chapter 25: nonsurgical periodontal therapy

what phase of the periodontal treatment plan is NSPT

second!:

assessment and preliminary therapy phase

nonsurgical periodontal therapy (phase I)

surgical therapy (phase II)

restorative therapy (phase III)

periodontal maintenance (phase IV)

what is nonsurgical periodontal therapy

control of plaque-induced gingivitis or periodontitis through:

patient daily self-care measures

periodontal instrumentation

the use of chemical agents

objectives of NSPT

eliminate inflammatory disease in the periodontium

return the periodontium to health

maintain health with professional care and daily patient self care

what should NSPT control or eliminate

primary etiologic factors

local risk factors

systemic risk factors

general indications for NSPT

usually controls plaque induced gingivitis and slight/moderate periodontal disease

usually precedes periodontal surgery in those patients with severe periodontitis

inflammation, more bacterial pathogens, progressive attachment/bone loss

T or F: NSPT is not the best therapy for periodontitis

true

patient self-care

remove supragingival biofilm with daily brushing

cons: many lack motivation and skills, professional care is still needed

professional care

routine periodontal instrumentation to keep biofilm under control

approx every 3 months to disrupt biofilm and prevent pd damage

can extend maintenance intervals if good compliance

oral prophylaxis vs. periodontal debridement

o.p: regular house cleaning, includes scaling and polishing as preventive measures

p.d: deep cleaning h\after things have built up

scaling/root planing

foundation of NSPT

to prevent, arrest, control, or eliminate periodontal diseases

evaluation of success: positive soft tissue response

types of procedures included in NSPT

customized patient education

instrumentation of teeth

use of antimicrobial agents

use of adjunctive irrigation

correction of local contributing factors

interprofessional collab

modulation of host defenses

treatment sequence

assessments

tx plan

informed consent

decide which anesthetic: topical anesthesia, local anesthesia

scaling (which parts of mouth per visit?) (may be influenced by anesthesia selected

power instrumentation benefits

optimum for periodontal debridement

more effective in deplaquing and treatment of furcations

slim tips to reach deeper into pockets

low/med power setting less root surface damage

water irrigation removes toxins

reduced instrumentation time

subgingival scaling

pocket epithelium will transform into JE

epithelial cells move very quickly to repopulate the root surface

JE forms a long epithelial attachment or closure

in the lamina propria, the inflammatory infiltrate will be replaced by collagen but the JE does not allow a new CT attachment to form

gingival curettage

can be purposeful or accidental

removal of diseased lining of soft-tissue pocket wall to reduce/eliminate pd inflammation

includes JE and connective tissue

indications: inflamed tissue, shallow suprabony pockets

reduction in probing depth is due to a combo of

gingival recession (shrinkage) AND increase in clinical attachment (decrease in probe penetration due to the inflammatory infiltrate being replaced by new collagen

factors affecting measurement of CALs

inflammation (location of free gingival margin)

probing technique (angulation, pressure)

tooth anatomy

presence of calculus

what happens when cementum becomes exposed in a periodontal pocket

it becomes contaminated due to migration of JE

how much cementum must be removed

very little, need cementum to facilitate attachment of new soft tissue

endotoxin is loosely and superficially attached to root surface (no need for extensive root planing)

adverse effects of sc/rp

recession, sensitivity of teeth (bc of recession and removal of subgingival calc) and gingiva

how does pocket depth effect periodontal debridement

less effective in probing depths > 3.73 mm

with increased probing depths, more calc

what is the most frequently lost tooth during perio tx

molars due to furcations

limitations of periodontal debridement

furcations and root anatomy (instruments too wide)

clinician skill- over instrumentation causes additional grooves of the root surface

may need to re-instrument after initial therapy

time spent

measurable endpoints of NSPT

gain in CALs

decreased probing depths

absence of inflammation

reduced/absence of bleeding on probing

alterations and reductions in subgingival microbiota

tissue changes after NSPT

healing occurs w epithelial changes

pocket epithelium → junctional epithelium

forms attachment to tooth via basal cell growth

epithelium grows apically until it meets connective tissue fibers in cementum

this is called long junctional epithelium

(no regeneration of bone, cementum, or PDL)

what causes tissue to shrink

elimination of erythema and edema

repair, not regeneration of supporting tissues

complete healing following sc/rp normally occurs in ____

1-2 weeks depending on severity of inflammation, depth of pockets

smoking, homecare, and immune system

what is reattachment in periodontal healing

reunion of connective tissue + epithelium to the same healthy root surface

occurs if root surface is undisturbed

results in normal epithelial and connective tissue attachment

ex: after scaling, the JE reattaches if root is unchanged

what is new attachment in periodontal healing

attachment to a previously diseased root surface

involves new PDL + new cementum

no new bone formation

more advanced/regenrative process

key difference: reattachment vs new attachment

reattachment- same healthy root, simple healing

new attachment- diseased root, true regeneration (new PDL + cementum) (does not occur after sc/rp)

what is regeneration in periodontal healing

regrowth of cementum, PDL, and alveolar bone

ideal outcome

occurs mainly with surgery (not NSPT)

healing time after NSPT

0-48 hours: inflammation subsides

up to 7 days: decreased inflammation, epithelial healing, and collagen deposition

reevaluation appointment following NSPT

4-8 weeks after last scaling, new standard 3 months

eval tissue response and homecare

redo assessments, remove residual calculus, determine need for further treatment/surgical therapy

establish recare schedule

lasers

indicated for sulcular debridement, reduction of subgingival bacteria, scaling and root planing

results are controversial