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Non-SurgicalPeriodontal Therapy

Presented By :Dr. Abhishek Gaur

Guided By :

Dr. Balaji Manohar

Dr. Ravikiran N.

Dr. Neema

Dr. Aditi Mathur

Dr. Barkha Makhijani

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Contents :1. Introduction2. Phases Of Periodontal Therapy3. Non – surgical periodontal therapy (NSPT) : Goals4. Rationale for Periodontal Debridement5. Emerging Terminology

6. PATIENT EVALUATION/EXAMINATION7. Instrumentation8. Systemic Antibiotic Therapy9. Locally Applied Antibiotic Therapy10.Healing11.Gingivitis12.Periodontitis13.Reduced Pocket Depths14.Gain in attachment level15.Repopulation of Pockets16.Limitations of Non-Surgical Therapy

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INTRODUCTIONPeriodontitis is an infectious inflammatory

destructive disease initiated by the microbial biofilm in a susceptible host.

The effect of dental plaque on gingival health has been early considered.

Periodontal disease is initiated by an infection; however, it appears to behave not like a classic infection but more like an opportunistic infection.

As a biofilm-mediated disease, periodontal disease is inherently difficult to treat. One of the greatest challenges in treatment arises from the fact that there is no way to eliminate bacteria from the oral cavity, so bacteria will always be present in the periodontal milieu.

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In addition, the bacteria within the biofilm are more resistant to antimicrobial agents and various components of the host response.

When certain, more virulent species exist in an environment that allows them to be present in greater proportions, there is the opportunity for periodontal destruction to occur.

Although it is apparent that plaque is essential for the development of the disease, the severity and pattern of the disease are not explained solely by the amount of plaque present.

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In the 1960s , Loe and co-workers started a series of experiment, beginning with his gingivitis study, proving that plaque is the main etiological factor of the disease. However, at the time, all plaques was consider bad, regardless of the type of bacteria present. This is termed “nonspecific plaque hypothesis”.

By the 1970s, specific bacteria changes was specified in health and disease site, thus leading to the idea of “specific plaque hypothesis”. This specific plaque hypothesis is supported by present day approach to periodontal therapy.

Loe H, Theilade F, Jensen SB. Experimental gingivitis in man. J Periodontology 1965:36:177-187.

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Emergency phase

Non-Surgical phase

Maintenance phase

Restorative phaseSurgical phase

Preferred sequence of Periodontal Therapy

Phases Of Periodontal

Therapy

Preliminary PhaseTreatment of Emergencies :

• Dental or Peri-apical

• Periodontal

• OtherExtraction of hopeless teeth and provisional replacement if needed (may be postponed to a more convenient time)

Non-Surgical Phase (Phase I Therapy)Plaque control & Patient Education.

• Diet control.

• Removal of calculus and root planing.

• Correction of restorative & prosthetic irritational factors.

• Excavation of caries & restorations.

• Antimicrobial Therapy.

• Occlusal Therapy.

• Minor orthodontic movement

• Provisional splinting & prosthesis.

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Evaluation of response to non-surgical phase

Rechecking :

Pocket depth & gingival inflammation.

Plaque & Calculus, caries.

Surgical Phase (Phase II Therapy)Periodontal therapy, including placement of implants.

Endodontic therapy.

Restorative Phase (Phase III Therapy)Final Restorations.

Fixed & removable prosthodontic appliances.

Evaluation of response to restorative procedures.

Periodontal Examination.

Maintenance PhasePeriodic rechecking :

• Plaque & calculus• Gingival condition (pockets & inflammation)• Occlusion, tooth mobility• Other pathologic changes.

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Diet controlDietary supplement use may modify the risk for the

development and progression of periodontal disease.The antioxidant activity of nutrients such as vitamin C, and α-tocopherol, and the anti-inflammatory activity of polyunsaturated fatty acids may attenuate the development of periodontal disease.

Studies using the NHANES III-a large cross-sectional survey study-have demonstrated that lower vitamin C intake is associated with a higher risk (OR 1.19) of having periodontal disease, and that higher vitamin C intake is associated with a reduced risk (OR 0.53) of severe periodontitis.

Chapple I.L., Milward M.R., Dietrich T. The prevalence of inflammatory periodontitis is negatively associated with serum antioxidant concentrations. J. Nutr. 2007;137:657–664.

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In addition to maintenance of periodontal health, a few studies have shown that diet may assist with wound healing from periodontal procedures.

These few studies have shown that micronutrients (vitamin D and the B vitamins) and macronutrients can improve patient recovery following periodontal therapy.

Bashutski J.D., Eber R.M., Kinney J.S., Benavides E., Maitra S., Braun T.M., Giannobile W.V., McCauley L.K. The impact of vitamin D status on periodontal surgery outcomes. J. Dent. Res.

2011;90:1007–1012.

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Removal of calculus and root planingScaling and root planing treatments are only performed after a

thorough examination of the mouth.

Depending on the current condition of the gums, the amount of calculus (tartar) present, the depth of the pockets and the progression of the periodontitis, local anesthetic may be used.

Scaling – This procedure is usually performed with special dental instruments and may include an ultrasonic scaling tool.  The scaling tool removes calculus and plaque from the surface of the crown and root surfaces.

Root Planing – This procedure is a specific treatment which serves to remove cementum and surface dentin that is embedded with unwanted microorganisms, toxins and tartar.  The root of the tooth is literally smoothed in order to promote good healing. Having clean, smooth root surfaces helps bacteria from easily colonizing in future.

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The long term effectiveness of scaling and root planing depends upon a number of factors.

These factors include patient compliance, disease progress at the time of intervention, probing depth, and anatomical factors like grooves in the roots of teeth, concavities, and furcation involvement which may limit visibility of underlying deep calculus and debris.

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Correction of restorative & prosthetic irritational factors

Overcotoured restoration makes the professional and individual cleaning impossible.

The overcontoured restorations protects only the plaque accumulation.

Effect of bad restoration quality on periodontal health

Sub-gingival microbiological samples coming from the overhanging margins composed a micro-flora resembling that of chronic periodontitis.

Increased proportions of Gram-negative anaerobic bacteria, black-pigmented Bacteroides (Porphyromonas and Prevotella species) and an increased anaerobe : facultative ratio were noted.

The overhanging restorations disturb the ecological balance in the periodontal pocket and allow a group of disease associated organisms.

Lang P. N., Kiel A. R. , Anderhalden: Clinical and microbiological effects of subgingival restorations with overhangings or clinically perfect margins. J. Clini Periodontol 1983; 10: 563-578.

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Excavation of caries & restorations

Nonsurgical Periodontal

TherapyOther terms used to describe this phase of

treatment :I. Initial periodontal therapy.II. Hygienic phase.III. Anti-infective phase.IV. Cause-related therapy.V. Soft tissue management.VI. Phase I therapy.VII. Etiotrophic phase.VIII.Preparatory therapy.

Indications1. Chronic Periodontitis

1. Gingivitis and mild chronic periodontitis may be controlled with nonsurgical periodontal therapy (NSPT) alone.

2. Moderate Chronic Periodontitis can be controlled with NSPT alone for may others may require some spot periodontal surgery after NSPT.

2. Severe Chronic Periodontitis control will probably require through NSPT followed by periodontal surgery.

3. Although periodontal surgery is frequently indicated for patients with more advanced periodontitis, all chronic periodontitis patients should undergo nonsurgical periodontal therapy prior to periodontal surgical intervention. Nonsurgical periodontal therapy is frequently successful in minimizing the extent of surgery needed.

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Goals of Non-SurgicalPeriodontal therapy

The goal of therapy can be classified as :

1. Immediate2. Ideal3. Pragmatic4. Ultimate goal

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Immediate goal :

The immediate goal of therapy is to prevent, arrest, control, or eliminate periodontal disease.

Ideal goal :

The ideal goal aims to promote healing through regeneration of lost form, function, esthetics, and comfort.

Pragmatic goal :

When the ideal can not be achieved, the pragmatic goal of therapy would be to repair the damage resulting from disease.

Ultimate goal :

ultimate goal of therapy is to sustain the masticatory apparatus - especially teeth, or their analogues, in the state of health.

Emerging Terminology

Periodontal debridement

Removal or disruption of DENTAL DEPOSITS and plaque-retentive DENTAL CALCULUS from tooth surfaces and within the periodontal pocket space without deliberate removal of CEMENTUM as done in ROOT PLANING and often in DENTAL SCALING.

The goal is to conserve dental cementum to help maintain or re-establish healthy periodontal environment and eliminate PERIODONTITIS by using light instrumentation strokes and nonsurgical techniques (e.g., ultrasonic, laser instruments).

Deplaquing

The disruption or removal of sub-gingival microbial plaque and its byproducts from cemental surfaces and the pocket space.

Components1. The patients role in Nonsurgical

Periodontal TherapyDaily plaque removal.

2. Professional TherapyI. Must be customized for the individual patient.II. Components may included :

Plaque control.Non-surgical instrumentation.The adjunctive use of chemical agents.

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PATIENT EVALUATION/EXAMINATION

Evaluation of the patient’s periodontal status requires obtaining a relevant medical and dental history and conducting a thorough clinical and radiographic examination with evaluation of extra-oral and intra-oral structures.

A medical history should be taken and evaluated to identify predisposing conditions that may affect treatment, patient management, and outcomes. Such conditions include, but are not limited to, diabetes, hypertension, pregnancy, smoking, substance abuse and medications, or other existing conditions that impact traditional dental therapy.

A dental history, including the chief complaint or reason for the visit, should be taken and evaluated. Information about past dental and periodontal care and records, including radiographs of previous treatment, may be useful.

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Extraoral structures should be examined and evaluated. The temporo-mandibular apparatus and associated structures may also be evaluated.

Intraoral tissues and structures, including the oral mucosa, muscles of mastication, lips, floor of mouth, tongue, salivary glands, palate, and the oropharynx, should be examined and evaluated.

The presence and distribution of plaque and calculus should be determined.

Periodontal soft tissues, including peri-implant tissues, should be examined. The presence and types of exudates should be determined.

Probing depths, location of the gingival margin (clinical attachment levels), and the presence of bleeding on probing should be evaluated.

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Muco-gingival relationships should be evaluated to identify deficiencies of keratinized tissue, abnormal frenulum insertions, and other tissue abnormalities such as clinically significant gingival recession.

The presence, location, and extent of furcation invasions should be determined.

In addition to conventional methods of evaluation; i.e., visual inspection, probing, and radiographic examinations, the patient’s periodontal condition may warrant the use of additional diagnostic aids. These include, but are not limited to, diagnostic casts, microbial and other biologic assessments, radiographic imaging, or other appropriate medical laboratorytests.

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All relevant clinical findings should be documented in the patient’s record.

Referral to other health care providers should be made and documented when warranted.

Based on the results of the examination, a diagnosis and proposed treatment plan should be presented to the patient.

Patients should be informed of the disease process, therapeutic alternatives, potential complications, the expected results and their responsibilities in treatment.

Rationale for Periodontal

Debridement• Arrest the progress of periodontal disease.• Induce positive changes in the sub-gingival bacterial flora (count and

content).• Create an environment that permits the gingival tissue to heal,

therefore eliminating inflammation.• Convert the pocket from an area experiencing increased loss of

attachment to one in which the clinical attachment level remains the same or even gains in attachment.• Eliminate bleeding.• Improve the integrity of tissue attachment.• Increase effectiveness of patient self-care.• Permit reevaluation of periodontal health status to determine if surgery

is needed.• Prevent recurrence of disease through periodontal maintenance therapy.

Appointment planning for calculus removal

Full-mouth debridement• Full-mouth debridement is defined as periodontal debridement

completed in a single appointment or in two appointments within a 24-hour period.• Since periodontal disease is an infection, the full-mouth approach

to periodontal debridement is based on the assumption that the remaining untreated areas of the mouth can reinfect the treated areas.

In research studies, the full-mouth debridement procedure was combined with the use of topical antimicrobial therapy (full-mouth disinfection), It is unclear, however, if the antimicrobial therapy actually contributed to the improved results derived form the full-mouth periodontal debridement alone.

Full-mouth debridement is best accomplished by the dental hygienist working with an assistant.

Initially, patients may be resistant to the concept of scheduling one or two long appointments for the purpose of periodontal debridement. One or two long appointments, however, may in reality be less disruptive to an individual’s work schedule than four to six 1 hour appointments over several weeks. In addition, the dental hygienist should explain the rationale behind full-mouth debridement.

Planned multiple appointments. If periodontal debridement is completed in sextants or quadrants over multiple appointments, at each appointment the clinician should treat only as many teeth, sextants, or quadrants as he or she can thoroughly debride of calculus and plaque during that appointment.

Ultrasonic InstrumentationGracey curet was the primary instrument• Now the precision-thin ultrasonic tip

Research indicates not only that the ultrasonic instrumentation is as effective as hand instrumentation, in the treatment and maintenance of periodontal pockets.

Slim-diameter curved tips

• Similar in design to a curved furcation probe.• Designed for use on:• Posterior root surfaces located more than 4mm

apical to the CEJ• Root concavities and furcations on posterior tooth

surfaces

Advantages of Ultrasonic

InstrumentationAbility to flush debris, bacteria, and unattached plaque from the periodontal pocket with the fluid lavage.

Ultrasonic Instrument Tip Design . Precision-thin ultrasonic tips have the following advantages

Precision-thin tip advantagesThinner and smaller than the working-end of a curet.Standard Gracey curets are too wide to enter the furcation area of more than 50% of all maxi. and mandi. first molars.Precision-thin tips have been shown to reach 1mm deeper than hand instruments and to teach the base of the pocket in 86% of 3-9mm pockets

Tissue Healing: End Point of

Instrumentation•Tissue Health: The goal of instrumentation is to render the tooth surface and pocket space acceptable to the tissue so that healing occurs.

•Healing After Instrumentation•The primary pattern of healing after periodontal

debridement is through the formation of a long junctional epithelium•There is no formation of new bone, cementum, or

periodontal ligament during the healing process that occurs after periodontal debridement

Tissue Healing: End Point of Instrumentation•Nonsurgical periodontal therapy can result in reduced probing depths due to the formation of a long junctional epithelium combined with the gingival recession that often occurs following NSPT.

•Assessing Tissue Healing-• Re-evaluation should be scheduled for 4 – 6 weeks after

completion of instrumentation.

•Non-responsive sites should be carefully re-evaluated with an explorer for the presence of residual calculus or roughness.

Dentinal Hypersensitivity•Description – a short, sharp painful reaction that occurs when some areas of exposed dentin are subjected to mechanical, thermal, or chemical stimuli•Associated with exposed dentin.•Usually pain is sporadic.•Precipitating Factors for Sensitivity :•Gingival Recession• Sometimes healing results in a small amount of tooth root being exposed• Conservation of cementum should be a goal of NSPT

Re-evaluation•4-6 weeks after treatment.

•Update medical status.•Perform a periodontal clinical assessment•Compare data gathered at the initial periodontal assessment with the data at re-evaluation.•Make decisions about the need for additional NSPT, periodontal maintenance, and periodontal surgery.

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Healing occurs as repair as opposed to regeneration.

Predictable outcomes include:1. Healing of epithelium.2. Resolution of inflammation.3. Formation of long junctional epithelial attachment.4. Recession.5. Repopulation of pockets by less pathogenic forms of bacteria.

Less predictable outcomes include:6. Regeneration of new bone.7. New connective tissue attachment.8. New cementum on root surfaces.

Healing

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Healing following intervention :1. Decrease of inflammatory cells2. Reduced edema3. New collagen formation4. Pocket epithelium heals – reduced rete pegs, lateral attachment

of junctional epithelium5. Reduction of bleeding6. Return of gingival color.7. Tissue shrinkage – recession becomes obvious8. Reduced probing depths

Gingivitis

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PeriodontitisHealing Response :

A. Injury to or separation of junctional epithelium occurs following debridement.

B. Healing takes approx. 1 week.1. Hemidesmosomes begin to reattach from apical end of JE2. Intact after approx.7 days.

C. Connective tissue healing takes considerably longer.

1. Up to several months.2. New connective tissue fiber attachment not an expected outcome.3. Development of an elongated junctional epithelium – this may result in

reduced probing depths.

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Reduced Pocket Depths

Greater reduction of pocket depths occurs in deeper pockets.

Pocket depths measuring 4-6 mm1. Pocket reduction approximates 1 mm2. Recession & minimal attachment gain ( 0.5 mm)

Pocket depths measuring > 7 mm3. Pocket reduction approximates 1.5-3.0 mm4. Combination of recession & attachment gain ( 1.0mm)

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Gain in attachment level

1. May represent more accurate reading of pocket probing depth

2. Inflamed tissues easily penetrated when probed

3. Inflates true pocket readings4. Probe less likely to penetrate when:

Junctional epithelium & CT has healed & fibers are intact

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Repopulation of Pockets1. Periodontal debridement reduces bacterial population

in pockets2. Shift from primarily Gram-negative flora to one that is

Gram-positiveFewer motile forms

3. Repopulation occurs in a specific order4. May take as long as 6 months & may depend on:

1. Completeness of initial therapy.2. Client’s compliance & ability to remove plaque.3. Presence of invasive bacteria.

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5. Specific order of repopulation:

I. Streptococcus & Actinobacillus speciesII. ViellonellaIII.BacteroidesIV.PorphyromonasV. PrevotellaVI.FusobacteriumVII.Capnocytophaga sp & spirochetes

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Limitations of Non-Surgical Therapy

Clinical skill & time spent1. Debridement technique & skill sensitive.2. Debridement of one periodontally. involved molar

(moderate involvement) takes approx. 10 minutes.3. Attention to technique, proper selection of

instruments important to success.

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Furcations1. Access difficult – residual calculus likely.2. Opening to furcation often smaller than diameter of periodontal

instrument.3. Clinical approach: use of slim-line inserts.

Root anatomy4. Depressions on proximal surfaces.5. Clinical approach: knowledge of root anatomy.

Pocket depths6. Residual calculus likely in deeper pockets7. Average pocket depth for adequate removal approx. 3.73 mm8. Clinical approach: curettes with longer shanks

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ConclusionThe field of periodontology is continually changing.

Dentists and Hygienist must stay abreast of the latest research discoveries in periodontal treatments in order to offer the most comprehensive therapy for patients.

With the recent studies indicating a possible correlation between periodontal disease and cardiovascular disease, it is even more imperative to remain current in knowledge of the diseases as well as the new treatment modalities as they become available.

Beck et al., 2009

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References1. Carranza 10th Edition2. NON-SURGICAL PERIODONTAL THERAPY –

Stephen M. Huppert.3. Minimally-Invasive Non-Surgical Periodontal Therapy –

Philip Ower, May 2013.4. J Clin Periodontol 2012; 39: 1065–1074.5. NONSURGICAL PERIODONTAL THERAPY Instructed

by Kelli R. Illyes, R.D.H, M.D.H.6. Nonsurgical Approaches for the Treatment of Periodontal

Diseases Maria Emanuel Ryan, DDS, PhD, Dent Clin N Am 49 (2005) 611–636

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