Non-Surgical Periodontal Therapy

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

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

3. Immediate Treatment Goals educate client instrument tooth surfaces remove plaque & calculus explore to evaluate root surfaces are root surfaces smooth & plaque free Long-termGoals of Therapy compliance with home care/PMP gingival health restored periodontal health controlled Non-Surgical Periodontal TherapyHealthy tissues = good plaque control + complete periodontal debridement + healing

4. 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 Goals of Debridement

5. 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)

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

13. 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

14. 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

15. 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 > 7 mm • Pocket reduction approximates 1.5-3.0 mm • Combination of recession & attachment gain ( 1.0mm)

16. 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

17. 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

18. 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 • Client’s compliance & ability to remove plaque • Presence of invasive bacteria

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

20. 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

21. 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

22. 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