1. Non-Surgical Periodontal Therapy Comprehensive Periodontics for the Dental Hygienist, Chapters 9, 12

2. Learning Objectives 1.Understand the differences between periodontal debridement, scaling, root planing & de-plaquing 2.Discuss the goals & rationale for non-surgical therapy 3.Discuss the process of wound healing following successful intervention 4.Select appropriate instruments for periodontal debridement

3. Non-Surgical Periodontal Therapy Healthy tissues = good plaque control + complete periodontal debridement + healing zImmediate Treatment Goals yeducate client yinstrument tooth surfaces x remove plaque & calculus yexplore to evaluate root surfaces x are root surfaces smooth & plaque free z Long-term Goals of Therapy ycompliance with home care/PMP ygingival health restored yperiodontal health controlled

4. Goals of Debridement zSuccess of treatment depends on: yImmune response to treatment yDisease severity yAppropriate use of chemotherapeutic agents yComplete treatment xRemoval of supra/subgingival plaque xRemoval of calculus (due to its plaque retentive nature) xProfessional expertise xUse of appropriate instruments xIntraoral constraints

5. Non-Surgical Periodontal Therapy zRationale ypromote tissue healing ydecrease probing depths yincrease CAL ydecrease bleeding yremove deposits yiatrogenic & anatomic factors considered (e.g. overhangs, malposed teeth)

6. Non-Surgical Periodontal Therapy - Definitions zScaling yremoval of sub/supra deposits yinstrumentation of tooth & root surfaces zRoot Planing ytreatment of root surfaces yremoval of deposits, by-products zDeplaquing yremoval of all plaque (supragingival & within sulcus or pockets) yre-evaluation & maintenance appointments

7. Non-Surgical Periodontal Therapy - Definitions zPeriodontal Debridement yconserves cementum yplaque control instrumental to good healing response yremoval of deposits, diseased or dead tissue from root surfaces, within pocket yincludes pocket space, pocket wall xBacterial products within non-adherent plaque most detrimental to soft tissue

8. Non-Surgical Periodontal Therapy zPeriodontal Debridement yIndications xgingival inflammation – where periodontal pockets exist xpresence of bacterial pathogens xprogressive attachment loss, bone loss yContraindications xsites that do not have true pocketing

9. Non-Surgical Periodontal Therapy zPeriodontal Debridement yOutcomes xassess clinical parameters probing depths clinical attachment levels alveolar bone height visual signs of gingival inflammation changes in subgingival pathogens bleeding on probing

10. Non-Surgical Periodontal Therapy zHealing occurs as repair as opposed to regeneration yPredictable outcomes include: xHealing of epithelium xResolution of inflammation xFormation of long junctional epithelial attachment xRecession xRepopulation of pockets by less pathogenic forms of bacteria

11. Non-Surgical Periodontal Therapy zLess predictable outcomes include: yRegeneration of new bone yNew connective tissue attachment yNew cementum on root surfaces

12. Non-Surgical Periodontal Therapy zGingivitis: Healing following intervention yDecrease of inflammatory cells yReduced edema yNew collagen formation yPocket epithelium heals – reduced rete pegs, lateral attachment of junctional epithelium yReduction of bleeding yReturn of gingival colour yTissue shrinkage – recession becomes obvious yReduced probing depths

13. Non-Surgical Periodontal Therapy zPeriodontitis: Healing Response yInjury to or separation of junctional epithelium occurs following debridement yHealing takes approx. 1 week xHemidesmosomes begin to reattach from apical end of JE xIntact after approx.7 days yConnective tissue healing takes considerably longer xUp to several months xNew connective tissue fiber attachment not an expected outcome xDevelopment of an elongated junctional epithelium – this may result in reduced probing depths

14. Non-Surgical Periodontal Therapy zPeriodontitis: Clinical Healing Response yReduced pocket depths yChanges in attachment levels yRecession yFewer bleeding sites, reduced redness yImprovement in tissue tone & colour

15. Non-Surgical Periodontal Therapy zPeriodontitis: Reduced Pocket Depths yGreater reduction of pocket depths occurs in deeper pockets yPocket depths measuring 4-6 mm xPocket reduction approximates 1 mm xRecession & minimal attachment gain (  0.5 mm) yPocket depths measuring > 7 mm xPocket reduction approximates 1.5-3.0 mm xCombination of recession & attachment gain (  1.0mm)

16. Non-Surgical Periodontal Therapy zGain in attachment level yMay represent more accurate reading of pocket probing depth yInflamed tissues easily penetrated when probed yInflates true pocket readings yProbe less likely to penetrate when: xJunctional epithelium & CT has healed & fibers are intact

17. Assessment Following Therapy zAssess response of tissues zAssess plaque & calculus deposits yResidual calculus? zNo improvement: yEvaluate health history yPlaque culture zRecommendations: yAntibiotics/antimicrobials yRepeat periodontal debridement yPeriodontal surgery

18. Repopulation of Pockets zPeriodontal debridement reduces bacterial population in pockets zShift from primarily Gram-negative flora to one that is Gram-positive yFewer motile forms zRepopulation occurs in a specific order zMay take as long as 6 months & may depend on yCompleteness of initial therapy yClient’s compliance & ability to remove plaque yPresence of invasive bacteria

19. Repopulation of Pockets zSpecific order of repopulation: yStreptococcus & Actinobacillus species yViellonella yBacteroides yPorphyromonas yPrevotella yFusobacterium yCapnocytophaga sp & spirochetes

20. Limitations of Non-Surgical Therapy zPocket depths yResidual calculus likely in deeper pockets yAverage pocket depth for adequate removal approx. 3.73 mm yClinical approach: curettes with longer shanks

21. Limitations of Non-Surgical Therapy zFurcations yAccess difficult – residual calculus likely yOpening to furcation often smaller than diameter of periodontal instrument yClinical approach: use of slimline inserts zRoot anatomy yDepressions on proximal surfaces yClinical approach: knowledge of root anatomy

22. Limitations of Non-Surgical Therapy zClinical skill & time spent yDebridement technique & skill sensitive yDebridement of one periodontally involved molar (moderate involvement) takes approx. 10 minutes yAttention to technique, proper selection of instruments important to success