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Non-Surgical Periodontal Therapy. Comprehensive Periodontics for the Dental Hygienist, Chapters 9, 12. Learning Objectives. Understand the differences between periodontal debridement, scaling, root planing & de-plaquing Discuss the goals & rationale for non-surgical therapy

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non surgical periodontal therapy

Non-Surgical Periodontal Therapy

Comprehensive Periodontics for the Dental Hygienist, Chapters 9, 12

learning objectives
Learning Objectives
  • Understand the differences between periodontal debridement, scaling, root planing & de-plaquing
  • Discuss the goals & rationale for non-surgical therapy
  • Discuss the process of wound healing following successful intervention
  • Select appropriate instruments for periodontal debridement
Immediate Treatment Goals

educate client

instrument tooth surfaces

remove plaque & calculus

explore to evaluate root surfaces

are root surfaces smooth & plaque free

Long-termGoals of Therapy

compliance with home care/PMP

gingival health restored

periodontal health controlled

Non-Surgical Periodontal TherapyHealthy tissues = good plaque control + complete periodontal debridement + healing
goals of debridement
Success of treatment depends on:

Immune response to treatment

Disease severity

Appropriate use of chemotherapeutic agents

Complete treatment

Removal of supra/subgingival plaque

Removal of calculus (due to its plaque retentive nature)

Professional expertise

Use of appropriate instruments

Intraoral constraints

Goals of Debridement
non surgical periodontal therapy1
Non-Surgical Periodontal Therapy
  • Rationale
    • promote tissue healing
    • decrease probing depths
    • increase CAL
    • decrease bleeding
    • remove deposits
    • iatrogenic & anatomic factors considered (e.g. overhangs, malposed teeth)
non surgical periodontal therapy definitions
Non-Surgical Periodontal Therapy - Definitions
  • Scaling
    • removal of sub/supra deposits
    • instrumentation of tooth & root surfaces
  • Root Planing
    • treatment of root surfaces
    • removal of deposits, by-products
  • Deplaquing
    • removal of all plaque (supragingival & within sulcus or pockets)
    • re-evaluation & maintenance appointments
non surgical periodontal therapy definitions1
Non-Surgical Periodontal Therapy - Definitions
  • Periodontal Debridement
    • conserves cementum
    • plaque control instrumental to good healing response
    • removal of deposits, diseased or dead tissue from root surfaces, within pocket
    • includes pocket space, pocket wall
      • Bacterial products within non-adherent plaque most detrimental to soft tissue
non surgical periodontal therapy2
Non-Surgical Periodontal Therapy
  • Periodontal Debridement
    • Indications
      • gingival inflammation – where periodontal pockets exist
      • presence of bacterial pathogens
      • progressive attachment loss, bone loss
    • Contraindications
      • sites that do not have true pocketing
non surgical periodontal therapy3
Non-Surgical Periodontal Therapy
  • Periodontal Debridement
    • Outcomes
      • assess clinical parameters
        • probing depths
        • clinical attachment levels
        • alveolar bone height
        • visual signs of gingival inflammation
        • changes in subgingival pathogens
        • bleeding on probing
non surgical periodontal therapy4
Non-Surgical Periodontal Therapy
  • Healing occurs as repair as opposed to regeneration
    • Predictable outcomes include:
      • Healing of epithelium
      • Resolution of inflammation
      • Formation of long junctional epithelial attachment
      • Recession
      • Repopulation of pockets by less pathogenic forms of bacteria
non surgical periodontal therapy5
Non-Surgical Periodontal Therapy
  • Less predictable outcomes include:
    • Regeneration of new bone
    • New connective tissue attachment
    • New cementum on root surfaces
non surgical periodontal therapy6
Non-Surgical Periodontal Therapy
  • Gingivitis: Healing following intervention
    • Decrease of inflammatory cells
    • Reduced edema
    • New collagen formation
    • Pocket epithelium heals – reduced rete pegs, lateral attachment of junctional epithelium
    • Reduction of bleeding
    • Return of gingival colour
    • Tissue shrinkage – recession becomes obvious
    • Reduced probing depths
non surgical periodontal therapy7
Non-Surgical Periodontal Therapy
  • Periodontitis: Healing Response
    • Injury to or separation of junctional epithelium occurs following debridement
    • Healing takes approx. 1 week
      • Hemidesmosomes begin to reattach from apical end of JE
      • Intact after approx.7 days
    • Connective tissue healing takes considerably longer
      • Up to several months
      • New connective tissue fiber attachment not an expected outcome
      • Development of an elongated junctional epithelium – this may result in reduced probing depths
non surgical periodontal therapy8
Non-Surgical Periodontal Therapy
  • Periodontitis: Clinical Healing Response
    • Reduced pocket depths
    • Changes in attachment levels
    • Recession
    • Fewer bleeding sites, reduced redness
    • Improvement in tissue tone & colour
non surgical periodontal therapy9
Non-Surgical Periodontal Therapy
  • Periodontitis: Reduced Pocket Depths
    • Greater reduction of pocket depths occurs in deeper pockets
    • Pocket depths measuring 4-6 mm
      • Pocket reduction approximates 1 mm
      • Recession & minimal attachment gain ( 0.5 mm)
    • Pocket depths measuring > 7 mm
      • Pocket reduction approximates 1.5-3.0 mm
      • Combination of recession & attachment gain ( 1.0mm)
non surgical periodontal therapy10
Non-Surgical Periodontal Therapy
  • Gain in attachment level
    • May represent more accurate reading of pocket probing depth
    • Inflamed tissues easily penetrated when probed
    • Inflates true pocket readings
    • Probe less likely to penetrate when:
      • Junctional epithelium & CT has healed & fibers are intact
assessment following therapy
Assessment Following Therapy
  • Assess response of tissues
  • Assess plaque & calculus deposits
    • Residual calculus?
  • No improvement:
    • Evaluate health history
    • Plaque culture
  • Recommendations:
    • Antibiotics/antimicrobials
    • Repeat periodontal debridement
    • Periodontal surgery
repopulation of pockets
Repopulation of Pockets
  • Periodontal debridement reduces bacterial population in pockets
  • Shift from primarily Gram-negative flora to one that is Gram-positive
    • Fewer motile forms
  • Repopulation occurs in a specific order
  • May take as long as 6 months & may depend on
    • Completeness of initial therapy
    • Client’s compliance & ability to remove plaque
    • Presence of invasive bacteria
repopulation of pockets1
Repopulation of Pockets
  • Specific order of repopulation:
    • Streptococcus & Actinobacillus species
    • Viellonella
    • Bacteroides
    • Porphyromonas
    • Prevotella
    • Fusobacterium
    • Capnocytophaga sp&spirochetes
limitations of non surgical therapy
Limitations of Non-Surgical Therapy
  • Pocket depths
    • Residual calculus likely in deeper pockets
    • Average pocket depth for adequate removal approx. 3.73 mm
    • Clinical approach: curettes with longer shanks
limitations of non surgical therapy1
Limitations of Non-Surgical Therapy
  • Furcations
    • Access difficult – residual calculus likely
    • Opening to furcation often smaller than diameter of periodontal instrument
    • Clinical approach: use of slimline inserts
  • Root anatomy
    • Depressions on proximal surfaces
    • Clinical approach: knowledge of root anatomy
limitations of non surgical therapy2
Limitations of Non-Surgical Therapy
  • Clinical skill & time spent
    • Debridement technique & skill sensitive
    • Debridement of one periodontally involved molar (moderate involvement) takes approx. 10 minutes
    • Attention to technique, proper selection of instruments important to success