NonSurgical Periodontal Therapy Comprehensive Periodontics for the Dental

Non-Surgical Periodontal Therapy Comprehensive Periodontics for the Dental Hygienist, Chapters 9, 12

Learning Objectives 1. Understand the differences between periodontal debridement, scaling, root planing & de-plaquing 2. Discuss the goals & rationale for non-surgical therapy 3. Discuss the process of wound healing following successful intervention 4. Select appropriate instruments for periodontal debridement

Non-Surgical Periodontal Therapy Healthy tissues = good plaque control + complete periodontal debridement + healing z Immediate Treatment Goals yeducate client yinstrument tooth surfaces x remove plaque & calculus yexplore to evaluate root surfaces x are root surfaces smooth & plaque free z Long-term Goals of Therapy ycompliance with home care/PMP ygingival health restored yperiodontal health controlled

Goals of Debridement z Success of treatment depends on: y. Immune response to treatment y. Disease severity y. Appropriate use of chemotherapeutic agents y. Complete treatment x. Removal of supra/subgingival plaque x. Removal of calculus (due to its plaque retentive nature) x. Professional expertise x. Use of appropriate instruments x. Intraoral constraints

Non-Surgical Periodontal Therapy z. Rationale ypromote tissue healing ydecrease probing depths yincrease CAL ydecrease bleeding yremove deposits yiatrogenic & anatomic factors considered (e. g. overhangs, malposed teeth)

Non-Surgical Periodontal Therapy Definitions z. Scaling yremoval of sub/supra deposits yinstrumentation of tooth & root surfaces z. Root Planing ytreatment of root surfaces yremoval of deposits, by-products z. Deplaquing yremoval of all plaque (supragingival & within sulcus or pockets) yre-evaluation & maintenance appointments

Non-Surgical Periodontal Therapy Definitions z. Periodontal Debridement yconserves cementum yplaque control instrumental to good healing response yremoval of deposits, diseased or dead tissue from root surfaces, within pocket yincludes pocket space, pocket wall x. Bacterial products within non-adherent plaque most detrimental to soft tissue

Non-Surgical Periodontal Therapy z. Periodontal Debridement y. Indications xgingival inflammation – where periodontal pockets exist xpresence of bacterial pathogens xprogressive attachment loss, bone loss y. Contraindications xsites that do not have true pocketing

Non-Surgical Periodontal Therapy z. Periodontal Debridement y. Outcomes xassess clinical parameters • • • probing depths clinical attachment levels alveolar bone height visual signs of gingival inflammation changes in subgingival pathogens bleeding on probing

Non-Surgical Periodontal Therapy z. Healing occurs as repair as opposed to regeneration y. Predictable outcomes include: x. Healing of epithelium x. Resolution of inflammation x. Formation of long junctional epithelial attachment x. Recession x. Repopulation of pockets by less pathogenic forms of bacteria

Non-Surgical Periodontal Therapy z. Less predictable outcomes include: y. Regeneration of new bone y. New connective tissue attachment y. New cementum on root surfaces

Non-Surgical Periodontal Therapy z Gingivitis: Healing following intervention y. Decrease of inflammatory cells y. Reduced edema y. New collagen formation y. Pocket epithelium heals – reduced rete pegs, lateral attachment of junctional epithelium y. Reduction of bleeding y. Return of gingival colour y. Tissue shrinkage – recession becomes obvious y. Reduced probing depths

Non-Surgical Periodontal Therapy z Periodontitis: Healing Response y. Injury to or separation of junctional epithelium occurs following debridement y. Healing takes approx. 1 week x. Hemidesmosomes begin to reattach from apical end of JE x. Intact after approx. 7 days y. Connective tissue healing takes considerably longer x. Up to several months x. New connective tissue fiber attachment not an expected outcome x. Development of an elongated junctional epithelium – this may result in reduced probing depths

Non-Surgical Periodontal Therapy z. Periodontitis: Clinical Healing Response y. Reduced pocket depths y. Changes in attachment levels y. Recession y. Fewer bleeding sites, reduced redness y. Improvement in tissue tone & colour

Non-Surgical Periodontal Therapy z Periodontitis: Reduced Pocket Depths y. Greater reduction of pocket depths occurs in deeper pockets y. Pocket depths measuring 4 -6 mm x. Pocket reduction approximates 1 mm x. Recession & minimal attachment gain ( 0. 5 mm) y. Pocket depths measuring > 7 mm x. Pocket reduction approximates 1. 5 -3. 0 mm x. Combination of recession & attachment gain ( 1. 0 mm)

Non-Surgical Periodontal Therapy z. Gain in attachment level y. May represent more accurate reading of pocket probing depth y. Inflamed tissues easily penetrated when probed y. Inflates true pocket readings y. Probe less likely to penetrate when: x. Junctional epithelium & CT has healed & fibers are intact

Assessment Following Therapy z Assess response of tissues z Assess plaque & calculus deposits y. Residual calculus? z No improvement: y. Evaluate health history y. Plaque culture z Recommendations: y. Antibiotics/antimicrobials y. Repeat periodontal debridement y. Periodontal surgery

Repopulation of Pockets z Periodontal debridement reduces bacterial population in pockets z Shift from primarily Gram-negative flora to one that is Gram-positive y. Fewer motile forms z Repopulation occurs in a specific order z May take as long as 6 months & may depend on y. Completeness of initial therapy y. Client’s compliance & ability to remove plaque y. Presence of invasive bacteria

Repopulation of Pockets z. Specific order of repopulation: y. Streptococcus & Actinobacillus species y. Viellonella y. Bacteroides y. Porphyromonas y. Prevotella y. Fusobacterium y. Capnocytophaga sp & spirochetes

Limitations of Non-Surgical Therapy z. Pocket depths y. Residual calculus likely in deeper pockets y. Average pocket depth for adequate removal approx. 3. 73 mm y. Clinical approach: curettes with longer shanks

Limitations of Non-Surgical Therapy z Furcations y. Access difficult – residual calculus likely y. Opening to furcation often smaller than diameter of periodontal instrument y. Clinical approach: use of slimline inserts z Root anatomy y. Depressions on proximal surfaces y. Clinical approach: knowledge of root anatomy

Limitations of Non-Surgical Therapy z. Clinical skill & time spent y. Debridement technique & skill sensitive y. Debridement of one periodontally involved molar (moderate involvement) takes approx. 10 minutes y. Attention to technique, proper selection of instruments important to success