nonsurgical periodontal therapy nield-gehrig chapter 19 and perry chaper 12

Nonsurgical Periodontal Therapy

Nield-Gehrig Chapter 19 and Perry Chaper 12


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


All chronic periodontitis patients should undergo nonsurgical periodontal therapy.

Nonsurgical periodontal therapy is frequently successful in minimizing the extent of surgery needed.

Indications

Chronic PeriodontitisGingivitis 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.

Indications

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.

Goals

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.

Periodontitis

Goals

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

Goals

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.

Components

The patients role in Nonsurgical Periodontal Therapy

Daily plaque removal

Professional TherapyMust be customized for the individual patient

Components may included plaque control, nonsurgical instrumentation, and the adjunctive use of chemical agents

Nonsurgical Instrumentation

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.

Instrumentation Terminology

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


Emerging TerminologyPeriodontal 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.


AdvantagesGreater parallelism of lower shank to the toothGreater parallelism for access to the base of the pocketImproved access to distal surfaces and third molarNeutral wrist position Utilizes larger muscles of palm and forearm, meaning less operator fatigueProper use of this fulcrum provides stability and control of the instrument stroke


DescriptionEstablish a 9:00 positionPosition patient’s head straight ahead or slightly away from operator on facials and toward operator with chin tipped upward on lingualsUse mirror to retract cheek on facialUse direct vision and illumination when possibleRest 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 faceExtend 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 aspectsRotate the instrument in the hand around the distal line angle to effectively implement the distal surfacesStrokes are activated by pulling the hand and forearm, not by flexing the fingers

Supplemental Fulcrum Max. Rt. Quad.

Supplemental Fulcrum

AdvantagesNeutral wrist positionUtilizes larger muscles of palm and forearmLess operator fatigueAdded support for the removal of tenacious subgingival calculusReduces muscle strain and workload from the dominant hand Added control and stabilityReduces instrument breakage


DescriptionEstablish a 9:00 positionPosition patient’s head toward operator with chin upPlace index finger of the non-dominant hand on the shank to apply supplemental lateral pressure to either the mesial or distal surfaces of the toothFulcrum may be established on the mandibular anteriors or and extra oral fulcrum is acceptable

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


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


Increase effectiveness of patient self-care

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 debridementFull-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.


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.


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.


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.

Ultrasonic Instrumentation

Introduction to Ultrasonic Instrumenttation

Gracey curet was the primary instrumentNow 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.

Slim-diameter curved tips

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

Precision-thin tip 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 epitheliumThere is no formation of new bone, cementum, or periodontal ligament during the healing process that occurs after periodontal debridement


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


Assessing Tissue Healing-Re-evaluation should be scheduled for4 – 6 weeks after completion of instrumentation.

Nonresponsive sites should be carefully re-evaluated with an explorer for the presence of residual calculus or roughness

Dentinal Hypersensitivity

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

Dentinal Hypersensitivity

Precipitating Factors for SensitivityGingival Recession

Sometimes healing results in a small amount of tooth root being exposed

Conservation of cementum should be a goal of NSPT

Re-evaluation

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 re-evaluation

Make decisions about the need for additional NSPT, periodontal maintenance, and periodontal surgery

AAP Guidelines for referrals

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

Level 3

Patients who should be treated by a periodontistAny patient with:Severe chronic periodontitisFurcation involvementVertical/angular bony defect(s)Aggressive periodontitisPeriodontal abscess and other acute periodontal conditionsSignificant root surface exposure and/or progressive gingival recessionPeri-implant disease

Any patient with periodontal diseases, regardless of severity, whom the referring dentist prefers not to treat.

Level 2

Patients who would likely benefit from comanagement by the referring dentist and the periodontist

Early onset of periodontal diseases Unresolved inflammation at any sitePocket depths > 5mmVertical bone defectsRadiographic evidence of progressive bone lossprogressive tooth mobilityProgressive attachment lossAnatomic gingival deformitiesExposed root surfacesDeteriorating 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 useDiabetesDrug-induced gingival conditions ( e.g., phenytoin, calcium channel blockers, immunosuppressants, and long-tem systemic steroids)Compromised immune system, either acquired or drug inducedA deteriorating risk profile

Level 1

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 thereapyCardiovascular surgeryJoint-replacement surgeryOrgan transplantation

nonsurgical periodontal therapy nield-gehrig chapter 19 and perry chaper 12

Documents

periodontitis slide

periodontal debridement

risk of periodontitis

spot periodontal surgery

chronic periodontitis

mild chronic periodontitis

moderate chronic periodontitis

advanced periodontitis