Non-Surgical Periodontal Therapy

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Non-Surgical Periodontal Therapy

• Comprehensive Periodontics for the Dental
  Hygienist, Chapters 9, 12

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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

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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

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Goals of Debridement

• Success of treatment depends on
• Immune response to treatment
• Disease severity
• Appropriate use of chemotherapeutic agents

• Complete treatment
• Removal of supra/subgingival plaque
• Removal of calculus (due to its plaque retentive
  nature)
• Professional expertise
• Use of appropriate instruments
• Intraoral constraints

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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)

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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

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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

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Non-Surgical Periodontal Therapy

• Periodontal Debridement
• Indications
• gingival inflammation where periodontal pockets
  exist
• presence of bacterial pathogens
• progressive attachment loss, bone loss
• Contraindications
• sites that do not have true pocketing

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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

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Non-Surgical Periodontal Therapy

• Healing occurs as repair as opposed to
  regeneration
• Predictable outcomes include
• Healing of epithelium
• Resolution of inflammation
• Formation of long junctional epithelial
  attachment
• Recession
• Repopulation of pockets by less pathogenic forms
  of bacteria

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Non-Surgical Periodontal Therapy

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

12
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

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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 JE
• Intact after approx.7 days
• Connective tissue healing takes considerably
  longer
• Up to several months
• New connective tissue fiber attachment not an
  expected outcome
• Development of an elongated junctional epithelium
  this may result in reduced probing depths

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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

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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 mm
• Recession minimal attachment gain (? 0.5 mm)
• Pocket depths measuring gt 7 mm
• Pocket reduction approximates 1.5-3.0 mm
• Combination of recession attachment gain (?
  1.0mm)

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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

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Assessment Following Therapy

• Assess response of tissues
• Assess plaque calculus deposits
• Residual calculus?
• No improvement
• Evaluate health history
• Plaque culture
• Recommendations
• Antibiotics/antimicrobials
• Repeat periodontal debridement
• Periodontal surgery

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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 order
• May take as long as 6 months may depend on
• Completeness of initial therapy
• Clients compliance ability to remove plaque
• Presence of invasive bacteria

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Repopulation of Pockets

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

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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

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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

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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