Periodontics

Failure of periodonta] treatment

Klaus H.Rateiischak'^

Treatment faihires appear to occur mare frequently in pcriodontology than in other

dental disciplinen, inappropriate patient selection, incomplete diagnostieprocedures,
errors in diagnosis or prognosis, treatment difficulties, unsupervised healing, and the
absence of maintenance therapy may be causes of such failures. A regular recall program can
largely prevent .such failures. {Qwúzss&T\cel-ntl994;25:449-457.)

Introduction According to this definition of successful treatment,

Analysis of a periodontal treatment failure can contrib-
ute more to practical understanding than can the de-
scription of a "nice" success. Periodontal treatment
failures seem to arise relatively frequently, possibly be-
cause, among other reasons, the periodontist works in a
field characterized by the presence of plaque, and the
marginal periodontium remains more or less exposed
to microorganisms—depending on the intensity and
quality of oral hygiene — even after successful primary
care. Not only does the amount of plaque play a role,
but the pathogenicity of the microorganisms and the
immune status of the patient, his or her "resistance,"
are also factors.
Causes of treatment failure
To discuss treatment failures, the concept of successful
periodontal treatment must be defined first. In the
past, treatment was only considered successful when
there was radical elimination of pockets; today, the
concept of treatment success is defined more modestly:
the following clinical parameters must be classified as
treatment failure:
1. Bleeding on probing is continued.
2. Symptoms of activity in addition to bleeding (exú-
date or pus) are seen in response to probing,
3. Probing depth is not reduced or continues to in-
crease.
4. Attachment loss is progressive.
5. looth mobility is increased.
The causes of failure are manifold. In addition to the
fact that periodontal therapy always takes place in re-
gions exposed to plaque formation, failures may be as-
cribed to the following factors;
1. Incorrect patient selection
2. Incomplete diagnostic procedures, improper diag-
nosis, and incorrect prognosis
3. Difficult (or inappropriate} treatment
4. Unsupervised heahng
5. Absenceof maintenance therapy

1. Bleeding (inflammation) is stopped. Incorrect patient selection

2. Pocket activity is eliminated.
3. Probing depth is significantly reduced. A patient is inappropriately selected for comprehen-
4. Gain ofattachment is achieved, sive periodontal therapy if. despite repeated efforts, he
5. Tooth mobility is stabilized. or she cannot be motivated to maintain proper oral hy-
giene. Such patients are programmed for treatment
failure.
The effort required to train the patient in proper oral
hygiene procedures is enormous and is underestimated
by most dentists. Just telling the patient repeatedly not
Professor, Univertity of Basel, Dental Inslituie, Petersplülz 14.
CH-4051 Basel, Switzerland. to forget to brush, or giving a quick demonstration on a

Quintessence International Volume25, Number 7/1994 449

Periodontics
model, simply does not suffice. Rather, the disease
must be explained, perhaps on the basis of a bleeding
index. The explanation proceeds to a description of the
bacterial cause of periodontitis (plaque). Finally, oral
hygiene measures, particularly interdental hygiene, are
taught and checked repeatedly.
Incorrectly selected patients also include those pa-
tients who have a serious systemic disease that could
promote periodontitis. The disease categories involved
include metabolic diseases, such as insulin-dependent
juvenile diabetes; blood dyscrasias,such as panmyelop-
450
Fig 1 a A 27-year-old woman with
Down's syndrome (Langdon-Down
syndrome, trisomy 21) and severe
periodontitis. Oral hygiene is ab-
sent. She has an anterior open bite
and her molars are in crossbite.
Treatment makes sense only if good
cooperation vjill be provided by her
caregivers; otherwise, failure is cer-
tain and radioal prosthetic treat-
ment is indicated.
Fig 1 b Radiographs of the pa-
tient's condition.
athy, the various leukemias, cyclic neutropenia, drug-
induced agranulocytosis. and erythroblastic anemia;
side effects of various drugs, such as hydantoin. cyclo-
sporine, and nifedipine; immunodeficiency, such as in-
fection with human immunodeficiency virus; genetic
syndromes, such as Down's syndrome. Papillon-
Lefèvre syndrome, Chédiak-Higashi syndrome, hypo-
phosphatasia.
As an example of this group of patients, a 27-year-old
woman with Down's syndrome (mongolism, trisomy
21) is shown (Fig, 1). Of course, patients afflicted by
Quintessence Internaiional Volume 25, Number 7/1994

Fig 2a A 28-year-olci woman with
rapidly progressive periodontitis,
Flareups are frequently localized
and irregular in this condition.
Fig 2b Radiographs of the same
patient. In this case of generalized
medium loss, deep losses of bone
are visible (eg, at teeth 14 and 15).
such conditions require special attention and must be
treated. The total treatment plan, however, is more
likely to be a radical one. Teeth with advanced loss of
attachment are extracted- The therapy uften can be
only symptomatic.
Incomplete diagnoscic procedures, improper diagnosis,
and incorrec! prognosis
The seriousness of the disease must be established ex-
actly through the diagnostic procedures, not only for
the entire dentition, but also for each tooth individually
Quintessence Inlemational Volume 25, Number 7/1994
Pehodontics
and for each side of a tooth. In addition to this perio-
dontal morphology, is also important to describe the
pathobiology of the periodontal state: Is it a case of
adult periodontitis (AP), rapidly progressive periodon-
titis of a young adult (RPP). or (rarely) localized juve-
nile periodontitis (UP)?' Depending on the phase of
the disease, and on the form of its course, treatment
plans and prognoses will vary. For example, therapy of
rapidly progressive periodontitis must be more radical
than that of adult periodontitis, if failure is to be avoided.
As an example, Fig 2 depicts a case of well-advanced
451
Pehodontics
rapidly progressive periodontitis that is not recogniz-
able through a diagnosis made by simple observation.
Only the most careful probing of each tooth side, anal-
ysis of radiographs, and determination of tooth mobil-
ity will reveal the severity of the disease, which requires
a correspondingly extensive treatment.
Another case is that of a caries-free 20-year-old pa-
tient (Fig 3). Initial observation indicates serious gingi-
vitis caused by plaque. Again, only careful probing, de-
termination of tooth mobility, and analysis of the radio-
graphs make it clear that she has severe postjuvenile
452
Fig 3a A caries-free 20-year-old
woman with serious postjuvenile
periodontitis. Cursory inspection
indicates oniy gingivitis.
Fig 3b Radiographsoftiiepatient
cieariy show extensive loss of at-
tachment, particularly in the an-
terior maxillary region.
periodontitis. If only gingivitis is diagnosed in such a
patient, and treatment is limited to removal of supra-
gingival plaque and calculus, tooth loss would result in
a short time and thus there would be a failure of treat-
ment.
Difficult (or inappropriaie) ireatment
The chief purpose of a causal periodontitis therapy is
the elimination of subgingival plaque, that is, cleaning
the root surface. Subgingival scaling can be performed
Quintessence Internationai Volume 25, Number 7/1994

Fig 4 Untreated incisor with pro-
found periodontitis and an extreme-
ly irreguiar course of the floor of the
pocket, (leñ) View from facial as-
pect; (right) view from mesial as-
pect. The remaining periodontal lig-
ament structures are blue, plaque
and calculus are black. The pocket
includes undercut regions that were
inaceessibie to a curette.
conservatively (closed), or open debridemeni can be
performed after formation of a surgical flap. As simple
as scaling sounds, its application in practice may be
quite difficult. Inconsistent treatment, however, inevi-
tably leads to failure.
Several difficulties can stand in the way of subgingi-
val scaling'^ •': an uneven course of the pocket floor. Ihe
micromorphology of the root surface, and the macro-
morphology of the root.
Uneven course of the pockei floor. The extracted an-
terior tooth in Fig 4 clearly illustrates the extraordinar-
ily uneven course of the pocket floor. This is a case of
severely advanced periodontitis, and the tooth was ex-
tracted. The course of the pocket floor can be irregular,
however, even in the eariy and middle stages of the dis-
ease. Although a very deep pocket may exist on one
side of the tooth, there may be little loss of attachment
on another surface. The course of the pocket floor even
may have undercut regions, so that it is very difficult—
particularly during a closed procedure—to reach the
pocket floor with the curette and thus to achieve
thorough root cleaning. If large masses of bacteria re-
main deep in the pocket, failure is certain.
Micromorphology of rhe root surface. Occasionally
small resorptive regions (lacunae) are present on the
root surface {Fig 5). These may be up to 80 \x.m deep
and cannot be reached by curettes or other instru-
ments, whether used in closed or open debridement
procedures. Microorganisms that promote recurrences
remain in these niches.''
Quintessence Intemational Volume25, Number 7/1994
Penodontícs
Macromorphology of the root. In practice, almost no
single-rooted teeth have round or oval cross sections.
Roots usually have hourglasslike depressions. Occa-
sionally, teeth have fused roots that often run together
in a deep groove (Fig 6). Such grooves act as a "guide
plane" for bacteria. They are largely inaccessible to
curettes. It may be possible to open the grooves slightly
and to pohsh them with diamonds in an open proce-
dure during the early stages of periodontitis, but fail-
ures are frequent in teeth with such unfavorable mac-
romorphology.
Tns matter becomes even more complicated in the
molar region. Cleaning the roots when open furcations
exist is particularly difficuh. The variety in macromor-
phology of these teeth is shown in Fig 7. As a rule, fur-
cations must be treated with open debridement proce-
dures. Despite treatment, these sites remain as minor
sites of resistance that can lead to failure. Only hemi-
sectionandapicoectomyof such teeth may lead to suc-
cess.
Unsupervised healing
Many failures arising soon after completion of treat-
ment can be traced to the absence of supervision of the
healing process. When the closed or open root cleaning
is finished, removal of the dressing or the stitches does
not mark the end of treatment. Rather, the treated re-
gion must be professionally cleaned supragingivally at
intervals of about 2 weeks. The oral hygiene status of
453
Periodontics

Fig 5a Electron micrograph ot a root surface after planing

with a 15-tJ,m Perio-diamond (Intensiv SA). The root surface
is clean on the smooth surfaces. It shows fine scrafches fol-
iowing the treatment, ¡arrow) A résorption lacuna, approxi-
mately 0.15 X 0.50 mm, is present. The cracks on the root
surface are artificial, arising from the preparation of the
specimen for electron microscopy.

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Fig 5b Enlargement of Fig 5a. The lacuna is thoroughly Fig 5c Bacteria in the iacuna depicted in Figs 5a and 5b.
filled with bacteria. The bacteria were inaccessible to tbe finest Perio-dia-
monds.

Fig 6a A bony pocket reaching almost to the apex becomes visible during a flap Fig 6b Same tooth after extraction.
operation on the maxillary right centrai incisor. This tootb has two fused roots. Two fused roots end in a groove in
Periodontaily, it is no longer treatable. which the infection is borne apicaily.

454 Quintessence International Volume 25, Number 7/1994

 Periodontics

Fig 7 (left) Mandibular and (right) maxillary molars. Approximately two thirds of the roots viiere separated apically. Note the
large variety of root fusions and furcations. If periodontal disease reaches these sites, treatment, whether open or closed, is
hardly possible. As a rule, only parts of such teeth can be retained after amputation of single roots or hemisection.

the patient must be assessed repeatedly at short inter-
vals. Westfelt et aF demonstrated that a large variety of
periodontal treatment procedures are successful when
supplemented with consistent supervision of healing
(treatment as required at 2-week intervals for 6
months). Their study revealed that the treatment pro-
cedure itself (closed scaling, modified Widman flap, api-
cally repositioned flap, etc) is not as important for suc-
cess as is optimal cleaning of the treated sections of the
dentition during the first few weeks and months after
the procedures. Such extensive follow-up treatment is
not identical with maintenance therapy at recall ap-
pointments.
Absence of maintenance thenipy
Maintenance therapy is decisive for long-term success.
Without regular recall examinations of the patient, new
infections can arise over the course of time. The fre-
quency of recall is not the same for all patients. It de-
pends on a variety of factors: the primary diagnosis
{course and severity of the disease), the success of pri-
mary treatment following the period of supervised
healing, and the extent to which the patient can be mo-
tivated to cooperate. Depending on the case, the inter-
val between recall appointments can vary from 2
months to a year. Specific examinations are necessary
at each recall appointment to determine whether the
results of therapy have remained stable or whether re-

Quintessence International Volume 25, Number7/1994 455

Pehodontics
currences or new infections are present. Il is not neces-
sary, however, Ihat a complete diagnostic process take
place at each recall appointment.
Some findings must be recorded at each recall ap-
pointment, hut other assessments must be made at
greater intervals. At each recall appointment, the gingi-
val status, and the amount of plaque should he deter-
mined, by calculation of the indices il' appropriate. At
longer intervals, perhaps annually, pocket depth and
the presence of symptoms of activity in single pockets
should be recorded.
Occlusion, need for reconstruction, condition of res-
torations, tooth vitality, and existence of new carious
lesions are checked at still greater intervals. New radio-
graphs are made at approximately 4-year intervals. If
pockets are found to recur or new pocket activity is
noted, radiographs are prepared as indicated.
Nor are the preventive and therapeutic measures
taken by the dentist and the dental hygicnist the same
at all recall appointments. As ii rule, remotivation of
the patient, assessment of oral hygiene and reinforce-
ment of patient instruction, and removal of plaque and
calculus at indicated sites are undertaken at each recall.
The last of these appears to be particularly important.
Scaling should not be done on all teeth. Teeth free of
deposits need not be touched with a sealer. Long- and
short-term studies have shown ihat frequently re-
peated scaling ofsound teeth can lead to loss of attach-
ment.''"" However, all teeth should be cleaned and pol-
ished with low-abrasion paste and rubber tips.
At longer intervals, if pockets or pocket activity is
found, subgingival scaling and new stirgery (rarely,
only for extensive recurrences) should be carried out.
The chairside time required for regular recall ap-
pointments intended to prevent periodontal treatment
failures is. in most instances, severely underestimated.
Ineluding the time required for disinfection of the op-
eratory and for bringing in a different patient, an hour
is not an excessive amount of time to schedule for a re-
call appointment. After the patient is greeted, the ap-
pointment begins with the more or less extensive diag-
nostic measures described previously (5 to 10 minutes).
Abriefconversationwith the patient about the present
status of the oral cavity, together with the associated re-
motivation efforts, requires about 5 minutes. Tliis is fol-
lowed by plaque disclosure and reinstruction about
oral hygiene (approximately 5 minutes).
Only after these preliminary steps are finished is in-
strumental removal of supragingival plaque and calcu-
lus completed at the indicated sites (20 minutes). As a
rule, this includes subgingival procedures, performed
456
without anesthesia, in pockets up to 4 mm deep. In ad-
dition to plaque, discoloration, from chlorhexidine or
smoking, for example, is removed (3 minutes) and all
teeth are polished with a low-ahrasion paste (5 min-
utes). After the teeth are dried, the entire dentition
should be treated with topical Ouoridc (5 minutes). Fi-
nally, the dentist checks everything (5 minutes). After
the patient is discharged, the operatory is disinfected
and fresh instruments are placed (5 minutes).
The great expenditure of time for diagnosis, motiva-
tion, instruction, and actual treatment of patients with
periodontitis has been noted. Maintenance therapy
also takes time. Twenty-minute recall appointments
are at besl "alibi exercises."
Summary
Because of numerous failures, periodontal treatment is
frequently discredited. Careful attention to a few im-
portant points can improve the success rate of perio-
dontal therapy;
1. Only those patients prepared for long-term cooper-
ation should be treated. Patients with certain serious
systemic diseases tend to have recurrences. Treat-
ment planning should be rather more radical and
the therapy perhaps should be provided by a spe-
cialist or in a clinic.
2. Time cannot be saved in diagnostic procedures.
Only a careful, comprehensive examination leads to
a well-founded diagnosis and prognosis, and thus to
a precise treatment plan.
3. The limits of successful therapy must be recognized.
Far advanced periodontitis, Class III furcation in-
volvement, and rapidly advancing disease are diffi-
cult to control over the longer term. A radical plan,
including multiple extractions, is indicated.
4. Reinfection of the pockets must be prevented
through supervision of the healing process hy re-
peated cleaning of the teeth and checking of oral hy-
giene immediately following each active interven-
tion (closed root planing or flap operation).
5. Long-term treatment success is possible only if the
patient, once treated, is placed on a regular recall
schedule.
6. Consistent periodontal therapy requires a great deal
of time. That time is usually underestimated. In-
forming the patient about the disease (case presen-
tation), instruction in and repeated checking of oral
hygiene, supervision of the healing process and re-
call all are enormously time consuming. The actual
Quintessence International Volume 25, Number 7/1994
 closed or open treatment is only a part—perhaps
the smaller part—of the total treatment.

References
1. Raieilichak KH, Raieitschak EM, Wolf HF. Hassell TM, Color
Alias of Denial Medicine, Vol. J, Pedodoniology ed 2 New
York. Stuttgart'Thieme. 1989.
2. Schwarz JR Guggenheim R. DUggelJn M, Hefli AF, Rateil-
schak-Plüss EM. Raieitschak KH. The effectiveness of rool de-
bridement in open flap procedures by means of a comparison
between hand instruments and diamond burs. A SEM sludy.
J Clin Periodontol 1989;t6:510-518.
3. Rateitschak-Plüss EM, Schwarz JP, Guggenheim R. Düggílin
M, Rateitschak KH. Non-surgical periodontal Ireatment —
Where are the limits'," J Clin Periodontol 1992; 19:240-244. Rubber Dam in Clinical Practice
4. Schrocder HE, Rateitschak-Plüss EM. Fotal root résorption la-
cunae causing retention of subgingival plaque in periudontal J. S. Reid, P, D. Callis, and C. J, W. Patterson
pockets. Acta Parodontologica. Schweiz Monats sehr Zahn-
heilkd 1983:93:1033/179-1041/187. Although the rubber dam was first introduced into
5. Westfell E. Bragd L, Socransky SS, Haffajee AD. Nynian S, dentistry more than lOO years ago. il is still not widely
Lindhe 1 Improved periodontal conditions following therapy. accepted in general dental practice. Yet this technique is
J Clin Periodontol 1985; 12:283-293. basically simple to use once it has been mastered and has
t. Knowles JW. Burgett FG, Nissie RR. Shick RA, Morrison EC, many advantages both for the patient and the dentist.
Ramfjord SP Resuhs of periodontal treatment related to pock-
et deth and attachment level. Eight years. J Periodontol The authors have set out to provide a clear text that
:979;50:2Z5-233- explains how and why the technique should be used; this
7. Lindhe J, Westfelt E, Nyman S, Socransky SS, HeijI L, Bratthall is supplemented hy excellent photograph.^ illustrating
G. Healing following surgical/non-surgical treatment of perio- details of the technique iti practice.
dontal disease, A clinical study, J Clin Periodontol 1982;
9:115-128,
All dentists will benefit from having this handbook readily
8. Pihistrom BL, McHugh RB, Oliphant TH, Ortiz-Campos C.
at hand so that they can put this technique to regular use
Comparison of surgical and nonsurgical treatment of periodon-
tal disease. A review of cunent studies and additional restjits af- and benefit from its advLintages of safety, better working
ter6'/, years. J Chn Periodontol 1983; 10:524-541, conditions in the mouth, and better patient management.
9. Lindhe J. Nyman S. Scaling and granulation tissue removal in
periodontal therapy, J Clin Periodontol 1985;12:374-388. CALL OR FAX TO ORDER: (800i62t.0387
10. Ramfjord SP Caffesse RG, Morrison EC, Hill RW, Kerry GJ, (708) 6S2-3223; Fas: (708)682-3288
Appleberry E A e t al. Four modalities of periodontal treatment or nil out Ihe oulur furm an,l scnij to
compared over 5 years. J Clin Periodontol 1987;14;445-452. Quintessence Publishing Co, Inc
11. Kaldah! WB. Kalkwarf KL. Patil KD. Molvar ME Responses of SSI N. Kimbcrty Drive
four tooth and site groupings to periodontal therapy. J Peri- Carol Stream, IL 6018S-t88l
odontol 1990;61:]73-179. G
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