Non-Surgical Treatment

7/28/2019 Non-Surgical Treatment

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NON SURGICAL THERAPY II

Learning objectives

Understand the rationale behind root debridementRecognise the various methods for non surgical tooth debridementRecognise the clinical and histological changes following root debridement

Why do we debride teeth?

Large body of evidence showing that bacterial plaque as the primary aetiological factor for periodontal disease (involved in initiation and progression)

Biofilms are naturally resistant to host defences and antimicrobial therapy

General principles of controlling periodontal infection

Differing supra and sub gingival environments

Most patients are not able to control the supra

gingival environment sufficiently to prevent the development and formation of potentially pathogenic subgingivalbiofilmControl of the subgingivalbiofilm on a regular basis is critical in the management of periodontal disease

Scaling & Root Debridement DefinitionsScaling removal of plaque and calculus from the root surface

Root Debridement removal and plaque and subgingivalcalculus leaving a relatively smooth root surface

Root planing removal of softened disease cementumand root surface made to feel hard and smooth

Subgingival curettage scraping and removal of soft tissue from within the pocket

SRD Objectivesto remove supragingival accretions leaving a smooth and polished surface which will facilitate rapid and simple day today plaque removal by the patient to remove subgingival root surface irritantse.g. plaque, calculus, to allow healing in the soft tissue pocket wall and, if possible, achieve new epithelial attachment

plaque the main aetiological factor

will facilitate day to day cleaning

remove overhangs


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Ultrasonic scalers

Magnetostrictive (Cavitron)

Periodontal work only

Piezoelectric (EMS)

Perio and endo uses

Tip movement is related to the cross section of the tip round tips will give elliptical tip movement

flattened tips will result in linear tip movement

Ultrasonic scalers

Magnetostrictive scalers

Some older pacemakers may be affected by magnetostrctive scalers

Keep handpiece and cables at least 1523 cm away from pacemaker

Contact patients physician if unsure

Caution with ultrasonicsCavitrons were designed initially to create cavities

Therefore you need to be careful with the use of ultrasonic instruments where cervical lesions are present

Rotary instrumentsUsed more with periodontal surgery

Round bursFlame shaped burs

Reciprocating handpiecesGood for overhang removal

not fatiguing hand.

metal plates expand and contract under high currentelliptical - able ot move in all directions

linear movement

recommendation

must restore lesion. aerosols created with ultrasonics. impt to wear mask. bur tips move in linear fashion


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Effectiveness of calculus removal

Pocket depthModified (slimline) ultrasonic inserts may be more effective in cleaning deeper pockets (Dragoo et al. 1992)

Furcation areasLimited accessThese areas are not cleaned as well as smooth surfaces and do not respond as well to treatment

Removal of Plaque Retention Factors

Illfittings crowns and restoration margins result in the extensive localised plaque accumulationShould be removed to facilitate removal of plaque and calculus and to establish an anatomy

which facilitates plaque control by the patientRemoved using burs, reciprocating flat diamond stones, finishing strips or by replacing the restoration/crown

good at removing calculus up to 3mm

tissues returned to normal gingival health

overhanging margins

overhand on tooth surface. restore to original contour


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Reassessment

Once cause related therapy is completed reassess patient 3 months laterEvaluate degree of control of the disease by patient, gingival condition, probing depths, attachment level, recession, furcation and

mobility

Do NOT review pt and redo periodontal charting if you have not completed cause related therapy

Definitive Treatment Planning

Patients will generally fall into three categories:

good OH but deep persistent pockets and BOPgood OH, resolution of gingivitis, no BOP and marked reduction of PD

poor OH and reinfectionFurther treatment depends on which category the patient is in and how severe and widespread the remaining disease is (a lecture will follow in 3rd Yr)

Definitive

(Corrective)

Treatment

Root Canal TherapyOrthodontic TherapyOcclusal TherapyTemporisationPeriodontal SurgeryFixed and Removable Prosthodontics

Review decision treeRedo cause related therapy calculus, poor OH

Review Periodontal surgery access, alter anatomy, regeneration

Maintenance inflammation resolved, good OH

remove overhang with scalermetal polishing strip creates an open contact - food impaction

majority of healing has occurred


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What does good healing look like clinically

Non surgical debridement followed by surgery

Maintenance care Maintenance Aims

Preservation of the health of the periodontiumContinued control of bacterial plaqueCritical reevaluation of treatmentMonitor health of other oral tissuesEncouragement of oral hygieneContinued patient education and motivationConsideration of future maintenance regimeRetreatment if necessary

Remember The clean which is done during the maintenance visit is not the scale and clean you do for your non perio patient

Your aim is to remove all the biofilm (supra AND subgingival plaque) from the tooth surface and so you need to tailor the clean to the patient

Maintenance procedureRecall appointments every 3 months to begin with (for patients with moderate to severe disease)

Based on individual patient needs and may be extended to 6 months or yearly

At each visit OH should be evaluated with SRP and polishing as necessary (lightly debride deep and BOP sites)Once a year assess(chart) caries, gingivitis, pocket depths, furcations, mobility and changes in bone level

pockets greater than 4 mm highlighted yellowgreater than 5 highlighted ipnk

healing has occurredafter surgery pocket depth has decreasedfrom 7mm to 4mm

make sure causative factors (biofilm)are removed

assess OH on as neededbasis


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Definitions

repair: healing by tissue not fully restoring architecture or function of part (i.e. granulation tissue)

reattachment: reunion of junctional epithelium with root surfaces where viable periodontal tissue is presentLong junctional epithelium

regeneration: reconstitution of a lost or injured part via the growth and differentiation of new cells and intercellular substances. Continuous physiological process wear and tear repair

new attachment: reunion of CT with root surface that has been deprived of PDL requires attachment of PDL cells and fibres, new cementum formation, the formation of functionally orientated fibrenetwork, and coronal regrowth of alveolar bone

Periodontal pocket lesion

Chronic inflammatory lesion, constantly undergoing destruction and repairPersistent local irritants, fluid and cell exudatecause degeneration of new tissue elements formed by repairDestructive/constructive changes determine tissue colour, contour and textureSoft tissue wall results from destructive and constructive tissue changes..oedematous/fibrotic pocket

Effect of plaque removal

Radical alteration in predominant floraGram ve organisms, Gram +ve organisms

Reduction in plaque mass renders residual organisms more susceptible to killing by the host defence mechanismsIf new flora stable and supra gingival plaque controlled, Gram ve organisms less likely to recolonise and healing will take place

Effect of plaque removalEven though the removal of plaque and subgingival calculus is often incomplete, it may be sufficient to alter the subgingivalenvironment

and change composition and proportion of microbials

thereby halting periodontal disease progression

(Haffajee et.al 1997)

Histological changes following therapy

2448 hours acute inflammatory reaction

2 7 days vasodilation, GCF & inflammatory cell numbers. Healing ulcers. Fibroblast migration, proliferation, collagen and ground substance production with concomittant decrease in gingival swelling and redness

1 8 weeks maturation of new gingival CT, remodelling of bone (not coronally), reattachment of pocket epithelium to root surface (LJE), formation of basement membrane and hemidesmosomes, long junctional epithelium

scar type repair - fibrous tissue

most situations won't get regeneration


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Clinical

changes

o Reduction in rednesso Reduction in swellingo BOP reducedo Gingiva becomes increasingly pink and firm as CT

matureso Reduced PD associated with gingival shrinkage as

inflammation subsideso Tightening of gingival cuff due to orientation of new

healthy collagen fiberso Little bony healing takes place in the alveolar bone

Clinical changesIn most situations following treatment the periodontium will heal with repair

Decreased swelling of the gingiva coronallywill result in gingival recessionDeep pockets will heal with repair apicallyHealthy tissue tone will prevent the penetration of the periodontal probe apically

All these three mechanisms will result in pocket depth reduction and attachment level gain

gingival recession part of normal healing

gingival recession and apical healing


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In deep angular defects some degree of regeneration may occur

Remember

Healing only occurs after adequate sub gingival debridement and effective plaque control during the healing phaseIncomplete debridement will allow persistence of inflammation and in due course recolonisation from bacterial residuesLikewise, failure to prevent supra gingival plaque accumulation will lead to the down growth of bacterial plaque, which will interrupt the healing process

Remember

Healing of the epithelium can take up to 8 weeks

Most healing in the periodontium will occur within the first 3 months (most changes in pocket depth will be seen during this time)

For deep sites however (7+ mm), healing (and PD reduction) will occur up to 9 months after treatment (Badersten et al. 1984)

CLINICAL CASES

Gingivitis

1st Visit Exam & Diagnosis

2nd Visit Plaque charts OHI S+Cl

3rd Visit (2 weeks later) Review, OHI, S+Cl as necessary

Recall 612 months

may take up to a year


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Periodontitis

Exam, Diagnosis and Tx plan 1. Extraction of hopeless teeth / emergency caries

control2. OHI / plaque index and SRD Q1 with LA3. SRD Q2 with LA (OHI)4. SRD Q3 with LA5. SRD Q4 and full mouth prophylaxis (OHI)6. (Restorations if required)7. Review appointment in 3 months

1. Assess periodontal condition on specific teeth2. Assess suitability for definitive restorations3. Assess suitability for prostheses (dentures)

My protocol for each scaling visit:

Set up unit with everything that I will needDont open kits until you know pt has turned up

Check how Patient felt in previous weekEspecially in terms of bleeding and sensitivity

Check Med Hx (in notes) and LAAssess OH as going numbAssess previously scaled areasSRD Ultrasonic and Hand InstrumentsReinforce OHI as required

pi tool for how well they are cleaning


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In patients maintained on a properly controlled OH regimen, SRP alone was equally as effective as SRP in combination with periodontal surgery in establishing healthy gingiva and preventing future attachment loss

(Lindhe et al. 1982)

SRP/SRD procedures have only be shown to be effective in controlling and preventing periodontal disease when done in conjunction with

Effective supragingivalplaque controlA periodontal maintenance regime (generally between 36 monthly)

References

LindheChapter 15Carranza 8th Ed Chapters 41 & 42Carranza 9th Ed Chapters 47 49Dragoo. A clinical evaluation of hand and ultrasonic instruments on subgingivaldebridement. Part I. With unmodified and modified ultrasonic inserts. Int J. Perio Rest Dent 1992; 12: 311323.Lindhe et al. Healing following surgical/non surgical treatment of periodontal disease. A clinical study. J Clin Periodontol. 1982Nyman S, WesfeltE, SarhedG, Karring, T. Role of diseased root cementum in healing following treatment of periodontal disease. A clinical study. J Clin Periodontol 1988;15:464 468.Taggeet al. The clinical and histological response of periodontal pockets to root planning and oral hygiene. J Periodontol. 1975Van der WeijdenGA, Timmerman MF. A systematic review on the clinical efficacy of subgingival debridement in the treatment of chronic periodontitis. J Clin Periodontol 2002; 29 (Suppl 3):5571.

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