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

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 TherapyHealthy tissues = good plaque control + complete periodontal debridement + healing

Immediate Treatment Goals educate client instrument tooth

surfaces remove plaque &

calculus explore to evaluate

root surfaces are root surfaces

smooth & plaque free

Long-term Goals of Therapy compliance with

home care/PMP gingival health

restored periodontal health

controlled

Goals of Debridement

Success of treatment depends on: Immune response

to treatment Disease severity Appropriate use of

chemotherapeutic agents

Complete treatmentRemoval of

supra/subgingival plaque

Removal of calculus (due to its plaque retentive nature)

Professional expertiseUse of appropriate

instrumentsIntraoral constraints

Non-Surgical Periodontal Therapy

Rationale promote tissue healing decrease probing depths increase CAL decrease bleeding remove deposits iatrogenic & anatomic factors considered

(e.g. overhangs, malposed teeth)

Non-Surgical Periodontal Therapy - Definitions

Scaling removal of sub/supra deposits instrumentation of tooth & root surfaces

Root Planing treatment of root surfaces removal of deposits, by-products

Deplaquing removal of all plaque (supragingival &

within sulcus or pockets) re-evaluation & maintenance

appointments

Non-Surgical Periodontal Therapy - Definitions

Periodontal Debridement conserves cementum plaque control instrumental to good

healing response removal of deposits, diseased or dead

tissue from root surfaces, within pocket includes pocket space, pocket wall

Bacterial products within non-adherent plaque most detrimental to soft tissue

Non-Surgical Periodontal Therapy

Periodontal Debridement Indications

gingival inflammation – where periodontal pockets exist

presence of bacterial pathogensprogressive attachment loss, bone loss

Contraindicationssites that do not have true pocketing

Non-Surgical Periodontal Therapy

Periodontal Debridement Outcomes

assess 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

Healing occurs as repair as opposed to regeneration Predictable outcomes include:

Healing of epitheliumResolution of inflammationFormation of long junctional epithelial

attachmentRecession Repopulation of pockets by less pathogenic

forms of bacteria

Non-Surgical Periodontal Therapy

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

Non-Surgical Periodontal Therapy

Gingivitis: Healing following intervention Decrease of inflammatory cells Reduced edema New collagen formation Pocket epithelium heals – reduced rete pegs,

lateral attachment of junctional epithelium Reduction of bleeding Return of gingival colour Tissue shrinkage – recession becomes obvious Reduced probing depths

Non-Surgical Periodontal Therapy

Periodontitis: Healing Response Injury to or separation of junctional epithelium

occurs following debridement Healing takes approx. 1 week

Hemidesmosomes begin to reattach from apical end of JEIntact after approx.7 days

Connective tissue healing takes considerably longer

Up to several monthsNew connective tissue fiber attachment not an expected

outcomeDevelopment of an elongated junctional epithelium – this

may result in reduced probing depths

Non-Surgical Periodontal Therapy

Periodontitis: Clinical Healing Response Reduced pocket depths Changes in attachment levels Recession Fewer bleeding sites, reduced redness Improvement in tissue tone & colour

Non-Surgical Periodontal Therapy

Periodontitis: Reduced Pocket Depths Greater reduction of pocket depths occurs in

deeper pockets Pocket depths measuring 4-6 mm

Pocket reduction approximates 1 mmRecession & minimal attachment gain ( 0.5 mm)

Pocket depths measuring > 7 mmPocket reduction approximates 1.5-3.0 mmCombination of recession & attachment gain (

1.0mm)

Non-Surgical Periodontal Therapy

Gain in attachment level May represent more accurate reading of

pocket probing depth Inflamed tissues easily penetrated when

probed Inflates true pocket readings Probe less likely to penetrate when:

Junctional epithelium & CT has healed & fibers are intact

Assessment Following Therapy

Assess response of tissuesAssess plaque & calculus deposits

Residual calculus?No improvement:

Evaluate health history Plaque culture

Recommendations: Antibiotics/antimicrobials Repeat periodontal debridement Periodontal surgery

Repopulation of Pockets

Periodontal debridement reduces bacterial population in pockets

Shift from primarily Gram-negative flora to one that is Gram-positive Fewer motile forms

Repopulation occurs in a specific orderMay take as long as 6 months & may depend

on Completeness of initial therapy Client’s compliance & ability to remove plaque Presence of invasive bacteria

Repopulation of Pockets

Specific order of repopulation: Streptococcus & Actinobacillus species Viellonella Bacteroides Porphyromonas Prevotella Fusobacterium Capnocytophaga sp & spirochetes

Limitations of Non-Surgical Therapy

Pocket depths Residual calculus likely in deeper

pockets Average pocket depth for adequate

removal approx. 3.73 mm Clinical approach: curettes with longer

shanks

Limitations of Non-Surgical Therapy

Furcations Access difficult – residual calculus likely Opening to furcation often smaller than

diameter of periodontal instrument Clinical approach: use of slimline inserts

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

Limitations of Non-Surgical Therapy

Clinical skill & time spent Debridement technique & skill sensitive Debridement of one periodontally

involved molar (moderate involvement) takes approx. 10 minutes

Attention to technique, proper selection of instruments important to success