s best estimate of the pathologic process, the etiologic factors for that process, and the morbid outcomes of the process present at the time of the examination.
The working diagnosis is the basis of the patient’s initial periodontal treatment planning. If later assessments are made at the re-evaluation of initial therapy, or for that matter, assessments are made at any time during therapy indicate that the working diagnosis may be incorrect, the working diagnosis may be changed to reflect the new information.
A differential diagnosis is one that includes two or more possible processes that may be consistent with initial clinical assessments. Rather than commit to one working diagnosis, the clinician may choose to provide a differential diagnosis and either perform or request additional diagnostic testing. In this instance, the clinician fully expects that a working diagnosis will emerge from the differential diagnosis.
The initial periodontal treatment planning is based upon the periodontal disease identified in the working diagnosis. The treatment plan addresses itself to each etiologic agent in a logical sequence. Pertinent etiologic factors that are not addressed in the treatment plan result in under treatment and failure of therapy.
The treatment of etiologic factors that either do not exist, or have been incorrectly identified by the clinician, leads to over- treatment, which prolongs treatment, or in the case of an incorrect assessment, under treatment, which prevents disease control.
Both over treatment and under periodontal treatment planning are outside the standard of care for any patient. Assuming that the clinical assessments are complete, control of the etiologic factors should effectively manage the periodontal disease (identified in the working diagnosis). Simply stated, control of etiologic factors translates to disease control.
SAMPLE periodontal treatment planning
While all periodontal treatment planning share a common goal (i.e., control of inflammatory periodontal diseases), the pathway to that goal from patient to patient is rarely the same.
For discussion purposes, models of periodontal treatment planning will be presented for each of the three basic periodontal disease categories: Gingivitis, periodontitis, and occlusal traumatism.
Gingivitis. The presence or absence of dental plaque as the primary etiologic factor distinguishes the two major categories of Class I Gingival Diseases. There are four categories of dental plaque-induced gingival diseases and eight categories of nonplaque-induced gingival lesions.
Since the majority of gingival diseases seen in a dental practice are related to the presence of plaque, the framework of a periodontal treatment planning designed to manage these common disorders is included here.
The correct working diagnosis is the critical first step in the periodontal treatment planning process. The therapeutic “mindset” of the provider should be based upon that diagnosis.
For example, a diagnosis of gingivitis associated with dental plaque only should ordinarily not include respective periodontal surgery, but a diagnosis of drug-influenced gingival enlargement might include a gingivectomy, apically positioned flaps, or systemic antibiotics as a therapeutic possibility if the gingival enlargement persists following nonsurgical mechanical therapy and attempts to modify the patient’s medication protocol. This is a part of periodontal treatment planning.