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Learningobjectives
Understandtherationalebehindroot

debridement Recognisethevariousmethodsfornon surgicaltoothdebridement Recognisetheclinicalandhistological changesfollowingrootdebridement

NONSURGICALTHERAPYII

Whydowedebrideteeth?
Largebodyofevidenceshowingthat

bacterialplaqueastheprimaryaetiological factorforperiodontaldisease(involvedin initiationandprogression)

Biofilmsarenaturallyresistanttohost

Generalprinciplesof controllingperiodontal infection

Differingsupra andsubgingival

environments
Mostpatientsarenotabletocontrolthesupra

defencesandantimicrobialtherapy
plaque the main aetiological factor

gingivalenvironmentsufficientlytopreventthe developmentandformationofpotentially pathogenicsubgingival biofilm Controlofthesubgingival biofilmonaregular basisiscriticalinthemanagementofperiodontal disease

Scaling&RootDebridement Definitions
Scaling removalofplaqueandcalculusfromtheroot

SRD Objectives
toremovesupragingival accretionsleavinga

surface

RootDebridement removalandplaqueandsubgingival

calculusleavingarelativelysmoothrootsurface
will facilitate day to day cleaning

Rootplaning removalofsofteneddiseasecementum

androotsurfacemadetofeelhardandsmooth fromwithinthepocket

Subgingival curettage scrapingandremovalofsofttissue

smoothandpolishedsurfacewhichwill facilitaterapidandsimpledaytodayplaque removalbythepatient toremovesubgingival rootsurfaceirritants e.g.plaque,calculus,toallowhealinginthe softtissuepocketwalland,ifpossible, achievenewepithelialattachment

remove overhangs

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SRD Procedure
Subgingival debridement segmentalapproach

SRD Rationale
Supragingival scalingaloneisnoteffectivein

(quartersorsextants,onepervisit)withor withoutlocalanaesthetic
InprovidingSRD,youshouldberemoving

themanagementofchronicperiodontitis

little benefits on gingiva/pd tissue. increase risk of flareups and abscess

supragingival plaqueandcalculusaswell Generallyaimtofinishprocedurewithin90minutes

LAwouldhavewornoffbythen Ptwouldbetired

SRDaimstoremovetheprimaryaetiological

quadrant or sextant of teeth

factorforperiodontitis(biofilm)andwellas secondaryfactors

Wholemouthpolishatthecompletionofall

quadrants

(prophy)

deeper pocketing - LA > 5mm pocket depth. EMS cold water will irritate the nerve

Fullmouthdebridement
Quirynen (late90s)
Fullmouthdebridement(fullmouthwithin24

SRD Instrumentation
Handscalers andcurettes Ultrasonicscalers Rotaryinstruments Polishingcupsandpastes

hours)inconjunctionwithfullmouthdisinfection toeliminateperiodontalpathogensfromall pocketsandotheroralsites

used in conjunction with CHX

Resultsnotreplicatedbyothergroups Notmore beneficialthanquadrantscaling

bacteraemia may enter blood streaming causing

FMDgenerallycausesaslightfever
can be beneficial

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not fatiguing hand.

Ultrasonicscalers
recommendation

Ultrasonicscalers
Magnetostrictive scalers
linear movement

Magnetostrictive (Cavitron)
Periodontalworkonly

Piezoelectric(EMS)
Perioandendo uses

metal plates expand and contract under high current elliptical - able ot move in all directions Tip movement isrelated tothecrosssectionofthetip roundtipswillgiveellipticaltipmovement flattened tipswillresultinlineartipmovement

Someolderpacemakersmaybeaffected bymagnetostrctive scalers

Keephandpieceandcablesatleast1523cm

awayfrompacemaker
Contactpatientsphysicianifunsure

Cautionwithultrasonics
Cavitrons weredesignedinitiallytocreate

Rotaryinstruments
Usedmorewithperiodontalsurgery
Roundburs Flameshapedburs

cavities
Thereforeyouneedtobecarefulwiththeuse

ofultrasonicinstrumentswherecervical lesionsarepresent
must restore lesion. aerosols created with ultrasonics. impt to wear mask.

Reciprocatinghandpieces
Goodforoverhangremoval
bur tips move in linear fashion

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Effectivenessofcalculus removal
Pocketdepth
Modified(slimline)ultrasonicinsertsmaybemore

effectiveincleaningdeeperpockets(Dragoo etal. 1992)

good at removing calculus up to 3mm

Furcationareas
Limitedaccess Theseareasarenotcleanedaswellassmooth

surfacesanddonotrespondaswelltotreatment

RemovalofPlaqueRetention Factors
Illfittingscrownsandrestorationmarginsresult
tissues returned to normal gingival health

intheextensivelocalisedplaqueaccumulation
Shouldberemovedtofacilitateremovalof

plaqueandcalculusandtoestablishananatomy whichfacilitatesplaquecontrolbythepatient Removedusingburs,reciprocatingflatdiamond stones,finishingstripsorbyreplacingthe restoration/crown

overhanging margins

overhand on tooth surface. restore to original contour

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

Reassessment
Oncecauserelatedtherapyiscompleted
majority of healing has occurred reassesspatient3monthslater Evaluatedegreeofcontrolofthediseaseby patient,gingivalcondition,probingdepths, attachmentlevel,recession,furcationand mobility

DefinitiveTreatment Planning
Patientswillgenerallyfallintothree

categories:
goodOHbutdeeppersistentpocketsandBOP goodOH,resolutionofgingivitis,noBOPand

markedreductionofPD
poorOHandreinfection

Furthertreatmentdependsonwhich
DoNOTreviewptandredoperiodontalcharting

ifyouhavenotcompletedcauserelatedtherapy

categorythepatientisinandhowsevereand widespreadtheremainingdiseaseis(a lecturewillfollowin3rdYr)

Definitive(Corrective) Treatment
RootCanalTherapy OrthodonticTherapy OcclusalTherapy Temporisation PeriodontalSurgery FixedandRemovableProsthodontics

Reviewdecisiontree
Redocauserelatedtherapy
calculus,poorOH

Review

Periodontalsurgery
access,alteranatomy,regeneration

Maintenance
inflammationresolved,goodOH

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Whatdoesgoodhealinglook likeclinically

Nonsurgicaldebridement followedbysurgery

pockets greater than 4 mm highlighted yellow greater than 5 highlighted ipnk

healing has occurred

after surgery pocket depth has decreased from 7mm to 4mm

Maintenancecare

Maintenance Aims
Preservationofthehealthoftheperiodontium Continuedcontrolofbacterialplaque Criticalreevaluationoftreatment Monitorhealthofotheroraltissues Encouragementoforalhygiene Continuedpatienteducationandmotivation Considerationoffuturemaintenanceregime Retreatmentifnecessary
make sure causative factors (biofilm) are removed

Remember
Thecleanwhichisdoneduringthe

Maintenance procedure
Recallappointmentsevery3monthstobegin

maintenancevisitisnotthescaleandclean youdoforyournonperio patient

Youraimistoremoveallthebiofilm(supra

with(forpatientswithmoderatetosevere disease)
Basedonindividual patientneedsandmaybe

extendedto6monthsoryearly

assess OH on as needed basis

AteachvisitOHshouldbeevaluatedwithSRP

AND subgingival plaque)fromthetooth surfaceandsoyouneedtotailorthecleanto thepatient

andpolishingasnecessary(lightlydebridedeep andBOPsites) Onceayearassess(chart)caries,gingivitis,pocket depths,furcations,mobilityandchangesinbone level

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Definitions
repair:healingbytissuenotfullyrestoringarchitectureor

functionofpart(i.e.granulationtissue)
whereviableperiodontaltissueispresent
Longjunctional epithelium

reattachment:reunionofjunctional epitheliumwithrootsurfaces

scar type repair - fibrous tissue

regeneration:reconstitutionofalostorinjuredpartviathe

growthanddifferentiationofnewcellsandintercellular substances.Continuousphysiologicalprocesswearand tearrepair

newattachment:reunionofCTwithrootsurfacethathasbeen

deprivedofPDL requiresattachmentofPDLcellsandfibres, newcementum formation,theformationoffunctionally orientatedfibre network,andcoronalregrowth ofalveolarbone

most situations won't get regeneration

Periodontalpocketlesion
Chronicinflammatorylesion,constantly

Effectofplaqueremoval
Radicalalterationinpredominantflora Gramve organisms,Gram+ve organisms Reductioninplaquemassrendersresidual

undergoingdestructionandrepair Persistentlocalirritants,fluidandcellexudate causedegenerationofnewtissueelements formedbyrepair Destructive/constructivechangesdetermine tissuecolour,contourandtexture Softtissuewallresultsfromdestructiveand constructivetissue changes..oedematous/fibroticpocket

organismsmoresusceptibletokillingbythe hostdefence mechanisms Ifnewflorastableandsupragingivalplaque controlled,Gramve organismslesslikelyto recolonise andhealingwilltakeplace

Effectofplaqueremoval
Eventhoughtheremovalofplaqueand

Histologicalchanges followingtherapy
2448hours acuteinflammatoryreaction 2 7days vasodilation,GCF&inflammatorycell

subgingival calculusisoftenincomplete,it maybesufficienttoalterthesubgingival environment

andchangecompositionandproportionof

microbials
therebyhaltingperiodontaldisease

numbers.Healingulcers.Fibroblastmigration, proliferation,collagenandgroundsubstance productionwithconcomittant decreaseingingival swelling andredness

1 8weeks maturationofnewgingivalCT,

progression (Haffajee et.al 1997)

remodelling ofbone(notcoronally),reattachmentof pocketepithelium torootsurface(LJE),formationof basementmembraneandhemidesmosomes, long junctional epithelium

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gingival recession part of normal healing

Clinicalchanges
o Reductioninredness o Reductioninswelling o BOPreduced o Gingiva becomesincreasinglypinkandfirmasCT matures o ReducedPDassociatedwithgingival shrinkageas inflammation subsides o Tighteningofgingival cuffduetoorientationofnew healthycollagenfibers o Littlebonyhealingtakesplaceinthealveolarbone

Clinicalchanges
Inmostsituationsfollowingtreatmentthe

periodontium willhealwithrepair
Decreasedswellingofthegingiva coronally will

resultingingivalrecession
Deeppocketswillhealwithrepairapically Healthytissuetonewillpreventthepenetrationof

theperiodontalprobeapically
Allthesethreemechanismswillresultinpocket

depthreductionandattachmentlevelgain

gingival recession and apical healing

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Remember
Indeepangulardefectssomedegreeof
Healingonlyoccursafteradequatesubgingival debridementandeffectiveplaquecontrolduringthe healingphase Incompletedebridement willallowpersistence of inflammation andinduecourserecolonisationfrom bacterialresidues Likewise, failuretopreventsupragingival plaque accumulationwillleadtothedowngrowthofbacterial plaque,whichwillinterruptthehealingprocess

regenerationmayoccur

Remember
Healingoftheepithelium cantakeupto8weeks Mosthealingintheperiodontiumwilloccurwithinthe first3months(mostchangesinpocketdepthwillbeseen duringthistime) Fordeepsiteshowever(7+mm),healing(andPD reduction)willoccurupto9monthsaftertreatment
(Badersten etal.1984)

CLINICALCASES

may take up to a year

Gingivitis

1stVisitExam&Diagnosis 2ndVisitPlaquechartsOHIS+Cl 3rdVisit(2weekslater)Review,OHI,S+Cl asnecessary Recall612months

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Periodontitis
Exam,DiagnosisandTx plan
Extractionofhopelessteeth/emergencycaries control 2. OHI/plaque indexandSRDQ1withLA 3. SRDQ2withLA(OHI) 4. SRDQ3withLA 5. SRDQ4andfullmouthprophylaxis(OHI) 6. (Restorations ifrequired) 7. Review appointment in3months
1.

1. Assess periodontalconditiononspecificteeth 2. Assess suitabilityfordefinitiverestorations 3. Assess suitabilityforprostheses(dentures)

Myprotocolforeachscaling visit:
SetupunitwitheverythingthatIwillneed
Dontopenkitsuntilyouknowpthasturnedup

pi tool for how well they are cleaning

CheckhowPatientfeltinpreviousweek
Especiallyintermsofbleedingandsensitivity

CheckMedHx (innotes)andLA AssessOHasgoingnumb Assesspreviouslyscaledareas SRDUltrasonicandHandInstruments ReinforceOHIasrequired

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EFFECTIVENESSOFNON SURGICALTHERAPY

EvidencebehindSRD
Thereisalargebodyofevidencethat SRPinconjunctionwithimprovedOH

subgingival SRDinpatientswithchronic periodontitis,(inconjunctionwith supragingival plaquecontrol)isaneffective treatmentinreductionprobingpocketdepth andimprovingtheclinicalattachmentlevel (VanderWeijden et.al 2002)

producesmuchlargerimprovementsin gingivalhealth(reducedPDandgingival inflammation)thanOHalone

(Tagge etal.1975)

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Inpatientsmaintainedonaproperly

SRP/SRDprocedureshaveonlybeshownto

controlledOHregimen,SRPalonewas equallyaseffectiveasSRPincombination withperiodontalsurgeryinestablishing healthygingivaandpreventingfuture attachmentloss

(Lindhe etal.1982)

beeffectiveincontrollingandpreventing periodontaldiseasewhendonein conjunctionwith

Effectivesupragingival plaquecontrol Aperiodontalmaintenanceregime(generally

between36monthly)

References

Lindhe Chapter15 Carranza8thEdChapters41&42 Carranza9thEdChapters47 49 Dragoo.Aclinicalevaluationofhandandultrasonicinstrumentson subgingival debridement.PartI.Withunmodifiedandmodified ultrasonicinserts.Int J.PerioRestDent1992;12:311323. Lindhe etal.Healingfollowingsurgical/nonsurgicaltreatmentof periodontaldisease.Aclinicalstudy.JClin Periodontol.1982 NymanS,Wesfelt E,Sarhed G,Karring,T.Roleofdiseasedroot cementum inhealingfollowingtreatmentofperiodontaldisease.A clinicalstudy.JClin Periodontol 1988;15:464468. Tagge etal.Theclinicalandhistologicalresponseofperiodontalpockets torootplanningandoralhygiene.JPeriodontol.1975 VanderWeijden GA,TimmermanMF.Asystematicreviewontheclinical efficacyofsubgingival debridementinthetreatmentofchronic periodontitis.JClin Periodontol 2002;29(Suppl 3):5571.

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