Transcript Nonsurgical Periodontal Therapy

Nonsurgical Periodontal
Therapy
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.
Indications
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.
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
Periodontitis
Periodontitis
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 Therapy
Must 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 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.
Instrumentation Terminology
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.
Instrumentation Terminology
Deplaquing = the disruption or
removal of subgingival microbial
plaque and its byproducts from
cemental surfaces and the pocket
space
Instrumentation Terminology
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.
Supplemental Fulcrum
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.
Ultrasonic Instrumentation
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.
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 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 HealingRe-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
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 Sensitivity
Gingival 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 reevaluation
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 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.
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 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
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 thereapy
Cardiovascular surgery
Joint-replacement surgery
Organ transplantation