ROOT PLANING

• Marginal periodontitis is induced by

bacterial plaque deposits and maintained by

subgingival plaque and calculus present on

root surfaces.

• Therefore therapy of periodontally involved

teeth is primarily directed towards removal

of these accretions from root surfaces in

order to allow for healing.

Non surgical therapyNon surgical therapy is defined as “plaque removal,

plaque control, supra and sub gingival scaling, root

planing and the adjunctive use of antibiotics.”

(Ciancio 1989,1992)

Scaling is the process by which plaque and calculus are removed from both supragingval and subgingival tooth surfaces .

Root planing: instrumentation to remove the microbial flora on the root surface or lying free in the pocket, all flecks of calculus and all contaminated cementum and dentin.( O Leary, 1977)

• DCNA

Meticulous instrumentation of the cemental

surface of the root during periodontal treatment

for the purpose of removing all the dental

accretions(calcified and noncalcified) to render the

surface biologically clean and clinically smooth

CLOSED DEEP SCALING

ROOT SURFACE

DEBRIDEMENT

ROOT SURFACE INSTRUMENTATION

ROOT DETOXIFICATIO

N

SYNONYMS

ROOT SURFACE DEBRIDEMENT OR

ROOT SURFACE INSTRUMENTATION

Debridement of the root surface with only

few strokes, and not to undertake

aggressive instrumentation to remove the

endotoxin and other root surface

irregularities

• This term has appeared recently in the literature to better describe periodontal instrumentation associated with periodontal therapy.

• “the treatment of gingival and periodontal inflammation through mechanical removal of tooth and root surface irritants to the extent the adjacent soft tissues maintain or return to a healthy , non inflamed state”

SCALING ROOT PLANING PERIODONTAL DEBRIDEMENT

Removal of calculus from all tooth surfaces and removal of cementum from root surfaces

Removal of plaque biofilms and calculus from tooth surface and within the pocket space

Aggressive instrumentation removes significant amounts of cementum

Conservation of cementum is a goal; bacterial products are removed with ultrasonic instruments or light instrumentation strokes

Hand activated instrumentation A combination of hand activated and ultrasonic instrumentation preferred

CLARITY OR CONFUSION- BEST WAY TO DEBRIDE

ROOT SURFACES

• “Root planing implies removal of cementum (and possibly dentine) exposed within the pocket to maximise the chance of removing all components of the subgingival plaque....

• Subgingival scaling is the removal of deposits of subgingival calculus

• “....in reality the procedures are similar and the term ‘root surface debridement’ is often used as a more generic term.”

• Subgingival Plaque Control - The Clinician( BDJ)

RATIONALE OF ROOT PLANING

REMOVAL OF DISEASED

CEMENTUM

GLASSY SMOOTH TOOTH SURFACE

NEW ATTACHMENT

Stripped of periodontal attachment

Contains remnants of embedded calculus, whole bacteria, and the products of microbial life.

Exposed to septic contents of periodontal pocket

DISEASED/ALTERED/NECROSED CEMENTUM

CHANGES IN DISEASED

CEMENTUM

STRUCTURAL CHANGES

• Hypermineralization/ Demineralization

• Presence of pathological granules

CHEMICAL CHANGES

• Changes in conc of Ca, Mg, Phosphate

• Adsorption from saliva

CYTOTOXIC CHANGES

• Adsorption of endotoxins

• Invasion of bacteria• Cell mediated

resoption lacunae

• Polson and Caton( 1982)

Role of reduced Periodontium and altered root surface

Role of altered root surface on wound healing

Experimental Periodontitis

Rhesus monkey

Block sections of periodontium evaluated after 40 days

• RESULTS

No new CT attachment . pathologically

altered root surface although placed in

healthy periodontium

• CONCLUSION

pathologically altered root surface rather

than reduced periodontium – prevented

regeneration

ENDOTOXINS• THE MOST COMMONLY STUDIED SEPTIC

COMPONENT IN DISEASED CEMENTUM IS ENDOTOXIN.

• THEY ARE LIPOPOLYSACCHARIDE OF GRAM NEGATIVE BACTERIA.

ROLE OF ENDOTOXINS

PYROGENICITYATTRACTION OF INFLAMMATORY

CELLS

ACTIVATION OF COMPLEMEMT

SYSTEM

STIMULATION OF

OSTEOCLASTIC ACTIVITY

MITOGENIC ACTIVITY

FIBROBLAST CYTOTOXICIT

Y

• Aleo et al. (1974)

LIMULUS LYSATE ASSAY

Periodontally involved root surfaces contained an

endotoxin-like material capable of depressing cell

growth of tissue culture fibroblasts.

Conclusion led to the long accepted concept that

endotoxin lies within cementum, and that cementum

removal during periodontal therapy might be

appropriate.

HATFIELD AND BAUMHAMMERS( 1971)

Periodontally involved roots which had been washed

and scaled (not root planed) and placed these roots in

sterile tissue cultures.

Controls - uninvolved third molar roots.

Results: After 24 to 96 hours, cell cultures over control

roots showed irreversible morphologic changes.

Conclusion: presence of some toxic factor, possibly

endotoxin, which had penetrated the diseased root and

was capable of upsetting cell attachment.

Jones and O’leary (1978)

• Effect of vigorous root planing on quantity of

endotoxin.

• 50 root surfaces each of

Diseased 146.8ng

Healthy roots(0.05-0.45ng)

• Meticulous instrumentation was performed.

• RESULT: Root planed roots contained only

about 1 ng more endotoxin than healthy

root surfaces. This small difference can be

accounted for small flecks of calculus

remaining after planing.

• Conclusion: Root planing performed in the

study was able to render diseased root as

free of endotoxin as healthy root.

ENDOTOXIN PENETRATION

• Endotoxin and whole bacteria may be found as deep as 12 microns beneath the cemental surface.

• Zander (1953)Penetration of calculus bacteriaCalculo-cementumMust be removed

• Selvig (1969)Normal appearing areasAreas of decreased radio- opacity & cavitationAreas of partial decalcification (300µ)Highly mineralized areas

ENDOTOXIN DOES NOT PENETRATE BUT LOOSELY

ATTACHED SUPERFICIAL LAYER

Nakib et al (1982)• Weakly adherent• No penetration into cementum• Brushed away

Nyman et al (1986)• Study on dogs• Endotoxins did not interfere with healing

following flap surgery once soft deposits were removed

• Endotoxin removed with bacteria during polishing

within cementum. Neutralized by inflammatory response

OPPOSING STUDIES

• Moore & coworkers (1986)

Toxins(LPS) weakly bound to root

surface

Washing for 1 minute removes 40%

Brushing for 1 minute removes 60%

Remainder1%

REMOVAL OF DISEASED

CEMENTUM• The portion of root exposed to the disease

process has little or no fibroblast cells attachment to the remainder of root surface. Following the mechanical removal of diseased cementum and the bacterial endotoxin, the cells attached normally on the planed root surfaces. The cementum bound endotoxin is capable of both cell death and decreased cell proliferation ( Simon, Goldman 1971)

LOPEZ et al,1980

• Inflammatory potential of diseased cementum

• Histologic results showed –

Implanted fragments from roots that had been scaled

caused the most response with acute inflammation up

to 14 days and chronic inflammation to 21 days.

Autoclaved Fragments- the acute inflammation was

not as severe.

• Autoclaved and planed roots- even less acute inflammation was seen in the 7-day specimens while some chronic inflammation persisted in the 21-day specimens.

• Implants from healthy roots evoked no response.

• The inflammation caused by the autoclaved diseased cementum: attributed to thermo-stable endotoxin.

• Conclusion- Necessary to remove all of the cementum exposed to the pocket to eliminate its potential for inducing inflammation

CONTRADICTORY STUDIES

• Nyman et al. (1986) demonstrated in beagle dogs that

the removal of diseased cementum was not necessary

for successful periodontal therapy.

• In a later study in humans, Nyman et al. (1988)

showed that the same degree of improvement of

periodontal status was achieved regardless of whether

cementum was removed or not.

• Results : Intentional root cementum removal is not

necessary for optimal postoperative healing.

ROOT SMOOTHNESS• EMPHASIS IN ROOT PLANING HAS ALWAYS BEEN ON

THE ELIMINATION OF PLAQUE AND CALCULUS ALONG

WITH SMOOTHENING THE ROOT SURFACE.

• HOWEVER THE IMPORTANCE OF ROOT SMOOTHNESS

NOT ESTABLISHED.

Jens Waerhaug(1956)

Effect of rough surfaces upon gingival tissue,

EXPERIMENT IN DOGS Described the irritating effect of calculus that is caused by bacteria or toxin.

• Emphasized - rough surface facilitates the retention

of bacterial plaque and stressed the needs of well

polished restoration below the gingival margin.

• Supported by :Lindhe et al1984Lekens KN 1996Quiryen N 1995

Rosenberg & Ash(1974)

Profilometer

Sig diff b/w curretted & control teethNo significant diff in mean plaque scores/inflammatory indicesRoot roughness not significantly related to mean inflammatory index

Khatiblou & Ghodssi (1983)Healing following surgical RxHealing not affected by root roughness

Hunter et al (1984)Gouges/ ripples ≤ 50µ smoothBiologically lack of evidence relating smooth surfaces to plaque formationRough area favor plaque & calculusSmoothness only indicator of calculus removal

OPPOSING STUDIES

PREPARATION FOR NEW

ATTACHMENT• Removal of contaminated root surface

Root surface demineralization with citric acid

Pre requisite for new connective tissue attachment

Accelerates new attachment in healing periodontal wounds

• Removal of hypermineralized surface- Prerequisite for effective demineralization.

• ROOT PLANING –

Prepared root surface for demineralization

New attachment

• Garrett et al (1978)

SEM & TEM

Citric acid- no effect on unplaned roots

Planed root surfaces- 4nm wide areas of demineralization

Failure- hypermineralized areas on diseased roots

• Polson et al (1984)

Root planing (smear layer)2-15µm thick

Citric acid (ph1 for 3 min)

Removal of smear layer

Fibrous mat like structure

Not evident on unplaned roots

OBJECTIVES OF ROOT PLANING

Restore health• Remove elements that provoke

gingival inflammation

Remove pathogenic microflora

• O’ LEARY

Biologically acceptable root surface

Probing depth

Resolving inflammation

Facilitating oral hygiene

Improving & maintenance of

attachment levels

Preparing tissues for surgical

procedures

INSTRUMENTATION

Hand instruments

• HOE

Blade, bowed -2 point contact instrument

Single blade 99-100, bevelled at 45o

Macalls type and Holst type

FILES

Series of cutting edge lined up on a single base

Series of hoes mounted on the base

Mode of use- held parallel to calculus and crushed,

Use of curette

• CHISEL

Only instrument used with the push motion

No more used for root planing

• CURETTES

Instrument of choice for root planing

Curved blade and rounded toe better adapted to the

root surface

2 TYPES –AREA SPECIFIC AND UNIVERSAL

• Universal curettes have limited adaptability:

Deep pocketsRoot convexities, and Developmental depressions

Gracey curettes are the new modifications

which are area specific and specially designed for

subgingival scaling and root planing in periodontal patients.

• Gracey curettes are a set of area-specific instruments .

• Designed by Dr. Clayton H. Gracey of Michigan in the mid-1930s

Four design features make the Gracey curettes unique: (1) They are area specific, (2) Only one cutting edge on each blade is used, (3) The blade is curved in two planes, and(4) The blade is “offset

Extended-Shank Gracey Curettes

• 3 mm longer in the terminal shank

• Deep pockets on maxillary

and mandibular posterior teeth,

Mini-Bladed Gracey Curettes

Mini-bladed Gracey curettes, such as the Mini Five

curettes and the Gracey Curvettes,

Terminal shank that is 3 mm longer than the standard

Gracey curettes

Blade that is 50% shorter.

Micro Mini Five curette blades are 20% smaller than Mini

Five curette blades

Standard Gracey curet vs a “Mini- Gracey

curet”.

GRACEY CURETTEMINI GRACEY CURETTE

• Micro Mini Five Gracey curettes (Hu-Friedy)

• Blades that are 20% thinner and smaller than the Mini Five curettes

• These are the smallest of all curettes,

• Provide exceptional access and

adaptation

• Deep, or narrow pockets; narrow

furcations; Developmental depressions;

line angles; and deep pockets on facial,

lingual, or palatal surfaces.

Langer and Mini-Langer Curettes

• Set of three curettes• Combining the shank design of the standard Gracey

#5-6, 11-12, and 13-14 curettes with a universal blade honed at 90

Marriage of the Gracey and universal curette

QUENTIN FURCATION CURETTE

• Shallow half moon radius that fits in to the roof or floor of the furcation

• Shanks are slightly curved• Available in two width, BL1 & MD1 – small and fine

0.9 mm width• BL2 & MD2- larger 1.3 mm

Diamond coated files• Coated with fine grit diamond . Do not have cutting

edge• Sharply abrasive – produce smooth, even clean

surface• Particularly used along with the endoscope• Disadv : can cause over instrumentation

• Diamond-coated ultrasonic instruments will

effectively plane roots, and that caution should be

used during periodontal root planing procedures.

Additionally, the diamond-coated instruments will

produce a rougher surface than the plain inserts or

the hand curettes.

( Vastardis 2005)

ULTRASONIC AND SONIC

INSTRUMENTS• Magnetostricitve & Piezoelectric• Air or sonic• Operated by the air line usually connected to air

turbine

COBB et al 2002• “When one considers the demands of clinical skill,

time and stamina, the instrument of choice for

universal application would appear to be either a

sonic or ultrasonic scaler.”

PERIOSCOPY SYSTEM

• The Perioscopy system consists of a 0.99-mm-diameter, reusable fiberoptic endoscope over which is fitted a disposable, sterile sheath.

Allows clear visualization deeply into subgingival

pockets and furcations

Permits operators to detect the presence and location

of subgingival deposits and guides them in the

thorough removal of these deposits.

Magnification ranges from 24X to 48X, enabling

visualization of even minute deposits of plaque and

calculus

PERIO TOR• Specially designed to optimize cleaning and planing

of the rough root cementum and • Prevent further removal of root cementum once the

surface is clean and smooth.

PERIOTOR

CURETTE ULTRASONIC/HANS SCALER

Vector™ system • Specially devised to reduce the amount of tooth

surface loss and treat the periodontal tissues less aggressively.

• Uniqueness of this system lies in the oscillations produced by the ultrasonic tip.

• Ultrasonic tip of this system vibrates

parallel to the tooth surface, which leads to

less removal of the tooth structure.

• Reduction in pain perception of the patient.

This may be attributed to vertical vibrations

of the ultrasonic tip.

AUTHOR STUDIES RESULTS

SCULEAN et al 2004 (Vector-ultrasonic system) or scaling and root planing (SRP) using hand instruments.

Non-surgical periodontal therapy with the tested ultrasonic device may lead to clinical improvements comparable to those obtained with conventional hand instruments.

DAHIYA et al 2011,2012

Gracey curette, ultrasonic tip and rotary bur, compared for root debridement

Favored the use of rotary instruments for root planing to achieve a smooth, clean root surface; however, the use of rotary instrument was more time consuming,

MARDA et al ,2012 Compare the remaining calculus, loss of tooth substance, and roughness of root surface after root planing with Gracey curette, ultrasonic instrument (Slimline® insert FSI-SLI-10S), and DesmoClean® rotary bur.

Slimline™ insert was shown to be better than the other methods as assessed by the indices scores and the instrumentation time.

Ana Chapper,2005 Compared the clinical effects of hand or ultrasonic scaling and root planing on the treatment of chronic periodontitis. ( BOP, PD,CAL)

Methods of subgingival instrumentation were equally efficacious in the improvement of the studied clinical parameters.

LASERS• ABLATIVE LASER THERAPY

Removes plaque and calculus with low mechanical stress

No smear layer

Can be reached to all the areas

Photoablative and Photodynamic diode laser in adjunct to

scaling -root planing (SRP) Diode laser treatment

(photoablation followed by multiple photodynamic cycles)

adjunctive to conventional SRP improves healing in

chronic periodontitis patients.

AUTHOR STUDIES RESULTS

Liu CM,1999 Nd:YAG laser treatment versus scaling/root planing (SRP) treatment on crevicular IL-1beta levels

SRP was found to have a superior IL- 1beta response,

Matthias Kreisler,2005

Clinical efficacy of semiconductorlaser periodontal pocket irradiation as an adjunct toconventional scaling and root planing.

Lasers can be recommended as anadjunct to conventional scaling and root planing.

Schwarz F,2001 Effectiveness of an Er:YAG laser to that of scaling and root planing for non-surgical periodontal treatment.

Er:YAG laser may represent a suitable alternative for non-surgical periodontal treatment

AIR POLISHING• The air-abrasive technology uses an abrasive powder

introduced into a stream of compressed air to clean or polish a surface by removing deposits attached to it or smoothing its texture.

PERIOPLANER/PERIOPOLISHER

• The system involves two motor driven handpieces.

One handpiece works with curettes and hoes

(Perioplaner) and the other works with diamond-

layered instruments (Periopolisher)

• Study has shown that the use of the Perioplaner and

Periopolisher results in about the same loss of root

substance as the use of hand instruments.

• Schweiz MZ, 1991

ROOT PLANING PROCEDURE

SUBGINGIVAL CALCULUS TENACIOUS

VISION OBSCUED BY BLEEDING

MUST RELY ON TACTILE SENSITIVITY

SRP COMPLEX THANSUBGINGIVAL SCALING

INSTRUMENT SELECTION

BEGIN WITH SMALL FILES/ HOES

LOWER POWER SET ULTRASONIC/SONIC SCALER OR RIGID CURET

FINISH WITH FINISHING CURET

STRATEGIES FOR INSTRUMENTATION

• SELECTION OF CURET

FINE SET: NON RETRACTABLE TISSUE

HEAVY SET: RETRACTABLE TISSUE

MEDIUM SET: RETRACTABLE TISSUE

• FINGER REST/GRASP

Grasp- modified pen and stable finger rest

Identify the cutting edge of curette

• ACTIVATION OF INSTRUMENT

Adaptation- lower shank parallel

Angulation- 45- 90 degree established

• STROKES

Stroke length

Stroke direction

Stroke activation

Terminal shank parallel to tooth long

axis.

• STROKE DIRECTION

Vertical and oblique strokes are most effective

strokes for root planing and exploring.

VERTICAL OBLIQUE HORIZONTAL

• STROKE LENGTHRoot planing strokes extend from the base of the pocket to the cemento enamel junction.

• STROKE ACTIVATIONWrist forearm motion is the fundamental means of activation.

CHANNELS OF INSTRUMENTATION

• FORCE MAXIMIZED BY SCALING IN CHANNELS AND

BY CONCENTRATING PRESSURE ONTO LOWER ONE

THIRD OF THE BLADE.

• Overlapping , short powerful stroke- Large calculus

removal( Carranza,10th ed)

• Root planing stroke- Long lighter overlapping with

less lateral pressure( Carranza,10th ed)

TERMINAL FEW MILLIMETERS OF THE BLADE ENGAGES THE LATERAL EDGE OF THE DEPOSIT

WITHOUT WITHDRAWING THE INSTRUMENT, LOWER THIRD OF THE BLADE ADVANCED LATERALLY AND REPOSITIONED TO ENGAGE THE NEXT PORTION

CHANNELS ON TOOTH

SURFACE

• HEAVY LATERAL PRESSURE WITH SHORT

CHOPPY STROKES AFTER CALCULUS

REMOVAL- ROOT SURFACE WITH NICKS

AND GOUGES

• HEAVY LATERAL PRESSURE WITH LONG

STROKES- SMOOTH BUT DITCHED OR

GOUGED ROOT SURFACE

NUMBER OF STROKES

• Root modification using periodontal curette- 10 to 70 strokes

• 20 strokes are sufficient for removing cementum • Aggressive root planing involves -10 or 20 strokes

more

• Study used a piezo-electric receiver

mounted into the upper shank of a curet in

Gracey 1/2 design.

• Results - 40 strokes at low force removed

148.7 μ and at high forces 343.3 μ .

With an increasing number of strokes the

amount of substance removed per stroke

became less. (Zappa et al,1991)

• Oda (1992)Series of in vitro studies

2 scaling strokes with a sharp manual scaler – enough to remove endotoxin

• Moore (1986)Gentle washing in water for 1 min or brushing with slowly rotating brush is enough to remove endotoxin

Ultrasonic scalers with its cavitational effect considered effective for removal of Endotoxin

Manual scalers

• Horning(1987) -57.8μ/40 strokes• Coldiron et al(1990) - 60μ/20 strokes

• Ishizuker and co workers(1980)3.9μ with 750g lateral pressure with 50 strokesFine curettes- 9.1μ with clinically applied force/working stroke

CEMENTUM REMOVAL

• U.S scaler-1 to 7.2 μ

• Sonic-4.3 to 7.8 μ

• Diamond file- 7.9 to 15.5μ

• Fine curette- 5 –22μ/stroke

ULTRASONIC SCALERS REMOVE LESS CEMENTUM BUT

LEAVE A ROUGHER SURFACE.( KOCHER ET AL 2001)

Pain and discomfort during SRP

• Tissue trauma due to inadvertent curettage

Philstrom( 1999)

• Pain of significant duration, peak in intensity

between 2 and 8 hrs post SRP- almost 25 % self

medicated

• Small portions of patients noted root sensitivity ,

reduction occurred over 4 weeks . Tammaro et al

( 2006)

• Steenburgh et al ( 2004)

1/3 of patients taking analgesia

1/2 of the total patients revealed gingival soreness

2/3 complained problem while eating.

• Ettin et al ( 2006)

Pre-emptive analgesics (ibuprofen arginine)may have

some beneficial effect.

LA DURING ROOT PLANING

• Usually do not require.

• Patients vary in their ability to tolerate pain.

• LIDOCAINE 25mg/g can be an useful alternative to injections anesthesia in pain sensitive patients. (Magnusson 2003)

• Perry DA et al,2008

Transmucosal lidocaine patches provided sufficient

anaesthesia for therapeutic quadrant scaling and root

planing procedures.Lidocaine patch (46.1mg/2m)

compared to placebo patch VA scale for pain

Results greater pain relief with treatment patches after

15 min and at the end of treatment.

• Scotelberg JL(2007)

Compared 20% topical benzocaine gel to 2%

injected lidocaine

21 patients – divided 2 groups

Results

• The injected anaesthesia had less pain

• 11 participants preferred topical – fear of injection

• Lidocaine plus prilocaine in a thermosetting agent

also has been shown to be effective in controlling

intra-operative pain during scaling and root

planing (Jeffcoat et al. 2001, Donaldson et al.

2003, Magnusson et al. 2003).

• Topical anaesthetics may be preferred over

injected anaesthetics .

EVALUATION OF SRP

• ROOT SMOOTHNESS

• HEALING OF SOFT TISSUE FOLLOWING SRP

ROOT SMOOTHNESS• RELATIVE SMOOTHNESS OF THE ROOT SURFACE IS THE

BEST IMMEDIATE CLINICAL INDICATION OF ADEQUATE

INSTRUMENTATION.

• Hu friedy 3-A

• No 17 or orban

• Pig tail (no 3ML)

• generally thin and good tactile sensitivity, working end

is curved, permits easy adaptation, enough to extend

to deep pocket

ODU- 11-12,

• Adapted from the gracey curette 11-12 by faculty of

old Dominion university

• Combines pigtail design with a long shank – deep

pockets

• Smoothness- does not guarantee the complete

removal of calculus

HEALING SEQUENCE

Histologic studies –humans and primatesLong junctional epithelium – repairNew dentogingival junction firms within 2 weeks

• Sequence

• 1-3 days • Hyperaemia, change in color& edema

PERIODONTAL DEBRIDEMENT

1 -2 weeks

• Resolution of edema

• Shrinkage of the gingival margin

• Color is about to normal

• Little or no bleeding/suppuration

2-3 weeks

• Color is normal

• Consistency firm ,no bleeding

• Reduced tooth mobility

• Histologically- connective tissue maturation-21 to

28 days, establishment of GM- 3-6 months

HEALING- CLINICAL END POINTS

• CLINICAL EVALUATION OF SOFT TISSUE RESPONSE

INCLUDING PROBING NOT CONDUCTED PRIOR TO

2 WEEKS FOLLOWING SRP.ASSESSMENT 4-6

WEEKS AFTER THERAPY.REPAIR CAN CONTINUE

FOR ADDITIONAL 9 MONTHS.

• RE EPITHELIAZATION OF THE WOUND CREATED

DURING INSTRUMENTATION TAKES FROM 1 TO 2

WEEKS.

MOST COMMON END POINTS EVALUATED:

• PROBING POCKET DEPTH

• CLINICAL ATTACHMENT LEVEL

• REDUCTION IN BLEEDING SITES AND EDEMA IS A

SURROGATE INDIACTOR FOR THE RESOLUTION OF

GINGIVAL INFLAMMATION.

Hajol(2004)

• True end point- relief of pain, esthetics, and chewing

comfort

• Surrogate end point- No B.O.P. , pocket closure,

attachment gain, and tooth loss

Probing depth and CAL

A)Clinical attachment levels:

• Loss of attachment low initial PD

• Gain Deeper PD

Proye et al (1982):

• Recession after 1 wk (0.84mm)

• Gain after 3 wks (0.52mm)

• Probing depths reduced to1.36mm

COBB 1996

• 1-3 MM PD RED OF 0.03MM CAL 0.34MM

• 4-6MM PD RED OF 1.3MM WITH GAIN OF 0.55MM

• >7MM PD RED 2.6MM WITH GAIN OF 1.19MM

• SIMILAR RESULTS REPORTED BY VENDER WEJDEN ET

AL, 2002

• HALF OF THE DECREAE IN PROBING DEPTH

ATTRIBUTED TO ATTACHMENT GAIN AND THE

REMAINING DECREASE IS THE RESULT OF

CHANGE IN GINGIVAL MARGIN POSITION.

Critical probing depth ( LINDHE et

al,1982)

BELOW- LOSS OF ATTACHMENT LEVELABOVE- GAIN IN ATTACHMENT LEVEL

2.92mm- Root planing4.2mm- Flap debridement surgery

Creeping attachment

• Goldman proposed the term mainly following FGG

• Coronal shift in the position of the gingival margin

Aimetti et al (2005)

• Coronal shift of 0.40 to 0.89 mm ( several

other studies reported same)

• This achieved complete root coverage

45.83% in 12 month

Reasons for root coverage in root

planing

• Initially thick gingiva will have better root coverage

• Reduction in the convexity of the root and m-d

distance between the periodontal space

• Plaque free and flat root surface helps in easy

regrowth of the marginal tissue

MICROBIOLOGICAL CHANGES

• DECREASE IN GRAM NEGATIVE MICROBES

ACCOMPANIED BY AN INCREASE IN GRAM POSITIVE

COCCI AND RODS.

• DOMINANCE BY BENEFICIAL SPECIES RESULTS IN:

DECREASE IN GINGIVAL INFLAMMATION

DECREASE IN PROBING DEPTH

DECREASE IN BLEEDING ON PROBING

COBB ET AL,2002

CUGNI ET AL 2000DNA PROBE COUNT STUDY

• DECREASE IN T.FORSYTHUS, P.GINGIVALIS,

T.DENTICOLA AND INCREASE IN ACTINOMYCES

SPS, STEPTOCOCCI, F.NUCLEATUM,VEILONELLA.

• SIMILAR RESULTS REPORTED BY HAFFAJEE1997,

MOMBELLI 2000.

Teles et al ( 2006)• Bacterial count decreased from 91+ 11x 105 to

23+6 x 105

Darby et al ( 2005) • Decreased T. forsythia and T.denticola several

week following SRP

Bickler et al ( 2004)• if home care not followed, re-establishment of the

pathogenic flora and rebound in the clinical parameters occur.

Haffejee( 2006) • Increase in the Streptococci and Actinomyces

species 3 months past SRP • Also noted re-emergence in the red complex and

orange complex 3 to 12 months results in the increase loss of attachment

Re-emergence can occur from following locations;

• Residual subgingival plaque deposit

• Radicular dentin or cementum

• Pocket epithelium or connective tissue

• Supragingival plaque deposits

• Subgingval deposits of adjacent teeth and from

intraoral soft tissue sites

EFFECT ON DENTIN AND PULP

• Minor structural alterations of both root surface and

restoration margins.(Lee SY,1995,Eberhard ,2003)

• Dentinal tubules are exposed, leading to direct

avenues to the pulp for bacteria and bacterial

elements present in the oral environment

(Bergenholtz

• & Lindhe 1978).

• Root sensitivity occurs in approximately half of the

patients following subgingival scaling and root

planing. The intensity of root sensitivity increases for

a few weeks after therapy, after which it decreases.(

Von Troil,2002- systematic review)

• Unnecessary excessive root substance loss (hour-

glass shaped roots),

• Root fracture or Pulpitis

SRP IN COMBINATION WITH PHOTODYNAMIC

THERAPY• SRP in combination with PDT seems to be

effective and Is therefore suitable as an adjuvant therapy to the mechanical conditioning of the periodontal pockets in patients with chronic periodontal diseases. (Berakdar 2012)

SRP WITH AND WITHOUT PERIODONTAL

FLAP

• Mean accessible depth by curettes – 4.6 mm

Supported by:

• RABBANI et al,1981 concluding that curettes can

not reach to a depth of more than 4 mm.

• CLIFFORD,1999: Available depth for curettes has

been re-ported to be 3.45 mm .The maximum

accessible depth was found to be 6 mm in distal

and buccal surfaces

• 1.Periodontal flaps for access provide a means for

greater reduction of residual calculus.

• 2. Periodontal flaps for access provide a means to

achieve more tooth surfaces free of calculus in

pockets >3 mm.

• 3. The % of residual calculus is related to probing

depth, despite the treatment approach.

• 4. Anterior and posterior teeth respond similarly.

CAFFESSE 1986

WYLAM ET AL 1993• Sixty multi-rooted teeth were assigned to one of

three groups:

Untreated controls,

Closed scaling/root planing, and

Open flap scaling/root planing.

• No significant difference in the percent stained

residual plaque and calculus in shallow areas of the

pocket

• Furcation regions demonstrated heavy residual

stainable deposits for both treatment methods, with

no significant differences between techniques.

QUIRYNEN ET AL Full mouth disinfection vs PDS vs full mouth root planing

Greater gain in clinical attachment and less bleeding upon probing with FRP and FDISReduced motile forms by 20%

BOLLEN ET AL 1998 FDIS VD PDS Better gain in clinical attachment levels with fdisFdis reduced motile rods and spirochetes reduced by 10% whereas pdis reduced by 20%

AUTHOR STUDIES RESULTS

Eberhard et al (Cochrane SR 2008)

Full-mouth disinfection for the treatment of adult chronic periodontitis

The treatment effects of FMD compared with conventional SRP are modest and the implications for periodontal care are not profound.”

Sanz & Teughels 6th (EWP 2008)

FMD and chronic periodontitis

Need to investigate the impact of different mechanical debridement protocols on patient centred outcomes and cost-effectiveness using appropriate methodology”

NON SURGICAL THERAPY VS SURGICAL THERAPY

Meta analysis

• Knowles( 1979)• Split mouth design• RP, RP+curettage, MWF, APF• 3 month maintenance, 6 yr follow up• Surgical technique better pocket depth reduction• All tech. yielded gain in attachment in deeper

pocket

• Kaldahl (1988, 1996)

• Split mouth

• Root Planing Vs Modified widman flap

• 6 yr follow up

• Result favored non surgical treatment

Conclusion:

• Shallow pocket- no significant difference of ---0.02

mm after 6 years

• Medium pockets- no significant difference of –

0.22 mm after 6 years

• Deep pockets – the difference is 1.03 mm after 6

months to 0.22 mm after 6 years

SRP VERSUS CURETTAGE

• CurettageClosed definitive surgical procedure aimed at pocket elimination, reattachment or new attachment.Removes pocket epithelium intentionally

WORLD WORKSHOP IN CLINICAL PERIODONTICS,1989Gingival curettage as a separate procedure has no justifiable application during active therapy during chronic preriodontitis.

Without clean, hard roots results of curettage are limited.(Cohen,2007)

Limitations

Anatomy of rootsDepth of pocketsPosition of teethInadequate instruments for diagnosisInadequate instruments for treatmentArea of mouth being treatedSize of mouthElasticity of cheeksRange of openingDexterity of operator

• Total substance removal by instrumentation

includes calculus and root substance removal.

• Calculus removal seems to require less than 20

working strokes to be complete, relative to a

standard area of 1-mm width on the

circumference of the root. The following strokes

serve only to remove root substance, which

seems to be unnecessary.

• Endotoxin removal is nearly completed after the

same number of working strokes, reaching levels

similar to periodontally healthy teeth. Clearly

these levels are low enough to enable good

clinical healing.

• Aggressive scaling and root planing might be

counterproductive for the future health of the

periodontally diseased tooth.

SUMMARIZE

Deep Endotoxin penetration

Endotoxin as a superficial layer

ROOT DEBRIDEMENTROOT CONDITIONING

• Clinicians should choose the modality of

debridement according to the needs and the

preferences of the patient, their personal skills

and experience, the logistic setting of the

practice and the cost-effectiveness of the therapy

rendered”

Thank you