C HAPTER 13 Nonsurgical Periodontal Therapy Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

CHAPTER 13

Nonsurgical Periodontal Therapy

Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

INTRODUCTION

The initial approach for treating gingival and periodontal diseases is débridement of plaque biofilm and calculus through nonsurgical therapeutic techniques.

Nonsurgical therapy includes all of the procedures performed to treat gingival and periodontal diseases up to the time of re-evaluation. Re-evaluation is when the patient begins

maintenance care and when the need for periodontal surgery is determined to enhance results.

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INTRODUCTION (CONT.)

Other terms used to describe nonsurgical periodontal therapy include: Initial therapy Phase I therapy Etiotropic phase Periodontal débridement

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DEFINITIONS OF NONSURGICAL PERIODONTAL THERAPY

Nonsurgical therapeutic procedures include: Scaling procedures

Hand instrumentation and powered instrumentation

Root planing Gingival curettage Polishing

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SCALING

The American Academy of Periodontology (AAP) defines scaling as “instrumentation of the crown and root surfaces of the teeth to remove plaque, calculus, and stains from these surfaces.”

Instrumentation removes calculus and biofilms. Explorer evaluation of root smoothness after

scaling procedures determines the success of the treatment.

Scaling may be accomplished with sharp hand instruments or with sonic or ultrasonic instrumentation with powered-scaling devices.

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ROOT PLANING

Root planing is defined by the AAP as “a treatment procedure designed to remove cementum or surface dentin that is rough, impregnated with calculus, or contaminated with toxins or microorganisms.”

The difference between scaling and root planing is a matter of degree; root planing involves a specific effort to instrument every portion of the root surfaces, not simply identifiable calculus deposits. Similar to scaling, hand instrumentation or

powered-scaling devices may be used to perform root planing successfully.

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POLISHING AND STAIN REMOVAL

Polishing is the use of polishing agents to remove stains and supragingival plaque biofilm from the teeth.

The rubber-cup application of polishing agents with a slow-speed handpiece is mostly used to perform polishing.

Air devices designed to polish teeth with a power-driven handpiece unit that sprays abrasive slurry against the tooth surfaces are also available.

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POLISHING AND STAIN REMOVAL (CONT.)

Polishing agents contain abrasives that can scratch amalgam, composite resin, and gold restorative materials. The least abrasive paste necessary should be

used to remove stains. Polishing is recommended to be performed

selectively. Selective polishing means choosing surfaces to

polish on the basis of the presence of plaque biofilm and stains.

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Air polishing works by mechanical abrasion using a slurry of sodium bicarbonate and water.

Because this system produces an extensive aerosol, it is contraindicated in patients with infectious diseases, respiratory illnesses, or hypertension and those who are on hemodialysis.

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Polishing has no proven therapeutic value. Stains on the teeth are considered harmless,

so their removal is secondary to the therapeutic and preventive goals of the dental hygienist.

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GINGIVAL CURETTAGE

Curettage had been defined by the American Academy of Periodontics (AAP) as scraping or cleaning the walls of a cavity or surface by means of a curette.

Gingival curettage involves the removal of inflamed soft tissue lateral to the pocket wall.

Traditionally, gingival curettage was called closed curettage or nonsurgical gingival curettage and was performed to remove inflamed pocket lining.

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GINGIVAL CURETTAGE (CONT.)

Removal of this tissue was assumed to enhance pocket reduction beyond the results achieved by scaling and root planing alone.

This rationale has been questioned for many years; consequently, the procedure is no longer considered standard treatment.

Curettage is considered to have little therapeutic value and is no longer listed as a method of treatment by the American Dental Association and the AAP.

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GOALS OF NONSURGICAL PERIODONTAL THERAPY

The goals of nonsurgical periodontal therapy are considered in terms of short-term and long-term treatment goals for the patient.

The short-term goal is to promote plaque biofilm control and to instrument the tooth surfaces until they are clean and smooth.

The long-term goal of nonsurgical periodontal therapy is to restore gingival health.

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RATIONALE FOR NONSURGICAL PERIODONTAL THERAPY

The rationale for nonsurgical periodontal therapy is to remove the etiologic agent of disease—bacterial plaque biofilm—and its associated factors.

Scaling and root planing reduces gingival inflammation, reduces probing depths, and results in gains of clinical attachment in most patients with periodontal disease.

Calculus, although not an etiologic agent in itself, is associated with plaque biofilm, and its removal is associated with improved periodontal health.

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PLAQUE BIOFILM

Various periodontal diseases have been identified with specific microbial organisms. Actinobacillus actinomycetemcomitans has been

associated with aggressive periodontitis. In the 1970s, the specific plaque

hypothesis was proposed by Dr. Walter Loesche. As a result of this hypothesis, periodontal

treatment changed to include both conventional therapy and the use of appropriate antibiotics.

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PLAQUE BIOFILM (CONT.)

The removal of subgingival plaque biofilm is essential in nonsurgical therapy.

Hand instruments or powered scalers adequately accomplish the removal of subgingival plaque biofilm.

A study published in the 1980s compared plaque removal in pockets performed with hand instruments versus ultrasonic tips. Both were effective in removing approximately

67% of the plaque in pockets deeper than 5 mm.

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CALCULUS

Calculus is calcified plaque biofilm. As plaque biofilm ages, the organic matrix and

bacterial cells calcify. Calculus adheres to tooth surfaces through

pellicle attachment, mechanical locking, and intercrystalline forces.

This material varies in crystal composition, type of attachment, and degree of difficulty in removal.

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CALCULUS (CONT.)

Although calculus is an inert substance, its role appears to be that of plaque biofilm retention, and its removal is associated with a return to periodontal health as demonstrated in the following figure.

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CALCULUS (CONT.)

The thoroughness of calculus removal by instrumentation has been studied, and even the best instrumentation techniques leave some residual deposits on the teeth. These residual deposits do not appear to cause

the treatment to fail.

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ROOT SMOOTHNESS

Glassy smooth root surfaces are not end points in treatment.

More importantly, no surfaces should feel rough, as if calculus is still present. Variations in smoothness are acceptable as long

as the calculus that makes the surfaces feel rough and irregular has been removed and plaque biofilm disrupted.

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ROOT SMOOTHNESS (CONT.)

Studies indicate that endotoxins do not penetrate deeply into cemental surfaces.

Extensive root instrumentation is not required beyond the removal of calculus and plaque.

The rationale for root planing to remove root roughness and to achieve glassy smooth root surfaces is no longer valid.

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ROOT SMOOTHNESS (CONT.)

Overinstrumentation resulting in dramatically thinned root surfaces is demonstrated in the following figure.

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HEALING

When periodontal débridement is performed: Inflammation resolves. Long junctional epithelial attachment occurs. Recession will often result. Subgingival bacterial plaque is removed.

Biofilm regrows, but initially it will consist of younger, less-pathogenic bacterial biofilm.

Formation of new bone, new connective tissue attachment to the root surface, and new cementum on the root are not predictable outcomes. 23


SOFT-TISSUE HEALING AFTER SCALINGAND PERIODONTAL DÉBRIDEMENT

Scaling and root planing causes some removal and disruption of the epithelial attachment to the tooth, junctional epithelium, and deeper connective tissue.

The epithelial lining of the pocket wall is disrupted and partially removed through inadvertent curettage.

When the junctional epithelium has been injured or separated from the tooth surfaces, healing takes approximately 1 week.

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SOFT-TISSUE HEALING AFTER SCALINGAND PERIODONTAL DÉBRIDEMENT (CONT.)

Healing of inflamed connective tissue takes up to several months.

New connective tissue fiber attachment to the tooth surface is not a predictable outcome, but the development of an elongated junctional epithelial attachment may result in reduced probe readings.

Because of the fragile state of healing connective tissues, probing after treatment should be avoided for 4 weeks.

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REPOPULATION OF MICROORGANISMS AFTER THERAPY

Scaling and periodontal débridement is effective in reducing the volume of plaque biofilm bacteria in treated sites.

Bacterial plaque shifts from predominantly gram-negative flora to gram-positive flora, with many fewer motile forms, especially spirochetes.

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REPOPULATION OF MICROORGANISMS AFTER THERAPY (CONT.)

The organisms grow back in different proportions and numbers and in a specific order.

Streptococcus and Actinobacillus species grow back first, followed by Veillonella, Bacteroides, Porphyromonas, Prevotella, and Fusobacterium species.

Capnocytophaga species and spirochetes are the last to grow back.

The cycle may take as long as 6 months to complete. 27


CLINICAL RESPONSE

After scaling and periodontal débridement procedures, the expected clinical response is a reduction in pocket depths, changes in attachment, recession, fewer bleeding sites, and less reddened tissue. Changes continue to occur up to 12 months after

treatment.

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CLINICAL RESPONSE (CONT.)

The following figure demonstrates overall healing results.

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Measuring the periodontal probe depth and then adding that distance to a fixed reference point on the tooth, usually the cementoenamel junction, calculates the attachment change.

Periodontal probes penetrate the epithelial attachment by 1 mm or more, especially in inflamed tissue.

What might be considered as attachment gain might simply be a more accurate reading of the probing pocket depth after healing from treatment. 30



The periodontal probe is less likely to penetrate healed junctional epithelium and intact connective tissue fibers.

The re-evaluation depths are important for monitoring the long-term results of treatment and for determining whether more extensive periodontal therapy is needed.

Results should not be evaluated in less than 3 or 4 weeks after therapy.

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SENSITIVITY

Dentin or root surface sensitivity is commonly created or increased after periodontal treatment procedures or after periodontal débridement. Patients usually report sensitivity to cold or

toothbrushing in previously treated areas. Most sensitivity is mild and resolves in a few

weeks. In some patients, however, sensitivity is

extreme and inhibits patients’ plaque control efforts.

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SENSITIVITY (CONT.)

Dentin sensitivity or root sensitivity is referred to as dentinal hypersensitivity, an extreme or unexpectedly elevated response to stimuli.

Periodontal débridement results in the removal of some cementum and dentin, which exposes some fresh dentin surfaces to the oral environment. Exposed dentin is sensitive, with root sensitivity

a better descriptor of this condition.

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SENSITIVITY (CONT.)

The hydrodynamic theory of dentin sensitivity is an explanation for root sensitivity.

Dentin can become sensitive when dentinal tubules are exposed to the oral environment.

Tubules, which are filled with fluid, course from the tooth root surface directly to the pulp chamber of the tooth.

The odontoblastic processes extend into the tubules at the pulpal ends.

Hydrodynamic forces stimulate pain responses through these open tubules.

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SENSITIVITY (CONT.)

Stimuli such as cold, sweet, acid (including plaque biofilm acids), drying, and scraping with metal instruments cause a rapid flow of the tubule contents, stimulating the odontoblastic processes and causing pain. Heat-stimulated pain is not considered dentin

sensitivity but a more serious indication of irreversible pulpal changes.

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SENSITIVITY (CONT.)

Several chemicals have been used to treat sensitivity. The most commonly used preparations are

fluorides. A variety of toothpastes also contain

desensitizing agents. These agents include potassium nitrate,

potassium citrate, and strontium chloride.

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PREDICTABILITY OF RESULTS

Scaling and periodontal débridement are effective for the treatment of infectious periodontal diseases.

Both treatments result in decreased probing depths and less bleeding, increases in attachment in deep pockets, and a generally healthier oral environment in almost all patients.

These results can be relied on to occur, even in patients with advanced periodontitis.

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TECHNIQUES HAND INSTRUMENTATION

Universal curettes and sickles are among the oldest instrument designs. These instruments have cutting edges on both

sides of the blade. Sickles are machined to a pointed end, and universal curettes have rounded ends.

Several variations of area-specific curettes are also used.

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TECHNIQUES HAND INSTRUMENTATION (CONT.)

In addition to design differences, materials vary.

Most curette manufacturers use stainless steel.

Carbon steel instruments are also available that hold a sharp cutting edge longer, but they are more brittle than stainless steel.

Some manufacturers cryogenically treat their stainless steel curettes and sickles and claim longer-lasting sharpness of the cutting edges.

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UNIVERSAL CURETTES

Universal curettes are designed to adapt and instrument all surfaces of all teeth in the mouth.

The curette blades have cutting edges on both sides and are usually double ended.

One universal curette can scale around all of the teeth in the dentition, which explains why these curettes are called “universal.”

40


AREA-SPECIFIC CURETTES

Gracey curettes are area-specific curettes. The blades have one cutting edge and are

usually double ended. Gracey curettes are numbered to identify the

recommended locations: Gracey 1/2, 3/4, and 5/6 curettes are generally

used in the anterior areas, possibly the premolars.

Gracey 7/8 and 9/10 curettes are designed to instrument the buccal and lingual surfaces of the posterior teeth.

41


AREA-SPECIFIC CURETTES (CONT.)

Gracey curettes are numbered to identify the recommended locations: (cont.) Gracey 11/12 curette has extra bends in the

shank to allow it to adapt to the mesial surfaces of the posterior teeth.

Gracey 13/14 curette adapts to the distal surfaces of the posterior teeth.

Gracey 15/16 and Gracey 17/18 are two modifications of the Gracey curette design.

These are modifications of the current Gracey 11/12 and 13/14 designs.

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The following figure illustrates a set of Gracey scalers as originally designed.

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Modifications of the Gracey design have extended shanks to reach into deeper pockets.

In addition, a modification of the length and thickness of the blade has resulted in an area-specific curette series with smaller blades that adapt well to the healthier tissues of patients who are in the maintenance phase of treatment.

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Examples of some modified Gracey instruments are presented in the following figure.

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SICKLE SCALERS

Sickle scalers are designed to remove heavy calculus and are primarily used to remove supragingival calculus.

The sickle has two cutting edges and ends in a sharp point.

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SICKLE SCALERS (CONT.)

An example of sickle scalers is presented in the following figure.

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SPECIAL INSTRUMENTS

Hoes, chisels, and files are instruments designed for removing heavy calculus.

The chisel is a push instrument, and the hoe and files are pull instruments.

All are designed to crush and disrupt heavy deposits of calculus.

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SPECIAL INSTRUMENTS (CONT.)

Specialized instruments are illustrated in the following figure.

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EXPECTATION OF COMPETENCE

Variations in instrument design provide many choices.

Many dental hygienists believe that area-specific curettes work better.

Other clinicians believe that universal curettes are the only acceptable instruments.

The knowledge and skill of the dental hygienist is far more important than the particular types of instruments used.

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SONIC AND ULTRASONICINSTRUMENTATION: POWERED SCALING

Sonic and ultrasonic instrumentation of tooth surfaces has dramatically increased in popularity in recent years.

Power instrumentation has the potential to make scaling less demanding, more time efficient, and more ergonomically friendly.

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ULTRASONIC AND SONIC DEVICES

Ultrasonic scaling devices generate vibrations in the range of 20,000 to 50,000 cycles per second. These are separate units that use

magnetostrictive or piezoelectric systems to generate ultrahigh frequencies of scaling tip movement.

Ultrasonic instruments work by a combination of mechanical forces, irrigation, cavitation, and acoustic streaming forces.

52


ULTRASONIC AND SONIC DEVICES (CONT.)

Sonic scalars generate vibrations of 3000 to 8000 cycles per second. Sonic scalers attach directly to the high-speed

handpiece.

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The technique for using both sonic and ultrasonic instruments requires the tip to be kept rapidly moving to prevent overheating the tooth and to maintain constant contact with the tooth surface to remove calculus.

The motion of the tip can be elliptical or linear, depending on the particular device.

No lateral pressure is applied because lateral force can cause severe root damage.

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Both ultrasonic and sonic scalers effectively remove calculus.

Studies comparing sonic, piezoelectric scaling, and magnetostrictive scalers show nearly equivalent clinical results, despite a wide variation of the relative frequencies of the units and the differences in the directional movements of the tips.

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PLAQUE REMOVAL

Ultrasonic instrumentation is efficient at removing plaque biofilm from root surfaces.

Cavitation, the inwardly collapsing bubbles of water that are produced as the stream touches the vibrating tip, appears to have an antimicrobial effect in lysing the bacterial walls and flushing debris out of the pockets.

The stream of fluid also reaches the bottom of the pocket, providing a flushing effect during treatment.

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ENDOTOXIN REMOVAL

Studies verify that ultrasonic instrumentation is as effective as hand instrumentation in removing endotoxins (detoxifying) from root surfaces.

Fibroblast attachment occurs equally on diseased root surfaces after either type of instrumentation.

Endotoxins (lipopolysaccharides) embedded in the root surface are removed by ultrasonic scaling with overlapping, light strokes.

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CALCULUS REMOVAL

Ultrasonic tips are effective in calculus removal.

A number of clinical studies have compared calculus removal with ultrasonic instruments versus hand instruments and found no difference in posttreatment healing. Both approaches are also effective for scaling

and root planing.

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ROOT SMOOTHNESS: SHORT-TERM GOAL OF NONSURGICAL THERAPY

Root smoothness is the yardstick by which the dental hygienist determines the end point of scaling and root planing.

Root smoothness is a short-term goal of nonsurgical therapy and is the objective during every treatment appointment.

All of the surfaces in a specific patient should be instrumented to approximately the same degree of smoothness, and all surfaces should be clean of plaque biofilm and free of calculus.

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HEALING AFTER TREATMENT: LONG-TERMGOAL OF NONSURGICAL THERAPY

The important comparison between ultrasonic instrumentation and hand instrumentation is healing after therapy.

The long-term goal of nonsurgical periodontal therapy, which is the healing of the periodontal tissues, provides the basis for selecting and determining the future course of treatment for the patient with periodontal disease.

Studies have verified that hand and ultrasonic instruments both achieve the long-term goals of therapy. 60


CONTRAINDICATION

One contraindication remains to providing treatment with ultrasonic scaling.

The electromagnetic field generated in the handpiece can interfere with the functioning of some cardiac pacemakers.

Most pacemakers, but not all, are shielded and are not affected by this field.

Sonic scalers do not create an electromagnetic field and may be used as a substitute.

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AEROSOLS

Aerosols generated by subgingival powered-scaling procedures contain blood.

The prevention of disease transmission and the use of barrier techniques during powered-scaling procedures is therefore essential.

Wearing appropriate face masks and protective eyewear when using these devices is necessary.

Patients rinsing for 30 seconds with an antiseptic mouthwash before ultrasonic scaling can reduce bacterial units from aerosols by 93%.

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NEW AND OLD DESIGNS FOR TIPS

Thin, curved ultrasonic tips, which are now commercially available for use with various ultrasonic units, make subgingival access more attainable.

The thinner, curved tips will adapt extremely well into deeper pockets and furcations.

Diamond-coated inserts are also available and have shown greater root surface removal but have greater residual root surface roughness after use.

The handles of some inserts have been improved, providing an ergonomic benefit to the clinician.

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LASERS

Many lasers (light amplification by simulated emission of radiation) are now approved for a variety of dental uses by the U.S. Food and Drug Administration.

Each type of laser has specific characteristics and applications as a result of its wavelength and waveform.

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LASERS (CONT.)

In periodontics, lasers have been used for removing calculus, reducing subgingival bacterial flora, “sterilizing” periodontal pockets, enhancing root instrumentation, and performing periodontal surgery.

Lasers are appropriately used as an adjunct to periodontal therapy but are not a substitute for conventional periodontal treatment at this time.

Lasers are also used for caries removal and cavity preparation, primarily for minimally invasive restorative procedures. 65


MAGNIFICATION

Several technologies are available to increase the visibility of the teeth and tissues during periodontal treatment.

Magnification is especially valuable for protecting the musculoskeletal system of the clinician because it makes it easier to sit up straight while working and enhances visual acuity.

A variety of loupes are available, and each has features that may appeal to the clinician. Loupes should be custom fitted to the user.

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MAGNIFICATION (CONT.)

The dental endoscope allows subgingival visualization and illumination to the working field.

The clinician views a video monitor that displays the magnified image transmitted by fiberoptics attached to a subgingival probe.

The subgingival root surfaces and soft tissues are magnified and illuminated, and the clinician can see into the periodontal pockets for instrumentation and irrigation.

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MAGNIFICATION (CONT.)

Microscopes are commonly used for magnification, and they have been adapted for use chairside in dentistry, especially in endodontics and restorative dentistry.

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ANTIMICROBIAL AGENTS—SYSTEMIC ANTIMICROBIAL AGENTS

Systemic antibiotics can be used along with nonsurgical instrumentation in a comprehensive treatment plan.

Antibiotics reduce the bacterial load and enhance the host’s defense to the infectious oral pathogens in chronic periodontitis, aggressive periodontitis, and periodontitis.

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ANTIMICROBIAL AGENTS—SYSTEMIC ANTIMICROBIAL AGENTS (CONT.)

Common antibiotics used to treat periodontal diseases are tetracycline, doxycycline, and occasionally penicillin.

Systemic antibiotics are particularly effective in aggressive forms of periodontitis and refractory periodontitis or for the treatment of multiple sites in advanced disease.

70


IRRIGATION WITH ANTIMICROBIAL AGENTS

Irrigation refers to a lavage or flushing of pockets during or after periodontal débridement procedures.

Irrigation with antimicrobial agents is applied with a syringe or with irrigation devices with a soft rubber tip or cannula.

For an antimicrobial agent to have an additional effect after nonsurgical therapy, the agent must: Reach the site of disease activity, the base of the

pockets Be used at bactericidal concentrations Be substantive

71


IRRIGATION WITH ANTIMICROBIAL AGENTS (CONT.)

Although mechanical scaling and root planing is the primary antimicrobial treatment, effective antimicrobial irrigants include: 0.12% chlorhexidine 0.4% stannous fluoride 0.05% povidone-iodine

Microbial suppression is not increased when a one-time irrigation is used after periodontal débridement.

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LOCAL DELIVERY

Antimicrobial agents that are incorporated in time-released delivery devices retain the drug at the site for many hours or days after scaling and root planing.

These delivery systems allow a concentration of a specific drug to be placed in active or nonresponsive periodontal pockets to achieve a therapeutic effect.

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LOCAL DELIVERY (CONT.)

A number of antimicrobial agents are available for use in the form of strips, chips, microcapsules, and gels.

The antiseptic chlorhexidine and the antibiotics tetracycline, minocycline, and doxycycline are placed by syringe delivery or chips or films placed in the periodontal pocket.

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These drug delivery systems do not routinely provide a superior result compared with scaling and root planing alone.

Indications for local site delivery of antimicrobial agents are limited to severe forms of disease and nonresponsive conditions including: Advanced chronic periodontitis Refractory periodontitis Recurrent periodontal disease

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The true measure of the quality of life for patients with periodontal disease is the function and preservation of the teeth in an esthetic state with a minimum of sensitive teeth.

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An example of the effectiveness of nonsurgical periodontal therapy is demonstrated in the following figure.

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C HAPTER 13 Nonsurgical Periodontal Therapy Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

Documents

imprint of elsevier

root surfaces

poweredscaling devices

selective polishing

nonsurgical therapy

periodontal diseases

use of polishing agents

root planingroot planing