Nonsurgical Periodontal Therapy

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Nonsurgical Periodontal Therapy

• Nield-Gehrig Chapter 19 and Perry Chaper 12

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Nonsurgical Periodontal Therapy

• Other terms used to describe this phase of
  treatment.
• Initial periodontal therapy
• Hygienic phase
• Anti-infective phase
• Cause-related therapy
• Soft tissue management
• Phase 1 therapy
• Etiotropic phase
• Preparatory therapy

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Nonsurgical Periodontal Therapy

• All chronic periodontitis patients should undergo
  nonsurgical periodontal therapy.
• Nonsurgical periodontal therapy is frequently
  successful in minimizing the extent of surgery
  needed.

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Indications

• Chronic Periodontitis
• Gingivitis and mild chronic periodontitis may be
  controlled with nonsurgical periodontal therapy
  (NSPT) alone
• Moderate Chronic Periodontitis can be controlled
  with NSPT alone for may others may require some
  spot periodontal surgery after NSPT.

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Indications

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

• To control the bacterial challenge to the patient
• Intensive training of the patient in appropriate
  techniques for self-care and professional removal
  of calculus deposits and bacterial products from
  tooth surfaces
• Removal of calculus deposits and bacterial
  products contaminating the tooth surfaces.
  Calculus deposits ALWAYS are covered with living
  bacterial biofilms that are associated with
  continuing inflammation if not removed.

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Periodontitis
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Periodontitis
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Periodontitis
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Periodontitis
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Goals

• 2. To minimize the impact of systemic factors
• Certain systemic diseases or conditions can
  increase the risk of periodontitis and the
  severity.
• Plan must minimized the impact of systemic risk
  factors

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Goals

• 3. To eliminate or control local risk factors
• Local environmental risk factors can increase the
  risk of developing periodontitis in localized
  sites.
• Plaque retention in a site allow damage over time
  to periodontium
• Local environmental risk factors should be
  eliminated.

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Components

• The patients role in Nonsurgical Periodontal
  Therapy
• Daily plaque removal
• Professional Therapy
• Must be customized for the individual patient
• Components may included plaque control,
  nonsurgical instrumentation, and the adjunctive
  use of chemical agents

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Nonsurgical Instrumentation

• Mechanical removal of calculus is necessary
  because it is a mechanical irritant and holds
  biofilm.
• Periodontal debridement is likely to remain the
  most important component of nonsurgical
  periodontal therapy for the foreseeable future.

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Instrumentation Terminology

• Traditional Terminology
• Scaling instrumentation of the crown and root
  surfaces of the teeth to remove plaque, calculus,
  and stains
• Root Planing treatment procedure designed to
  remove cementum or surface dentin that is rough,
  impregnated with calculus, or contaminated with
  toxins or microorganisms.

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Instrumentation Terminology

• Emerging Terminology
• Periodontal debridement includes
  instrumentation of every square millimeter of
  root surface for removal of plaque and calculus,
  but does not include the deliberate, aggressive
  removal of cementum
• Conservation of cementum while removing all
  calculus and biofilm is the goal of periodontal
  debridement.

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Instrumentation Terminology

• Deplaquing the disruption or removal of
  subgingival microbial plaque and its byproducts
  from cemental surfaces and the pocket space

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Instrumentation Terminology

• Considerations Regarding Emerging Terminology
• Periodontal Debridement is not currently a ADA
  procedure name. (no code)
• Some authors have redefined the definition of
  root planing because of this.

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Extra Oral Fulcrum Max. Rt. Quad.
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Extra Oral Fulcrum Max. Rt. Quad.

• Advantages
• Greater parallelism of lower shank to the tooth
• Greater parallelism for access to the base of the
  pocket
• Improved access to distal surfaces and third
  molar
• Neutral wrist position
• Utilizes larger muscles of palm and forearm,
  meaning less operator fatigue
• Proper use of this fulcrum provides stability and
  control of the instrument stroke

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Extra Oral Fulcrum Max. Rt. Quad.

• Description
• Establish a 900 position
• Position patients head straight ahead or
  slightly away from operator on facials and toward
  operator with chin tipped upward on linguals
• Use mirror to retract cheek on facial
• Use direct vision and illumination when possible
• Rest the backs of the fingers, not the pads or
  tips, firmly against the skin overlying the
  lateral aspect of the mandible on the right side
  of the face
• Extend the grasp of the instrument in the hand to
  effectively implement an extra-oral fulcrum for
  mesial and distal surfaces of both the facial and
  lingual aspects
• Rotate the instrument in the hand around the
  distal line angle to effectively implement the
  distal surfaces
• Strokes are activated by pulling the hand and
  forearm, not by flexing the fingers

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Supplemental Fulcrum Max. Rt. Quad.
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Supplemental Fulcrum

• Advantages
• Neutral wrist position
• Utilizes larger muscles of palm and forearm
• Less operator fatigue
• Added support for the removal of tenacious
  subgingival calculus
• Reduces muscle strain and workload from the
  dominant hand
• Added control and stability
• Reduces instrument breakage

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Supplemental Fulcrum Max. Rt. Quad.

• Description
• Establish a 900 position
• Position patients head toward operator with chin
  up
• Place index finger of the non-dominant hand on
  the shank to apply supplemental lateral pressure
  to either the mesial or distal surfaces of the
  tooth
• Fulcrum may be established on the mandibular
  anteriors or and extra oral fulcrum is acceptable

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Supplemental Fulcrum Max. Rt. Quad.
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Supplemental Fulcrum Max. Rt. Quad.
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Rationale for Periodontal Debridement

• Arrest the progress of periodontal disease
• Induce positive changes in the subgingival
  bacterial flora (count and content)
• Create an environment that permits the gingival
  tissue to heal, therefore eliminating
  inflammation

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Rationale for Periodontal Debridement

• 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

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Rationale for Periodontal Debridement

• 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

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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.

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Appointment planning for calculus removal

• 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.

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Appointment planning for calculus removal

• 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
  individuals 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.

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Appointment planning for calculus removal

• 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.

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Ultrasonic Instrumentation

• Introduction to Ultrasonic Instrumenttation
• Gracey 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, but also that ultrasonic
  instrumentation is as effective as hand
  instrumentation in the treatment and maintenance
  of periodontal pockets.

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Slim-diameter curved tips

• Similar in design to a curved furcation probe
• Designed fo use on
• Posterior root surfaces located more than 4mm
  apical to the CEJ
• Root concavities and furcations on posterior
  tooth surfaces

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Advantages of Ultrasonic Instrumentation

• Mechanism of Action of Ultrasonic Instruments
• Ability 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

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Precision-thin tip advantages

• Thinner 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 max. and
  mand. 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

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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

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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

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Tissue Healing End Point of Instrumentation

• Assessing Tissue Healing-
• Re-evaluation should be scheduled for
• 4 6 weeks after completion of instrumentation.
• Nonresponsive sites should be carefully
  re-evaluated with an explorer for the presence of
  residual calculus or roughness

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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

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Dentinal Hypersensitivity

• 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
  

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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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AAP Guidelines for referrals

• Meant to help identify patients who are at
  greatest risk early and, therefore would benefit
  from specialty care.

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Level 3

• Patients who should be treated by a periodontist
• Any patient with
• Severe chronic periodontitis
• Furcation involvement
• Vertical/angular bony defect(s)
• Aggressive periodontitis
• Periodontal abscess and other acute periodontal
  conditions
• Significant root surface exposure and/or
  progressive gingival recession
• Peri-implant disease
• Any patient with periodontal diseases, regardless
  of severity, whom the referring dentist prefers
  not to treat.

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Level 2

• Patients who would likely benefit from
  comanagement by the referring dentist and the
  periodontist
• Early onset of periodontal diseases
• Unresolved inflammation at any site
• Pocket depths gt 5mm
• Vertical bone defects
• Radiographic evidence of progressive bone loss
• progressive tooth mobility
• Progressive attachment loss
• Anatomic gingival deformities
• Exposed root surfaces
• Deteriorating risk profile

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Level 2 - Patients who would likely benefit from
comanagement by the referring dentist and the
periodontist

• Medical or Behavioral Risk Factors/Indicators
• Smoking/tobacco use
• Diabetes
• Drug-induced gingival conditions ( e.g.,
  phenytoin, calcium channel blockers,
  immunosuppressants, and long-tem systemic
  steroids)
• Compromised immune system, either acquired or
  drug induced
• A deteriorating risk profile

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Level 1

• Patients who may benefit from comanagement by the
  referring dentist and the periodontist
• Any patient with periodontal inflammation/infectio
  n and the following systemic conditions
• Cancer thereapy
• Cardiovascular surgery
• Joint-replacement surgery
• Organ transplantation