Non Surgical Perio Report of Luz Aug 12

Page 1

Non–surgical TherapyLuz D. Villanueva D.M.D.

Page 2

Typical Tx regimen for periodontities Px Management

Page 3

Aims of Non-surgical Therapy

1. Eliminate both living bacteria in biofilm and calcified biofilm microorganism from tooth surface and adjacent soft tissues.

1. Create an environment in w/c the host can more effectively prevent pathogenic microbial recolonization using personal oral hygiene methods.

Page 4

Detection and removal of dental calculus

• WAERHAUG J ( 1952) The gingival pocket; anatomy, pathology, deepening and elimination .

• The rough surface of calculus does not in itself induce inflammation but that the deleterious effect of calculus relates to its ability to provide an ideal surface for microbial colonization.

Page 5

Detection and Removal of dental calculus

• Listgarten & Ellegaard ( 1973) Electron microscopic evidence of a cellular attachment between junctional epithelium and dental calculus. Journal of Periodontal Research, 8, 143-150

• Epithelial adherence to subgingival calculus can occur following its disinfection with chlorhexidine.

• Eliminate surface irregularities as much as possible

Page 6

Removal of tooth substance is not necessary???

• Hughes FJ, Smales FC. (1986) Immunohistochemical investigation of the presence and distribution of cementum-associated lipopolysaccharides in periodontal disease. J Periodontal Res. 1986 Nov;21(6):660-7.

• LPS ( Liposaccharides)Not bound to root surface

Page 7

Factors that influence complete calculus removal

• Extent of the disease• Anatomic factors• Skill of the operator• Instruments used

Page 8

Extent of the disease

• Waerhaug, J. (1978b)• Healing of the

dentoepithelial junction following subgingival plaque control. II. As observed on extracted teeth. Journal of Periodontoiogy 49, 119-134.

• more than 90% of cases, deposits of plaque and calculus remained in sites with pockets depths >5mm following SRP.

Page 9

Extent of the disease

• Rabbani A, Ash M, CaffeseR,

• The effectiveness of subgingival scaling and root planing in calculus removal J Periodontol 1981;52:119-123

Page 10

Skill of the operator

• Brayer et al ( 1989)

Scaling and root planing effectiveness: the effect of root surface access and operator experience. J Periodontol. 1989 Jan;60(1):67-72.

• more experienced operators produced a significantly greater number of calculus-free root surfaces than the less experienced operators in periodontal pockets with moderate and deep probing depths

Page 11

Anatomical factors

•  Caffesse et al ( 1986)• Scaling and root

planing with and without periodontal flap surgery

• More residual calculus following non-surgical root debridement compared to root debridement as part of a surgical procedure,

• 50% or more of surfaces with

PD >7mm showed residual calculus irrespective of methodology.

Page 12

Anatomical factors

• Buchanan SA, Robertson PB.

• Calculus removal by scaling/root planing with and without surgical access.

• J Periodontol. 1987 Mar;58(3):159-63.

• There are more residual calculus following non-surgical treatment on molar and premolar tooth surfaces than non molar teeth.

Page 13

Instruments used

• Matia et al (1986)• Int J Periodontics

Restorative Dent. 1986;6(6):24-35.

• Efficiency of scaling of the molar furcation area with and without surgical access.

• No difference in quality of root debridement following evaluation of ultra sonic, sonic or hand instrumentation.

• None of these sites were totally free of calculus.

Page 14

• Sherman et al.• The effectiveness of

subgingival scaling and root planning. I. Clinical detection of residual calculus.

J Periodontol. 1990 Jan;61(1):3-8.

• If calculus is not detected clinically but may be present on a microscopic level.

• If detected clinically, the site is more likely to display ongoing inflammation.

Page 15

METHODS USED FOR NON-SURGICAL ROOT SURFACE DEBRIDEMENT

Page 16

Page 17

SCALING

• Removal of plaque and calculus from the tooth surface ( supra or subgingival instrumentation)

ROOT PLANING

• Instrumentation by which “softened cementum is remove and root surface is made hard and smooth.

• ROOT DEBRIDEMENT removal of plaque and calculus from the root surface w/o intentional removal of tooth structure

Page 18

debridement

It involves the non-surgical, mechanical removal of tooth surface irritants using manual and/or ultrasonic methods

is the treatment of gingival and periodontal inflammation through supra gingival and sub

gingival debridement and deplaquing within the gingival sulcus or periodontal pocket

Page 19

INSTRUMENTATION for SRP

Periodontal probes/ NASA ultrasonic perio probe Perioscopy Explorers Scaling, root planing and curetting instruments

- Sickle scalers

- curettes

-hoe, chisel and file scalers

- ultrasonic instruments

- lasers – LANAP/ new KEY Pulse technology ( Kavo short pulse feedback system)

Cleaning and polishing instruments

Page 20

Page 21

PROBES

Used to assess periodontal pocket depths, attachment levels, anatomy configurations and gingival bleeding.

Community Periodontal Index of Treatment Needs, PERIODONTAL SCREENING AND RECORDING

Page 22

Page 23

Page 24

Supra gingival scaling

Sickles- Macfarlane 4/5 Ultra sonic instruments

CurretesCurretes

Page 25

Periodontal Scaler

used to remove calculus and stain from the clinical crown of the tooth.

McCall 13-14S and 17-18S, Younger-Good 7/8,

Orban straight sickle 14, Crane-Kaplan 6, Towner U-15, Kirkland 13K/13KL, and Pritchard.

Page 26

Universal Curette Design triangular blade

are designed so that the working ends can be adapted to all tooth surfaces of all regions of the mouth with one double-ended instrument.

Page 27

Page 28

Periodontal Curette

Page 29

Page 30

Gracey curettes are area specific

1-2 1-2 Anterior Anterior teethteeth

3-4 Anterior 3-4 Anterior teethteeth

5-6 Anterior 5-6 Anterior and bicuspid and bicuspid teethteeth

7-8 Posterior 7-8 Posterior teeth - buccal teeth - buccal and lingual and lingual surfacessurfaces

9-10 Posterior 9-10 Posterior teeth -buccal teeth -buccal and lingual and lingual surfacessurfaces

11-12 11-12 Posterior Posterior teeth - mesial teeth - mesial surfacessurfaces

13-14 13-14 Posterior Posterior teeth - distal teeth - distal surfacessurfaces

Page 31

Page 32

Subgingival S and root planing using Universal or Gracey curette

Modified Pen grasp Adapt cutting edge to the tooth Insert blade under gingiva At the base, 45 to 90 degrees

working angulation Apply lateral pressure against

tooth surface coronal direction Confine only to “Instrumentation

zone”- portions where calculus is found on tooth surface

Page 33

Blade angulation

Page 34

Angulation of cutting edge

Page 35

Shank position

correct position of shank, parallel with long axis of tooth

engage apical or lateral edge of deposit with cutting edge of scaler

Enter facially and lingually with overlapping strokes

Page 36

Sickle, hoe and file

A. For supragingival debridement or scaling in shallow pockets

B- for supragingival scaling and subgingival calculus C. for smoothing roots in areas of stubborn deposits

sharpening of instrunments.DAT

Page 37

Principles for Subgingival instrumentation

• Local A• Explore root surface ( PD, root anatomy,

location of c. deposits)• Modified pen grasp• Finger rest• Proper cutting position• Strokes start from apical to coronal• Re-assess with probe• Cutting edge must undergo frequent sharpening

Page 38

Hand instrumentation vs. ultrasonic

• Good tactile sensation

• < risk of contaminated aerosol production

• > time• > tooth substance

removal• > technique sensitive• >instrument sharpening• <access to furcations

/deep PP

Page 39

Sonic and ultrasonic scalers

• Sonic scaler • Ultrasonic scaler

Page 40

Page 41

Magnetostrictive—CAVITRON

1950's as an electronic alternative to manual scaling.- ( 25,000 or 30,000 Hz) oscillating magnetic field across a conductive metallic stack.

Page 42

Page 43

Care and maintenance of inserts

Page 44

Page 45

Page 46

Page 47

Piezoelectric scalers

Page 48

Page 49

Magneto vs Piezo

• In magnetostrictive units, the pattern of tip movement is elliptical with all sides transferring energy

piezoelectric units feature linear tip movement with the lateral edge transferring energy.

This influences the positioning of the piezoelectric tip, since the lateral surfaces of the tip are most active during deposit removal.

Page 50

Diamond coated tips

• Thinnest tips- for Fine scaling and root planing in narrow furcations

• Figure 6: Piezoelectric Diamond Coated mini tips, from left to right: a) EMS HPL3 Perio Diamond tip for rough cleaning and odontoplasty; b) EMS DPL3 Perio Diamond tip for polishing; c) Satelec H2R for premolars and molars; d) Satelec H1 for anterior teeth and premolars; and e) Satelec H2L for premolars and molars.

Page 51

Piezo vs Magneto

• Piezoelectric units are predominately used in

Europe and Asia .

• Magnetostrictive devices are more widely used in the United States

http://www.dimensionsofdentalhygiene.com/ddhright.aspx?id=641

Page 52

Instructional video on the 1-S tip PIEZO

• http://www.youtube.com/watch?v=2Ve-_JBpTgI&feature=related

Page 53

Periosoft™ mini-tips PH1 tip

• http://www.youtube.com/watch?v=uPJuqd1sfJ0&feature=related

• PROSTHETIC AND IMPLANT MAINTENANCE

Page 54

Reciprocating instruments

• Less root surface loss and less time consuming( Obeid et al 2004).

- has nylon plastic inserts that can remove both plaque and calculus.

- ideal for supra- and submucosal debridement and areas that have limited access, such as a hybrid restoration (the abutments are supragingival and a denture-like restoration is attached) with heavy plaque and calculus.

Page 55

Page 56

NASA Ultrasonic perio probe

• Nondestructive Evaluation Sciences Laboratory at Langley Research Center

• adapted to the Periodontal Structures Mapping System, invented at Langley by John A. Companion,

•

• Research support was provided by NASA’s Technology Applications Engineering Program and by the Naval Institute for Dental and Biomedical Research

http://www.sti.nasa.gov/tto/Spinoff2008/hm_8.html

Page 57

Reevaluation

Every 4 weeks after completion of scaling and root planing procedures

To permit time for epithelial and connective tissue healing and time to assess oral hygiene skills of Px

Page 58

Response to non-surgical treatment- guidelines

IDEAL SATISFACTORY UNSATISFACTORY

Plaque score <15 % >15-40% >40%

Probing depths 1-3mm Most 1-4 few 4-6mm

Many >6mm

Furcation involvement

None Early grade/incipient

Grade II/III

Bleeeding score for non smokers

<10% >10% < 40% depending on susceptibility

>40%

Future treatment options

Simple maintenance

1. Maintenance with subgingival removal from residual pockets and

re-evaluation in 1 year

2. Surgery if plaque scores are low.

1. Improve plaque scores and re treat.

2. Extract untreatable teeth

3. Maintain as best as possible.

Page 59

PERIOSCOPY

Page 60

Perioscopy makes use of a

technology similar to the

orthoscopic and endoscopic procedures used in medicine for many years.

If perioscopy is properly paired with regenerative proteins, and anti-inflammatory medication, bone loss damage can be reversed.  This unique synergistic protocol is known as RPE - Regenerative Periodontal Endoscopy.

Page 61

1 meter in length and .99 mm in diameter. It is made up of 10,000 optical and 19 illumination elements.

Page 62

RPE: Regenerative Periodontal Endoscopy.

Non-surgical periodontal disease treatment

RPE is an advanced non-invasive periodontal procedure combining fiber optic microscope technology with regenerative proteins.

RPE is a conservative treatment program. RPE can dramatically reduce or even eliminate the need for

aggressive periodontal surgery, as well as the need for multiple rounds of antibiotics and deep cleanings.

In addition, all dental disease conditions can be pinpointed much earlier, preventing further problems.

Page 63

Subgingival endoscopy, DV2 Perioscopy System

miniature fiberoptic camera , 24-48x magnification.

light, water irrigation, a digital processor, and video monitor .

foot-activated control system.

magnifies root surfaces, furcations, and soft tissue in the pocket.

It pinpoints residual calculus remaining after traditional instrumentation and

allows for more thorough removal of tenacious deposits

Page 64

Perioscope technique

http://www.youtube.com/watch?v=lqBSIsY2pRE&feature=related

http://www.youtube.com/watch?v=e2ZTeTmgmIE

Page 65

Subgingival micro ultrasonic endoscopic periodontal debridement

Periodontal Endoscopic Subgingival Debridement is a minimally invasive non-surgical periodontal treatment.

Page 66

Benefits of Dental Endoscopy to the General Dentist

High Patient AcceptancePerioscopy is a comfortable and well-tolerated

minimally-invasive procedureMost patients who are aware they are

periodontally-involved are compelled by a way to save their teeth that can possibly avoid surgery

The dental endoscopy option gives your patients the choice to be treated in the setting where they are most comfortable – your office

Page 67

Clinical Treatment Results and User Skills Will Improve

Periodontist is able to see exactly where other non-invasive therapies are being applied and better monitor how they are progressing

Superclean Perioscopy root surfaces are highly likely to reduce or stop tissue inflammation

Page 68

QUIXONIC……………………….

SCALERS……………. ……….

Page 69

Page 70

Manual vs Ultrasonic Scaling

Shigeru O et al. Current concepts and advances in manual and power- driven instrumentation. Periodontology 2000, Vol. 36,2004 page 45=58.

• Hand and Power-driven instruments are equally effective in reducing the probing depth, attaining attachment level gains and reducing inflammation by removal of plaque bacteria, calculus, and endotoxin.

• Ultrasonic debridement is more effective than manual scaling in Class II and Class III furcation invasion

Page 71

Ablative Laser Therapy

Page 72

ablate

Page 73

Light Amplification by Stimulated Emission of

RAdiation

MAIMAN 1960

Page 74

CO2 laser

• Targets both soft and hard tissues of the periodontium

• Has bactericidal and detoxification effects

• Can remove epithelium lining and granulation tissue within the periodontal pocket thus promotes healing.

• Curettage of granulation tissues had no added benefit over SRP (Lindhe & Nyman 1985)

• Laser therapy is capable of removing plaque and calculus with extremely low mechanical stress and no formation of smear layer on root surfaces

Page 75

Adjunct to Scaling and Root Planing (SRP)

1. After SRP, the diode laser is used on the soft tissue side of the periodontal pocket to remove the inflamed soft tissue and reduce the pathogens.(Kreisler, et al 2005)

2. Increased reduction of bacteria (especially specific periopathogens) when diode lasers are utilized after SRP (Moritz et al 1997, Haranszthy et al 2006)

3. Significant improvement in decontamination and effective treatment of peri-implantitis also occurs with the addition of diode laser therapy.19

• Gingival health parameters are significantly improved with the addition of the diode laser to SRP. Studies have shown decreased gingival bleeding,17, 20 decreased inflammation and pocket depth,16, 17 as well as decreased tooth mobility and decreased clinical attachment loss.16 This improvement in gingival health remains more stable than with conventional SRP treatment alone and tends to last longer21. Moreover, patient comfort is significantly enhanced during the post operative healing phase, with the addition of diode laser therapy.7

Page 76

Page 77

Various types of lasers

Page 78

Page 79

Page 80

Page 81

Page 82

ER:YAG AND ER:YSGG LASER ABLATION

• Er:YAG laser was evaluated for removal of subgingival calculi in periodontal treatment

• further pulsed Erbium laser, the Er:YSGG laser was proposed for treatment of dental hard tissue.,During perforation of dentin slice, the temperature increase is more pronounced for the Er:YSGG

COMPARISON OF ER:YAG AND ER:YSGG LASER ABLATION OF DENTAL HARD TISSUES Karl Stock, Raimund Hibst, Ulrich Keller* Institut für Lasertechnologien in der Medizin und Meßtechnik an der Universität Ulm and *University of Ulm, Dental School Dep. for Oral Surgery and Radiology Ulm, F.R.G. SPIE Vol. 3192; 0277-786X/97

Page 83

Er:YAG Laser

• http://www.youtube.com/watch?v=mAr3NlWH3Hg

• KaVo KEY III Laser Feedback System Demo

This video demonstrates the use of the KaVo KEY III Er:YAG Laser with feedback system. Calculus is detected and selectively ablated. The healthy root cementum substance remains untouched by the Er:YAG laser.

Page 84

Laser treatment protocols

LANAP (laser-assisted new attachment procedure)

LPT (Laser Periodontal Therapy) from Millennium Dental Technologies,

WPT (Wavelength-optimized Periodontal Therapy) from Lares Dental Research

LAPT (Laser-Assisted Periodontal Therapy) from other companies such as Biolase, Kavo, and HOYA ConBio -

Page 85

CHOICE OF DEBRIDEMENT METHOD

1. periodontal healing response

2. Debridement time

3. Root surface loss

4. Technique sensitive

5. Access

6. Removal of debris

7. Tactile sensation

8. Aerosol contamination

9. comfort

Page 86

Hand instrumentation

• Minimize the risk of contaminated aerosol production

Page 87

Lasers and SRP

• Results compared with SRP

• Damage from reflection• Tissue destruction• cost

Page 88

Effects of non-surgical therapy

Page 89

The influence of mechanical debridement on subgingival

biofilms

Page 90

The influence of mechanical debridement on subgingival

biofilms

Page 91

Implication of furcation involvement

• Patient performed home care and professionaly performed subgingival debridement become more difficult(Wylam et al 1993)

• Clinical improvement was found to be less pronounced in furcation sites than in other locations (Loos et al 1989)

Page 92

Socransky et al 1998

• Microorganism do not exist in isolation but rather as members of communities.

• Periodontitis- where red and orange complexes identified

Page 93

Page 94

The RED COMPLEX

Page 95

Haffajee et a 2006

• A reemergence of these species 3-12 months post debridement means ongoing attachment loss

Page 96

Repopulation of subgingival habitat

• From residual subgingival plaque deposits• Radicular dentinal tubules or cementum• Pocket epithelium and connective tissue• Supragingival plaque deposits• Subgingival deposits of adjacent teeth• From other intraoral soft tissue sites

Page 97

Pain and discomfort following non-surgical therapy

Page 98

Page 99

Page 100

Pain and discomfort following non-surgical therapy

• Pain which is highly variable from individual to individual reported to peak in intensity between 2 to 8 hours post-op and on average lasted for 6 hours (Philstrom et al 1999)

Page 101

Pain and discomfort following non-surgical therapy

Page 102

Re- evaluation

• Measurement made at baseline , and 3 months

1.Plaque scores

2.Bleeding on probing

3.Suppuration on probing

4.Probing pocket depth

5.Recession

6.Probing attachment level

7.mobility

Page 103

Interpretation of probing measurements at re-evaluation

Page 104

Interpretation of longitudinal changes at individual sites

1. Lack of reproducibility due to

-probing force

-probe tip diameter

-angulation of probe

-position in the mouth

-probing depth

-inflammatory status itself

2. Variations in changes may just reflect changes in inflammatory status at the base of the pocket rather than true connective tissue gain or loss.

Page 105

Probing measurements should be interpreted with CAUTION

Page 106

Prediction of outcome and evaluation of treatment

• Patient level– Extent of baseline bleeding scores, probing attachment

loss and probing depths have been found to relate to future probing attachment loss in untreated patient

– No LA- risk of further attachment loss.

– Level of sites >6mm at re evaluation bears a direct relationship to future periodontal breakdown.

Page 107

Prediction of outcome and evaluation of treatment

• Site level

- bleeding on probing is a moderate predictor of future attachment loss

- Absence of bleeding on probing has been demonstrated as a useful indicator of health( Lang et al 1990)

- Deep residual probing depth was of limited predictive value when observed over short periods

Page 108

Tx planning methods

Single appointments- for small amounts of calculus and healthy tissues

One or two long appointments to remove pathogens from entire mouth as quickly as possible so as not to re-infect previously instrumented areas. ( 45 min to root plane 7 teeth with moderately deep pockets)

Page 109

Full mouth disinfection FMD

• 1995 Quirynen et al

• Full mouth scaling and root debridement within 24 hour treatment period

• Subgingival irrigation with 1% chlorhexedine gel ( 3 x within 10 min)

• Tongue brushing with 1%Cgel and mouth rinsing with 2 % Cgel

Page 110

th

Results of phase I therapy and maintenanceCase : Severe Chronic periodontitis after 3 weeks and 18 monthsWith non surgical perio dontal treatment- scaling, root planing and plaque control therapy

p. 607 Clinical Perio, Carranza

Page 111

Page 112

These innovations will raise the standard of instrumentation in education and practice and improve the success of nonsurgical therapy and maintenance.

Page 113

Page 114

Sogndalstrand

That;s all for now and thank you for your attention…