Nield-Gehrig Chapter 19 and
Perry Chaper 12

Nonsurgical Periodontal Therapy
Other terms used to describe this phase of treatment.
Initial periodontal therapy
Hygienic phase
Anti-infective phase
Cause-related therapy
Soft tissue management
Phase 1 therapy
Etiotropic phase
Preparatory therapy

Nonsurgical Periodontal Therapy
All chronic periodontitis patients should undergo nonsurgical periodontal therapy.
Nonsurgical periodontal therapy is frequently successful in minimizing the extent of surgery needed.

Chronic Periodontitis
Gingivitis and mild chronic periodontitis may be controlled with nonsurgical periodontal therapy (NSPT) alone
Moderate Chronic Periodontitis can be controlled with NSPT alone for may others may require some spot periodontal surgery after NSPT.

Severe Chronic Periodontitis control will probably require through NSPT followed by periodontal surgery.
Although periodontal surgery is frequently indicated for patients with more advanced periodontitis, all chronic periodontitis patients should undergo nonsurgical periodontal therapy prior to periodontal surgical intervention. Nonsurgical periodontal therapy is frequently successful in minimizing the extent of surgery needed.

1. To control the bacterial challenge to the patient
Intensive training of the patient in appropriate techniques for self-care and professional removal of calculus deposits and bacterial products from tooth surfaces
Removal of calculus deposits and bacterial products contaminating the tooth surfaces.
Calculus deposits ALWAYS are covered with living bacterial biofilms that are associated with continuing inflammation if not removed.

2. To minimize the impact of systemic factors
Certain systemic diseases or conditions can increase the risk of periodontitis and the severity.
Plan must minimized the impact of systemic risk factors

3. To eliminate or control local risk factors
Local environmental risk factors can increase the risk of developing periodontitis in localized sites.
Plaque retention in a site allow damage over time to periodontium
Local environmental risk factors should be eliminated.

The patients role in Nonsurgical
Periodontal Therapy
Daily plaque removal
Professional Therapy
Must be customized for the individual patient
Components may included plaque control, nonsurgical instrumentation, and the adjunctive use of chemical agents

Mechanical removal of calculus is necessary because it is a mechanical irritant and holds biofilm.
Periodontal debridement is likely to remain the most important component of nonsurgical periodontal therapy for the foreseeable future.

Traditional Terminology
Scaling = instrumentation of the crown and root surfaces of the teeth to remove plaque, calculus, and stains
Root Planing = treatment procedure designed to remove cementum or surface dentin that is rough, impregnated with calculus, or contaminated with toxins or microorganisms.

Emerging Terminology
Periodontal debridement = includes instrumentation of every square millimeter of root surface for removal of plaque and calculus, but does not include the deliberate, aggressive removal of cementum
Conservation of cementum while removing all calculus and biofilm is the goal of periodontal debridement.

Deplaquing = the disruption or removal of subgingival microbial plaque and its byproducts from cemental surfaces and the pocket space

Considerations Regarding Emerging
Terminology
Periodontal Debridement is not currently a ADA procedure name. (no code)
Some authors have redefined the definition of root planing because of this.

Extra Oral Fulcrum Max. Rt. Quad.

Extra Oral Fulcrum Max. Rt. Quad.
Advantages
Greater parallelism of lower shank to the tooth
Greater parallelism for access to the base of the pocket
Improved access to distal surfaces and third molar
Neutral wrist position
Utilizes larger muscles of palm and forearm, meaning less operator fatigue
Proper use of this fulcrum provides stability and control of the instrument stroke

Extra Oral Fulcrum Max. Rt. Quad.
Description
Establish a 9:00 position
Position patient’s head straight ahead or slightly away from operator on facials and toward operator with chin tipped upward on linguals
Use mirror to retract cheek on facial
Use direct vision and illumination when possible
Rest the backs of the fingers, not the pads or tips, firmly against the skin overlying the lateral aspect of the mandible on the right side of the face
Extend the grasp of the instrument in the hand to effectively implement an extra-oral fulcrum for mesial and distal surfaces of both the facial and lingual aspects
Rotate the instrument in the hand around the distal line angle to effectively implement the distal surfaces
Strokes are activated by pulling the hand and forearm, not by flexing the fingers

Supplemental Fulcrum Max. Rt.
Quad.

Advantages
Neutral wrist position
Utilizes larger muscles of palm and forearm
Less operator fatigue
Added support for the removal of tenacious subgingival calculus
Reduces muscle strain and workload from the dominant hand
Added control and stability
Reduces instrument breakage

Supplemental Fulcrum Max. Rt.
Quad.
Description
Establish a 9:00 position
Position patient’s head toward operator with chin up
Place index finger of the non-dominant hand on the shank to apply supplemental lateral pressure to either the mesial or distal surfaces of the tooth
Fulcrum may be established on the mandibular anteriors or and extra oral fulcrum is acceptable

Supplemental Fulcrum Max. Rt.
Quad.

Supplemental Fulcrum Max. Rt.
Quad.

Rationale for Periodontal
Debridement
Arrest the progress of periodontal disease
Induce positive changes in the subgingival bacterial flora (count and content)
Create an environment that permits the gingival tissue to heal, therefore eliminating inflammation

Rationale for Periodontal
Debridement
Convert the pocket from an area experiencing increased loss of attachment to one in which the clinical attachment level remains the same or even gains in attachment
Eliminate bleeding
Improve the integrity of tissue attachment

Rationale for Periodontal
Debridement
Increase effectiveness of patient selfcare
Permit reevaluation of periodontal health status to determine if surgery is needed
Prevent recurrence of disease through periodontal maintenance therapy

Appointment planning for calculus removal
Full-mouth debridement
Full-mouth debridement is defined as periodontal debridement completed in a single appointment or in two appointments within a 24-hour period.
Since periodontal disease is an infection, the full-mouth approach to periodontal debridement is based on the assumption that the remaining untreated areas of the mouth can reinfect the treated areas.

Appointment planning for calculus removal
In research studies, the full-mouth debridement procedure was combined with the use of topical antimicrobial therapy (full-mouth disinfection), It is unclear, however, if the antimicrobial therapy actually contributed to the improved results derived form the full-mouth periodontal debridement alone.

Appointment planning for calculus removal
Full-mouth debridement is best accomplished by the dental hygienist working with an assistant.
Initially, patients may be resistant to the concept of scheduling one or two long appointments for the purpose of periodontal debridement. One or two long appointments, however, may in reality be less disruptive to an individual’s work schedule than four to six 1 hour appointments over several weeks. In addition, the dental hygienist should explain the rationale behind full-mouth debridement.

Appointment planning for calculus removal
Planned multiple appointments. If periodontal debridement is completed in sextants or quadrants over multiple appointments, at each appointment the clinician should treat only as many teeth, sextants, or quadrants as he or she can thoroughly debride of calculus and plaque during that appointment.

Introduction to Ultrasonic
Instrumenttation
Gracey curet was the primary instrument
Now the precision-thin ultrasonic tip
Research indicates not only that the ultrasonic instrumentation is as effective as hand instrumentation, but also that ultrasonic instrumentation is as effective as hand instrumentation in the treatment and maintenance of periodontal pockets.

Similar in design to a curved furcation probe
Designed fo use on:
Posterior root surfaces located more than 4mm apical to the CEJ
Root concavities and furcations on posterior tooth surfaces

Advantages of Ultrasonic
Instrumentation
Mechanism of Action of Ultrasonic
Instruments
Ability to flush debris, bacteria, and unattached plaque from the periodontal pocket with the fluid lavage.
Ultrasonic Instrument Tip Design .
Precision-thin ultrasonic tips have the following advantages

Thinner and smaller than the working-end of a curet.
Standard Gracey curets are too wide to enter the furcation area of more than 50% of all max. and mand. first molars.
Precision-thin tips have been shown to reach 1mm deeper than hand instruments and to teach the base of the pocket in 86% of 3-9mm pockets

Tissue Healing: End Point of
Instrumentation
Tissue Health: The goal of instrumentation is to render the tooth surface and pocket space acceptable to the tissue so that healing occurs.
Healing After Instrumentation
The primary pattern of healing after periodontal debridement is through the formation of a long junctional epithelium
There is no formation of new bone, cementum, or periodontal ligament during the healing process that occurs after periodontal debridement

Tissue Healing: End Point of
Instrumentation
Nonsurgical periodontal therapy can result in reduced probing depths due to the formation of a long junctional epithelium combined with the gingival recession that often occurs following
NSPT

Tissue Healing: End Point of
Instrumentation
Assessing Tissue Healing-
Re-evaluation should be scheduled for
4 – 6 weeks after completion of instrumentation.
Nonresponsive sites should be carefully re-evaluated with an explorer for the presence of residual calculus or roughness

Description – a short, sharp painful reaction that occurs when some areas of exposed dentin are subjected to mechanical, thermal, or chemical stimuli
Associated with exposed dentin
Usually pain is sporadic

Precipitating Factors for Sensitivity
Gingival Recession
Sometimes healing results in a small amount of tooth root being exposed
Conservation of cementum should be a goal of NSPT

4-6 weeks after treatment
Update medical status
Perform a periodontal clinical assessment
Compare data gathered at the initial periodontal assessment with the data at reevaluation
Make decisions about the need for additional NSPT, periodontal maintenance, and periodontal surgery

Meant to help identify patients who are at greatest risk early and, therefore would benefit from specialty care.

Patients who should be treated by a periodontist
Any patient with:
Severe chronic periodontitis
Furcation involvement
Vertical/angular bony defect(s)
Aggressive periodontitis
Periodontal abscess and other acute periodontal conditions
Significant root surface exposure and/or progressive gingival recession
Peri-implant disease
Any patient with periodontal diseases, regardless of severity, whom the referring dentist prefers not to treat.

Patients who would likely benefit from comanagement by the referring dentist and the periodontist
Early onset of periodontal diseases
Unresolved inflammation at any site
Pocket depths > 5mm
Vertical bone defects
Radiographic evidence of progressive bone loss progressive tooth mobility
Progressive attachment loss
Anatomic gingival deformities
Exposed root surfaces
Deteriorating risk profile

Level 2 -
Patients who would likely benefit from comanagement by the referring dentist and the periodontist
Medical or Behavioral Risk
Factors/Indicators
Smoking/tobacco use
Diabetes
Drug-induced gingival conditions ( e.g., phenytoin, calcium channel blockers, immunosuppressants, and long-tem systemic steroids)
Compromised immune system, either acquired or drug induced
A deteriorating risk profile

Patients who may benefit from comanagement by the referring dentist and the periodontist
Any patient with periodontal inflammation/infection and the following systemic conditions:
Cancer thereapy
Cardiovascular surgery
Joint-replacement surgery
Organ transplantation