Advanced periodontal therapy may take the form of non-surgical debridement with advanced visualization, localized minimally invasive surgery, or generalized surgical access. This may be a repetition of the treatment performed during initial therapy, but in most instances advanced periodontal therapy is required. If signs of inflammation are present at the reevaluation following initial periodontal treatment or at any periodontal maintenance appointment, further periodontal treatment is indicated. The determination of whether these goals have been accomplished and maintained can only be achieved by routine and rigorous reevaluations of the patient’s periodontal condition. If these goals are not achieved, there will always be a continuation of periodontal inflammation and an ongoing risk for progression of periodontitis. All clinicians who treat periodontitis know that accomplishing these goals can be very difficult. The clinical application of this goal is stated simply as the removal of plaque and calculus from the tooth and establishing acceptable conditions for the patient to perform adequate oral hygiene. At a purely scientific level this requires the removal of any contaminated material from the periodontal sulcus and the establishment of a stable microbiota of non-harmful organisms. These guidelines for periodontal treatment combined the 2018 classification of periodontal disease with the previously defined decision points in therapy.Īll clinical treatment of periodontal disease is based on the basic tenet of eliminating inflammation and then maintaining an inflammation free state. Later in 2022, the same group who had developed the decision points published clinical guidelines for periodontal therapy. The decision points aided in defining critical phases where further evaluation was necessary but did not define what further treatment may be indicated. Based on the finding of the reevaluation, a decision could then be made regarding whether the patient could be placed in a periodontal maintenance program or if more advanced periodontal therapy was indicated. The purpose of the decision points was to define where reevaluation of the response to the treatment performed up to that point should be assessed so a determination could be made as to whether treatment had been successful. The decision points were based on the 2018 classification system, and they defined points during the clinical treatment of a patient with periodontal disease where reassessment of the patient’s periodontal condition was required. These decision points were outlined by Harrel et al. Due to the need for clinical guidance, specific decision points for treatment were developed by a group of academic and clinical periodontists with many years of experience in the private practice of periodontics, teaching of periodontics within an academic institution, and clinical periodontal research. While multiple treatment possibilities were outlined by the EFP, specific decision points to guide clinical treatment were difficult to ascertain. Treatment was addressed by the EFP in 2020. While the new classification gives definitive parameters for the stage and grade of periodontal disease, it does not give treatment recommendations for the different stages. Conclusions: The inadequate removal of calculus plays an important role in the frequent failure of non-surgical periodontal therapy to eliminate inflammation. The inadequate removal of calculus is a factor in the failure of periodontal therapy. Recent studies indicate that the pathologic risk of calculus goes beyond the retention of biofilm and may represent a different pathophysiologic pathway for periodontal disease separate from the direct action of biofilm. Results: The published literature supports that calculus is a major risk factor for periodontal inflammation. Methods: A narrative review of the literature discussing the influence of calculus on inflammation was performed and the effects of inadequate removal of calculus during periodontal therapy were analyzed in light of the 2018 classification of periodontal disease, the decision points of periodontal therapy, and the guidelines of periodontal therapy. The articles are reviewed with a focus on the finding of inadequate calculus removal at the decision points and how that finding impacts treatment outcomes. Background: Based on the 2018 classification of periodontal disease, a series of articles have been published describing the decision points of periodontal therapy and how the findings collected at those decision points can be used as guidelines for periodontal therapy.
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