Module 1: Healing After Debridement, Periodontal Re-Evaluation, Risk and Maintenance

Topic 1: Healing After Debridement

“Effects of Nonsurgical Periodontal Therapy” by Anita Badersten

  • reduction of probing depth increase in gingival recssion over 9 months

  • smaller probing depth bc of recession

  • loss of attachment occurs in shallow sites after thorough debridement

  • deeper the probing depth = likely to have less attachment

Gives concrete evidence that non-surgical root debridement reduces bleeding + reduce inflammation + gain attachment

Intro:

  • Ideal form of healing is regeneration however repair via long junctional epithelium is more predictable

Periodontal Structures:

Healing:

  • Repair of periodontal structures comes from the blood vessels in periodontium

Junctional Epithelium

  • non-keratinized

  • fast tissue turnover

  • wide intercellular spaces

  • pathway for transudate + inflammatory exudate

  • anchors via hemidesmosomes

Reattachment + Restoration of JE occurs after:

  • periodontal probing

  • scaling + root debridement

  • curettage

  • flap surgery

  • gingivectomy

Healing Events:

  1. Repair (scar)

  • after injury to re-establish functional tissue

  • principal tissue: long junctional epithelium

  1. Regeneration

  • slower

  • replacement of lost damaged tissue w/ the same tissue prior to disease

  • restoration of PDL, alveolar bone, root cementum

Healing Events:

  • immediately after debridement: RBC adhere to root surface

  • 60 mins: RBC form fibrin clot (inflammaroty cytokines are released, making capillaries bigger)

  • 6 hours: early inflammation

  • 3 days: late inflammation + granulation tissue formation

  • 7 days: highly cellular connective tissue attachment to dentin

  • 21 days: immature collagen present, junctional epithelium reattaches

Microbial Events of Debridement

Effects of Poor Oral Hygiene after SRD

  • original microflora re-establishes itself within weeks of SRD

  • if patient doesn’t remove plaque, periodontal pockets won't heal

  • residual calculus + plaque disrupts healing

  • rough root surfaces result in plaque retention + inflammation

Factors that Affect Complete Debridement

  • access (probing depth)

  • access (tooth type)

  • presence of root irregularities + furcation

  • instrument

Topic 2: Periodontal Re-Evaluation

We know that SRD and oral hygiene works in the long-term from:

  1. Randomised clinical trials demonstrate measurable clinical improvements were achieved through periodontal therapy in comparison to untreated controls. (Axelsson and Lindhe (1981) series)

  2. Observable results from long-term, retrospective trials of patients treated for periodontal disease (maintenance populations). Long-term maintenance studies include Hirschfeld and Wasserman (1978), and McFall (1982).

When Should We Re-Evaluate Patients? Why?

  1. Gingivitis = 6 months

  2. Moderate Periodontitis w/out systemic risk factors = 8-12 weeks

  3. Severe Periodontitis w/ systemic risk factors = 6-8 weeks

Questions for Patients:

  • has presenting complaint resolved?

  • any changes in medical history/smoking habits/stress?

  • oral hygiene

  • any dental treatment since debridement appointments

Baseline Exam Process

  1. Review teeth

  • new carious lesions

  • review restorations + appliances

  1. Visual Evaluation of Gingival Tissues

  • colour/contour/attachment

  1. Review Oral Hygiene Routine

  2. Repeat Diagnostic Tests

  • visual exam

  • perio chart

  • review radiographs

  • supplementary tests

COMPARE THESE RESULTS W BASELINE

What are some reasonable changes in probing depth + CAL after debridement?

Once a patient has periodontitis, the damage to the periodontal ligament and alveolar bone is irreversible. 

The pocket heals and reduces in depth by recession of the gingival tissue, formation of repair tissue (long junctional epithelium) and a small amount of regenerated PDL and bone in the most apical part of the pocket.

Topic 3: Risk Assessment in Periodontics

2 Types of Risk Factors:

  1. Modifiable Risk Factors

  2. Fixed Risk Factors

Patient Level Risk Factor:

  1. Patient Level

— systemic, genetic, social, behavioural factors

— medical status

— full mouth plaque score

— loss of teeth (lost more than 8 = risk)

— compliance w/ treatment

  1. Tooth Level

— restorative status (caries, fractures, resorptive lesions)

— tooth position/crowding

— furcation involvement (plaque retention)

— residual support

— mobility

— Iatrogenic factors (clinician errors such as overhangs)

— open contacts

— ortho

— mouth breathing

— xerostomia

  1. Site Level

— Periodontal parameters (probing depth, recession, CAL, furcation lesions)

— Root grooves

— Developmental anomolies

— Vertical bone loss

Topic 4: Periodontal Maintenance or Supportive Periodontal Therapy

Why isn’t non-surgical periodontal treatment not enough to treat periodontitis?

  • perio patients are always susceptible to breakdown in the presence of plaque

  • pockets recolonize even with good oral hygiene

  • periodic debridement is required to reduce bacteria and disrupt the biofilm

  • periodic exams are to detect sites breaking down and to detect other oral conditions

How does recolonisation happen?

  • bacerial resevoirs on the tongue/tonsils

  • bad oral hygiene

  • incomplate plaque/calculus removal

  • deep residual pockets hide bacteria well

Control Group:

  1. Excellent plaque control

  2. healthy gingiva

  3. shallow PD

  4. stable attachment levels

  5. no tooth loss

No Recall Group:

  1. Recurrent periodontitis

  2. GIngivitis

  3. Deep pocjets

  4. Ongoing attachment loss

  5. Some tooth loss

Results:

  • tooth loss was related to patient type (rather than the treatment provided)

  • most teeth lost in each group were furcation-involved molars

What are the aims of periodontal maintenance?

  1. Preserve periodontal attachment

  2. Resolve inflammation

  3. Re-evaluate home care

  4. Maintian a healthy + functional oral environment

  5. Prevention of re-infection of pockets

  6. Periodically disturb sub-gingival plaque to prevent establishment of pathogens

Does SPT (supportive periodontal therapy) help to compensate for poor oral hygiene?

  • yes

  • “Ramfjord and coworkers (1982) observed 78 periodontitis patients over seven years of maintenance. Baseline treatment consisted of scaling and root planing and occlusal adjustment as required. The cohort was then divided into four groups according to plaque control. The long-term results of the group with the worst oral hygiene were compared to those of the best plaque control group.”

How do we improve patient compliance?

  • simplify routine

  • accomodate for the patient’s needs

  • keep records of compliance

  • involve patients in treatment

  • positive reinforcement

  • identify non-compliers to adjust treatment

  • hygienists ensure dentist is involved in maintenance visit

  • explain what gingivitis/periodontitis is (why, who, how)

Summary:

Healing after debridement

  • Ideally periodontal wound healing would predictably result in formation of new cementum, periodontal ligament (PDL) and alveolar bone.

  • Most of the healing is achieved via a long junctional epithelial scar.

  • Excellent plaque control is vital for healing to prevent re-infection of the healing pocket.

Periodontal re-evaluation

  • Periodontal re-evaluation detects uncontrolled periodontal risk factors.

  • Re-evaluation identifies the need for active treatment of unresponsive sites.

  • Changes in a patient’s periodontal risk profile are accounted for by formulating a new post-treatment diagnosis statement.

Periodontal risk assessment

  • Periodontal re-evaluation identifies changes in periodontal parameters that occur after non-surgical debridement and also during the maintenance phase of periodontal treatment.

  • Patient-level risk assessment:

    • determines the risk profiles of a patient at baseline, re-evaluation and during the maintenance phase.

    • is used to schedule appropriate recall periods for a patient to remain periodontally stable by adequate control of risk factors.

  • Tooth and site-level risk assessment:

    • identifies teeth and sites that are at high risk of ongoing attachment loss.

    • determines the treatment needs for a site which is breaking down.

  • Changes in a patient’s periodontal risk profile are accounted for by formulating a new post-treatment diagnosis statement.

Periodontal maintenance

  • Supportive periodontal therapy (SPT) plays a big role in controlling and reducing modifiable risk factors on a patient, tooth and site level. 

  • The reduction in risk over consecutive appointments can be demonstrated using serial spiderwebs (PRA).

  • SPT aims to prevent periodontal breakdown by periodically breaking up subgingival plaque to maintain symbiosis and to reinforce oral hygiene practices with the patient.

  • SPT visits include a re-evaluation phase, a reinstruction phase, an instrumentation phase, treatment of reinfected sites and a polishing phase.

  • Excellent oral hygiene and SPT visits are required for good healing outcomes, irrespective of the type of periodontal therapy provided (i.e. nonsurgical or surgical).

  • SPT can compensate for poor plaque control provided patients are compliant with appointments. 

  • Patient motivation for oral hygiene can be improved by simplifying their routine, accommodating their needs, keeping records and showing patients their current status, involving patients in their treatment and providing positive reinforcement.