Transcript Non surgical treatment /Dr Omar

By Dr. Omar Alkaradsheh
Treatment of periodontal disease
Outline
 Non-surgical therapy
 Rationale
 Goals
1.
2.
3.
4.
5.
6.
7.
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Plaque control
Scaling & root planing
Antiinfective therapy
Host modulation
Occlusal evaluation and therapy
Adjunctive role of orthodontic treatment
Re-evaluation:
Healing
Results
Non-Surgical Therapy
 Synonyms:
 Phase I therapy
 Initial therapy
 Cause-related therapy
 Etiotropic phase of therapy.
 Refer to the procedures performed to treat gingival and
periodontal infections, up to and including tissue
reevaluation, which is the point at which the course of
ongoing care is determined.
Rationale
 Achieve:
 comprehensive daily plaque control regimen
 thorough removal of calculus and microbial plaque
 correction of defective restorations
 treatment of carious lesions
 phase I therapy provides an opportunity for the dentist to evaluate
tissue response and patient motivation about periodontal care, both of
which are crucial elements to the overall success of treatment.
 The long-term success of periodontal treatment depends
predominantly on maintaining the results achieved with phase I
therapy and much less on any specific surgical procedures.
Goals
 Decrease the quantity of organisms below a critical mass
and alter the composition of the remaining bacterial flora
to one associated with health.
 Reach an Equilibrium between the remaining bacterial
plaque and host response.
 halt the progression of disease .
 Restore gingival and periodontal health.
Nonsurgical Phase
(Phase I Therapy)
 Plaque control and patient education:
Daily plaque control regimen
 Diet control (in patients with rampant caries)
 Smoking cessation

 Removal of plaque and calculus and local factors:
 Removal of calculus and root planing
 Correction of restorative and prosthetic irritational factors
 Excavation of caries and restoration (temporary or final)
 Antimicrobial therapy (local or systemic)
 Extraction of hopeless teeth
 Occlusal therapy
 Minor orthodontic movement
 Provisional splinting and prosthesis
 Evaluation of response to nonsurgical Phase
 In many cases, phase I therapy will be the only set of
procedures required to restore periodontal health
Non-Surgical Treatment
1. Education &
Plaque Control
4. Treat/temporize
carious lesions
2. Scaling & Root
planing
5. Adjunctive
aids
3. Remove local
factors
6. Re-evaluation
Step. 1 Patient Education &Plaque
Control
Step 1: Plaque Control Instruction
 Plaque control is the essential component to successful
periodontal therapy
 Should begin in the first treatment appointment.
 “Targeted oral hygiene” emphasizes thorough plaque
removal around the periodontal tissues.
Rationale
 The cause and effect relationship between supragingival plaque and
gingivitis was demonstrated by Loe and his colleagues in 1965.
 When plaque was allowed to accumulate, gingivitis developed within
21 days. When plaque control was initiated, the gingivitis was
reversed (by means of efficient plaque control, i.e., brushing and
flossing) to clinical gingival health
 The removal of microbial plaque leads to cessation of gingival
inflammation, and cessation of plaque control measure leads to
recurrence of inflammation
 The removal of plaque also decreased the rate of formation of calculus.
( Sanders , 1962)
 Thus eliminating the plaque is the key to prevent the occurrence of
periodontal disease or halting the progression of the disease.
 Masses of plaque first develop in Molar , Premolar areas , followed by
proximal surfaces of the anterior teeth , and the facial surfaces of the
molar and premolar( Lang,1973)
Plaque Control
methods
Mechanical
Chemical
 Chemical Plaque
Control
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Antibiotics
enzymes
Metal ions
Fluorides
Natural products
Bisguanides antiseptics
Oxygenating agents
Amine Alchohols
Phenols and essential oils
Mouth rinse
Irrigation
Gel
Slow releasing device
Plaque Control Methods
Mechanical
methods
Toothbrush
• Manual
• Powered
Dentifrices
Interdental
Aids
• dental floss
• toothpick
• interproximal brush
Oral Irrigation
supragingival
subgingival
Irrigation
 Work by directing a pulsating stream of water through a nozzle to the tooth
surface
 Supragingival Irrigation:
 irrigators clean nonadherent bacteria and debris from the oral cavity more
effectively than toothbrushes and mouth rinses.
 They are particularly helpful for removing debris from inaccessible areas around
orthodontic appliances and fixed prostheses.
 When used as adjuncts to toothbrushing, these devices can have a beneficial
effect on periodontal health by:


reducing the accumulation of microbial plaque and calculus
decreasing inflammation and pocket depth
Subgingival Irrigation
 Home irrigation is performed by aiming or placing the irrigation tip into the
periodontal pocket, attempting to insert the tip at least 3 mm, using a soft rubber,
each pocket flushed for a few seconds.
 Dental office: lavage or flushing of the periodontal pocket, as a one-time
treatment after scaling and root planing, has not been shown to improve clinical
healing, and data do not support its use in improving therapeutic results.
 Used to deliver antimicrobial agents, mouthrinses into the periodontal pockets.
 chlorhexidine diluted to one-third strength and performed regularly at home
and after scaling, root planing, and in-office irrigation therapy has produced
significant gingival improvement compared with controls.
 Subgingival irrigation has been shown to disrupt more than half the subgingival
plaque and reach about half the depth of pockets, up to 7 mm, much further
apically than a toothbrush or floss can reach.
 These data suggest that patients can benefit from daily subgingival irrigation,
particularly in difficult sites such as furcations and residual pockets
Oral Irrigation
 Pulsation
creates two
zones of
hydrokinetic
activity: the
impact zone
and the
flushing zone.
Subgingival Irrigation
Recommendations
 Supragingival irrigation reduces gingival
inflammation and is easier for some patients than
using mechanical interdental aids.
 Subgingival irrigation with specialized tips for deep
pockets and furcation areas is effective when used
daily as part of the home care routine.
 Patients requiring antibiotic premedication for dental
procedures should use supragingival techniques.
Non-Surgical Treatment
1. Education &
Plaque Control
4. Treat/temporize
carious lesions
2. Supra &
subgingival calculus
removal
5. Adjunctive
aids
3. Remove local
factors
6. Re-evaluation
Step 2. Removal of
Supragingival and Subgingival
Calculus
Outline
 Introduction,
 Detection and removal of dental calculus,
 Methods used for non-surgical root surface debridement
 Scaling & root planing



Hand instrumentation
Sonic and ultrasonic scalers,
Side effects
 Ablative laser therapy,
 Photodynamic therapy
 Evidence-based choice of debridement method
 Outcome of S/RP:
 Clinical and microbioligical
 Implication of furcation involvement,
 Healing following successful phase I therapy
 All periodontal treatment is based on successful initial NSPT.
 S/RP is the most common used method to remove supra and
subgingival calculus.
 Periodontitis is strongly associated with the presence of dental
calculus on root surfaces
 The rough surface of calculus does not in itself induce
inflammation but that the deleterious effect of calculus relates to
its ability to provide an ideal surface for microbial colonization
(Waerhaug 1952)
1- visual examination .
2- tactile exploration .
 Scaling is the process by which plaque
and calculus are removed from both
supragingval and subgingival tooth
surfaces .
 Root planning :
The process by which residual embedded
calculus and portion of cementum are
removed from the roots to produce a
smooth ,hard and clean surface.
Rationale
o Epithlelial adherence to subgingival calculus can occur following its
disinfection with chlorhexidine
(Lisgarten & Ellegaard 1973)
 LPS were thought to be present within calculus and underlying cementum. For
this reason it was thought necessary to remove not only calculus but also
underlying cementum. However later evidence suggested that removal of tooth
substance was not necessary.
 On no occasion was LPS seen penetrating into sub-surface cementum
(Hughes & Smales 1986)
 Animal and human studies which demonstrated that removal of superficial
plaque on subgingival calculus resulted in the healing of periodontal lesions
and the maintenance of health, provided supragingival hygiene was meticulous
(Nyman et al. 1986, 1988; Mombelli et al. 1995)
 Root debridement: removal of plaque and/or calculus
from the root surface without the intentional removal
of tooth structure.
Claffey et al. 2004
 A rationale for the removal of calculus relates to
eliminating, as far as possible, surface irregularities
harbouring pathogenic bacteria.
Factors that may influence calculus
removal include :
The extent of disease,
II. Anatomic factors,
III. Skill of the operator,
IV. Instruments used.
I.
a. Hand Instruments
c. Laser
b. Powered Instruments
d. Photodynamic therapy
 Access to the Root surface
The root surface are not easy to access
because Limitation of penetration of
instruments.
In subgingival access.
scaling and root planing skills is needed.
in deep pockets .
open procedure may be needed.
 Supra gingival scaling technique:
Sickles ,curettes ,and ultrasonic and sonic
instrument are most commonly used for
removal of supragingival calculus .
 Sub gingival scaling and Root
planning technique:
The curette is preferred by most clinicians
because of the advantages afforded by its
design.
Manual Instruments
Sickle
Hoe
File
 Subgingival instrumentation should preferably be
performed under local anesthesia.
 Modified pen grasp
 Finger rest
 As close as possible to the site of instrumentation
 to facilitate controlled use of the instrument
 Provides:
(1) stable fulcrum,
(2) permit optimal angulation of the blade,
(3) enable the use of wrist–forearm motion .
Principles
 The optimal angle between the cutting edge and the tooth is approximately 80º :
 Too obtuse an angle, will result in cratering and consequent roughening of the root
surface.
 Too acute an angle, will result in ineffective removal and burnishing of subgingival
calculus deposits.
Cutting position: The shank of the curette
held parallel to the long axis of the tooth
during instrumentation of a posterior site.
Activation:
 The grasp of the instrument is tightened
somewhat, the force between the cutting
edge and the root surface is increased,
and the blade is moved in a coronal
direction.
 Strokes must be made in different
directions to cover all aspects of the root
surface (crosswise, back and forth) but,
as stated above, strokes should always
start from an apical position and be
guided in a coronal direction.
 Sharpening
 Sonic scalers:
 Use air pressure
 The frequencies of vibration ranging from
2000–6000 Hz.
 Ultrasonic scalers:
 convert electrical current to mechanical energy in the form of high-frequency
vibrations at the instrument tip;
 The vibration frequencies ranging from 18 000–45 000 Hz.
 Piezoelectric scalers
 Alternating electrical current
 Pattern of vibration is linear
 Magnetostrictive scalers
 Electrical current  magnetic field in the handpiece  the insert to vibrate.
 The pattern of vibration at the tip is elliptical.
 Ultrasonic scaling:
Ultrasonic instrument have been used as a
valuable adjunct to conventional hand
instrumentation .
 Uses of Ultrasonic scaling devices :
1- Scaling and gingival curettage .
2-Removal of stains .
3- Remove overhangs and excess cement
 Contraindications of ultrasonic scaling:
Patient with cardiac pacemaker .
Patients with Known communicable diseases .
Chronic pulmonary problems.
Porcelain bounded restoration .
Patient with Titanium implant ( plastic-tipped ultrasonic
and sonic insert and Teflon-coated sonic scaler tips are available)
 Meticulous and requires more
experienced operator .
 Time consuming(×2 the time needed for
surgery)
 Less predictable in deep pockets
,furcations and interproximal groove.
 Ineffective as mono therapy in the
treatment of aggressive periodontitis .
 Pain
 Dentine hypersensitivity
 The extent of the sensitivity can be diminished through good plaque
removal.
 Higher in pre-existing sensitivity, intensity decrease with time
 Gingival recession
 Warning patients about these potential outcomes at the beginning of
the treatment sequence will avoid surprise if these changes occur.
 Unexpected and possibly uncomfortable consequences to treatment
may result in distrust and loss of motivation to continue therapy.
 From a clinical standpoint, minimizing the total volume of
dental calculus present seems to be desirable. However,
aggressive tooth substance removal does not seem warranted.
(Claffey et al. 2004)
 There was no difference between hand and powered
instrumentation in deposits removal and improved clinical
parameters.
(Badersten et al.1981,loos et al . 1987,Laurell et al . 1988)
 There was no difference between hand and powered instruments
in the treatment of class I furcation involved areas , while
powered instruments were more effective than hand instruments
in class II and III furcation due to smaller tip size
(Matia et al .1986 ,Leon &Vogel 1987)
 Endotoxins are superficially attached to the root surface
and can be removed by brushing (Moore et al .1986),polishing
(Nyman et al .1988) or light overlapping strokes with
ultrasonic scalers (smart et al .1990)
 The critical probing depth for scaling and root planing is
2.9 mm ± 0.4 and for periodontal surgery is 4.2 mm ± 0.2
(Lindhe et al .1982 )
 Scaling and root planing did not result in total removal of
subgingival calculus particularly in deep pockets
( Rabbani et al .1981)
Ablative Laser therapy
 Carbon dioxide lasers
 Er:YAG lasers
 Nd:YAG lasers
Ablative laser therapy
Advantages:
 It has bacteriocidal and detoxification effects.
 Can remove the epithelium lining and granulation tissue within
the periodontal pocket which may potentially improve healing.
 Removing plaque and calculus with extremely low mechanical
stress and no formation of a smear layer on root surfaces.
 May allow access to sites that conventional mechanical
instruments cannot reach.
Ablative Laser therapy
 Carbon dioxide lasers
o when used with relatively low energy output in a
pulsed and/or defocused mode
o have root conditioning, detoxification, and
bacteriocidal effects on contaminated root surfaces.
o However, at low energy outputs they are unable to
remove calculus.
 Er:YAG lasers
o Are capable of effectively removing calculus from
the root surface.
o Energy is absorbed by water and organic components
of the biological tissues which causes their evaporation
resulting in heat generation, water vapour production,
and thus an increase in internal pressure within the
calculus deposits. The resulting expansion within the
calculus causes its separation from the root surface
Er: YAG
Ablative laser therapy
 Use of lasers produces results comparable to scaling
and root planing .
 Benefit of the use of lasers over scaling and root
planing alone has been demonstrated.
(Schwarz et al. 2003; Ambrosini et al. 2005)
 Currently there is minimal evidence to support use of
a laser for the purpose of subgingival debridement
either as monotherapy or adjunt to S/RP.
 Precautions:
 Inadvertent irradiation and reflection from shiny metal
surfaces may cause damage to patient’s eyes, throat, and
oral tissues other than the targeted area.
 Risk of excessive tissue destruction by direct ablation and
thermal side effects.
 Also the high cost of the laser apparatus is a drawback for
many
Photodynamic therapy (PDT)
PDT principle
Int Poster J Dent Oral Med 14 (2012), No.
1, Poster 587
Photodynamic therapy (PDT)
 Advantages:
 PDT is non-invasive local therapy,
 PDT offers thorough irrigation and elimination of pathogens in
inaccessible areas of periodontal pocket within short span of
time, thus beneficial to both operator and the patient.
 The risk of bacteraemia after periodontal debridement can be
minimized.
 There is no need to prescribe antibiotics, therefore the
possibility of side effects is avoided.
 There is no need to anaesthetize the area and destruction of
bacteria is achieved in a very short period (<,60 seconds).
Photodynamic therapy (PDT)
 Antimicrobial photodynamic therapy acts as a beneficial
adjunct to SRP in non-surgical treatment and management
of chronic periodontitis in short-term.
 Further studies are required to assess the long-term
effectiveness of a PDT.
(Sgolastra et al. 2013, Betsy et al. 2014)
Choice of method used
 In contrast to hand instrumentation, the use of
sonic and ultrasonic scalers is less technique sensitive,
requires less time to complete, and removes less
root surface cementum. It has been shown to provide better access to
deep pockets and furcation areas.
(Kocher et al. 1998; Beuchat et al. 2001).
 In addition the flushing action of water used in sonic and ultrasonic
scalers removes, to a certain extent, debris and bacteria from the
pocket area. However, tactile sensation is reduced, and there is
production of contaminated aerosols
(Harrel et al. 1998; Barnes et al. 1998; Rivera-Hidalgo et al. 1999; Timmerman et al. 2004).
 Some patients may find the vibration, sound, and water spray
uncomfortable.
Conclusions
 Removal of calculus is accomplished using scalers,
curettes, ultrasonic instrumentation, or
combinations of these devices during one or more
appointments.
 Evidence suggests that the treatment results for
chronic periodontitis are similar for all
instruments, and some dentists now incorporate
laser technology into periodontal therapy,
including phase I therapy.
Non-Surgical Treatment
1. Education &
Plaque Control
4. Treat/temporize
carious lesions
2. Supra & subgingival
calculus removal
5. Adjunctive
aids
3. Remove
local factors
6. Re-evaluation

Corrections for restorative
defects, which are plaque traps,
may be made by smoothing
surfaces and overhangs with
burs or hand instruments or
by replacing restorations.

These procedures can be
completed concurrently with
other phase I procedures.
EVA SYSTEM
 Most efficient and least
traumatic instruments
for correcting overhangs
or overcontoured
proximal alloy or resin
 These files are made of
Aluminum in the shape
of a wedge protruding
from a shaft.
 Reciprocating
handpiece.
EVA system
Non-Surgical Treatment
1. Education &
Plaque Control
4. Treat/temporize
carious lesions
2. Supra & subgingival
calculus removal
5. Adjunctive
aids
3. Remove local
factors
6. Re-evaluation
 Removal of the carious tissue and placement with
either temporary or permanent restorations is
indicated in phase I therapy because of the infectious
nature of the caries process.
 Healing of the periodontal tissues will be maximized
by removing the reservoir of bacteria in these lesions
so that they cannot repopulate the microbial plaque.
Caries Control

Dental caries, particularly root caries, is a problem for periodontal patients because of attachment
loss associated with the disease process and periodontal therapeutic procedures

Fluoride works primarily by topical effects to prevent and reverse the caries process, whether in
enamel, cementum, or dentin.

Low concentrations of topical fluoride inhibit demineralization, enhance remineralization, and
inhibit the enzyme activity in bacteria by acidifying the cells

All periodontal patients should be encouraged to use a fluoride-containing toothpaste daily, 1000 to
1100 ppm, to reduce demineralization and enhance remineralization of tooth surfaces.

Patients at high risk for caries, including those with a history of root lesions or who have active
lesions, should use higher-concentration fluoride toothpaste or gels, 5000 ppm, daily until the risk for
caries is controlled, then maintain with the lower concentration toothpastes and mouthrinses.

Other considerations in caries control, such as diet and reduced salivary flow, should be evaluated as
with all dental patients.
Non-Surgical Treatment
1. Education &
Plaque Control
4. Treat/temporize
carious lesions
2. Supra & subgingival
calculus removal
5. Adjunctive
aids
3. Remove local
factors
6. Re-evaluation
 Anti-infective therapy: systemic & local
 Host modulation therapy
 Orthodontic treatment
 An anti-infective agent is a chemotherapeutic
agent that acts by reducing the number of bacteria
present
 Antibiotics, antimicrobials, antiseptics, disinfectants
 Locally, orally or systemically
Systemic Antibiotics
 An ideal antibiotic for use in prevention and treatment of periodontal diseases
should be:
I.
specific for periodontal pathogens,
II.
allogenic and nontoxic,
III.
substantive,
IV.
not in general use for treatment of other diseases,
V.
inexpensive.
 Currently, an ideal antibiotic for the treatment of periodontal diseases does not
exist.
 Although oral bacteria are susceptible to many antibiotics, no single antibiotic
at concentrations achieved in body fluids inhibits all putative periodontal
pathogens.
 Indeed, a combination of antibiotics may be necessary to eliminate all putative
pathogens from some periodontal pockets
Background and Rationale
 The treatment of periodontal diseases is based on the
infectious nature of these diseases .
 Ideally, the causative microorganism(s) should be
identified and the most effective agent should be
selected using antibiotic-sensitivity tests.
 Although this appears simple, the difficulty lies
primarily in identifying specific etiologic
microorganism(s) rather than microorganisms simply
associated with various periodontal disorders.
Rationale
 Systemic antibiotics aims to reinforce mechanical
treatment and to support host defences in
ovcercoming periodontal infections by killing
subgingival pathogens remaining after periodontal
instrumentation
 Pathogens may escape the effect of mechanical
debridement because of their ability to invade
periodontal tissue, to reside in anatomical tooth
structure inaccessable to instrumentation, or as a
result of poor host defense
( position paper. J periodontol 2004; 75:1553-1565)
TABLE 47-2 -- Common Antibiotic Regimens Used to Treat Periodontal Diseases*
Regimen
Dosage/Duration
Amoxicillin
500 mg
Three times daily for 8 days
Azithromycin
500 mg
Once daily for 4–7 days
Ciprofloxacin
500 mg
Twice daily for 8 days
Clindamycin
300 mg
Three times daily 10 days
Doxycycline or minocycline
100–200 mg
Once daily for 21 days
Metronidazole
500 mg
Three times daily for 8 days
250 mg of each
Three times daily for 8 days
Systemic antibiotics
Single Agent
Combination Therapy
Metronidazole + amoxicillin
Metronidazole + ciprofloxacin 500 mg of each
Twice daily for 8 days
A. Subgingival Chlorhexidine
B. Tetracycline-Containing Fibers
C. Subgingival Doxycycline
D. Subgingival Minocycline
E. Subgingival Metronidazole
Tetracyclin- containing fibers
Tetracyclin- containing fibers
 An ethylene/vinyl acetate copolymer fiber (diameter, 0.5 mm) containing tetracycline.
 When packed into a periodontal pocket, it was well tolerated by oral tissues, and for 10
days it sustained tetracycline concentrations exceeding 1300 µg/ml, well beyond the 32 to
64 µg/ml required to inhibit the growth of pathogens isolated from periodontal pockets.
 In contrast, GCF concentrations of only 4 to 8 µg/ml were reported after systemic
tetracycline administration, 250 mg qid for 10 days.
 tetracycline fibers applied with or without scaling and root planing reduced probing
depth, bleeding on probing, and periodontal pathogens and provided gains in clinical
attachment level.
 Such effects were significantly better than those attained with scaling and root planing
alone or with placebo fibers.
 No change in antibiotic resistance to tetracycline was found after tetracycline fiber
therapy among the tested putative periodontal pathogens.

However, these fibers are no longer commercially available.
Doxycyclin gel
 A gel system using a syringe with 10% doxycycline
(Atridox)
 Resistance?
10% doxycycline (Atridox) gel.
Metronidazole (Elyzol 25%)
 It is applied in viscous consistency to
the pocket, where it is liquidized by
the body heat and then hardens
again, forming crystals in contact
with water. As a precursor, the
preparation contains metronidazolebenzoate, which is converted into the
active substance by esterases in GCF.
 Two 25% gel applications at a 1-week
interval have been used.
 metronidazole gel is equivalent to
scaling and root planing but have not
shown adjunctive benefits with
scaling and root planing.
Minocycline microspheres
 The 2% minocycline is encapsulated
into bioresorbable microspheres in a
gel carrier.
 Sustained release
 This product is available in the US
and a number of other countries.
 When compared to controls (scaling
and root planing with nonactive
vehicle as subgingival irrigant), there
was a statistically significant increase
in clinical attachment levels in
patients who presented with pockets
of 6 mm or greater probing depth
minocycline microspheres (Arestin).
Chlorhexidine chip
 PerioChip is a small chip (4.0 ×
5.0 × 0.35 mm) composed of a
biodegradable hydrolyzed gelatin
matrix.
 2.5 mg CHX incorporated
 This delivery system releases
chlorhexidine and maintains drug
concentrations in the GCF greater
than 100 µg/ml for at least 7 days,
concentrations well above the
tolerance of most oral bacteria.
 Because the chip biodegrades in 7
to 10 days, a second appointment
for removal is not needed
chlorhexidine gluconate chip (PerioChip)
 Adjuncts to scaling and root planing
 A recent systematic review concluded “adjunctive local therapy generally reduced
probing depth levels. Differences between treatment and SRP-only groups in the baseline
to follow up period typically favored treatment groups but usually only modestly (e.g.,
from about 0.1 mm to nearly 0.5 mm). Effects for clinical attachment level gains were
smaller
(Bonito 2005)
 American Academy of Periodontology stated:
 “the clinician's decision to use locally delivered agents (LDA) should be based upon a
consideration of clinical findings, the patient's dental and medical history, scientific
evidence, patient preferences and advantages and disadvantages of alternative therapies.”
 The report also stated that use of LDAs may be of value when probing depths greater
than 5 mm with inflammation are still present after conventional therapy.
However if multiple sites are present in the same quadrant, therapy other than LDAs
should be considered.
 Anti-infective therapy: systemic & local
 Host modulation therapy
 Orthodontic treatment
“there are compelling data from studies in animals and
human trials indicating that pharmacologic agents
that modulate the host responses believed to be
involved in the pathogenesis of periodontal
destruction may be efficacious in slowing the
progression of periodontitis”
 Locally (Topical NSAIDs) or systemically applied
(NSAIDs, Bisphosphonates, Subantimicrobial dose
doxycyclin)
Host modulation and
comprehensive periodontal
management
Rationale
Sub-Antimicrobial doseDoxycycline (SDD)
 SDD is currently the only FDA-approved (Periostat) , systemically administered
HMT indicated specifically in the treatment of periodontitis.
 MOA: in addition to its antibiotic properties, doxycycline has the ability to
downregulate MMPs, a family of zinc-dependent enzymes that are capable of
degrading extracellular matrix molecules, including collagen.
 The rationale for using SDD as a HMT in the treatment of periodontitis is that
doxycycline downregulates the activity of MMPs by a variety of synergistic
mechanisms, including reductions in cytokine levels, and stimulates
osteoblastic activity and new bone formation by upregulating collagen
production
 SDD is used as an adjunct to SRP and must not be used as a stand-alone
therapy (monotherapy)
 20mg capsules twice daily
Orthodontic therapy can provide several benefits to the adult periodontal patient. The following six factors should be
considered:
1.
Aligning crowded or malposed maxillary or mandibular anterior teeth permits the adult patient better access to
clean all surfaces of their teeth adequately. This could be a tremendous advantage for patients who are susceptible to
periodontal bone loss or do not have the dexterity to maintain their oral hygiene.
2.
Vertical orthodontic tooth repositioning can improve certain types of osseous defects in periodontal patients. Often,
the tooth movement eliminates the need for resective osseous surgery.
3.
Orthodontic treatment can improve the aesthetic relationship of the maxillary gingival margin levels before
restorative dentistry. Aligning the gingival margins orthodontically avoids gingival recontouring, which could
require bone removal and exposure of the roots of the teeth.
4.
Orthodontic therapy also benefits the patient with a severe fracture of a maxillary anterior tooth that requires forced
eruption to permit adequate restoration of the root. Erupting the root allows the crown preparation to have
sufficient resistance form and retention for the final restoration.
5.
Orthodontic treatment allows open gingival embrasures to be corrected to regain lost papilla. If these open gingival
embrasures are located in the maxillary anterior region, they can be unesthetic. In most patients, these areas can be
corrected with a combination of orthodontic root movement, tooth reshaping, and restoration.
6.
Orthodontic treatment could improve adjacent tooth position before implant placement or tooth replacement. This
is especially true for the patient who has been missing teeth for several years and has drifting and tipping of the
adjacent dentition.
Adjunctive Role of Orthodontic
Therapy
This patient was missing the mandibular
left second premolar, and the first molar
had tipped mesially (A). Pretreatment
periapical radiograph (B)revealed a
significant hemiseptal osseous defect on
the mesial side of the molar. To eliminate
the defect, the molar was erupted, and the
occlusal surface was equilibrated (C). The
eruption was stopped when the bone
defect was levelled (D). The posttreatment
intraoral photograph (E) and periapical
radiograph (F) show that the periodontal
health had been improved by correcting
the hemiseptal defect orthodontically.
Orthodontic Treatment of Gingival
Discrepancies
This patient initially had triangular-shaped
central incisors (A and B), which produced
an open gingival embrasure after
orthodontic alignment (C).Because the
roots of the central incisors were parallel
with one another, the appropriate solution
for the open gingival embrasure was to
recontour the mesial surfaces of the central
incisors (D). As the diastema was
closed (E), the tooth contact moved
gingivally and the papilla moved incisally,
resulting in the elimination of the open
gingival embrasure (F).
Non-Surgical Treatment
1. Education &
Plaque Control
4. Treat/temporize
carious lesions
2. Supra & subgingival
calculus removal
5. Adjunctive
aids
3. Remove local
factors
6. Re-evaluation
 Healing following non-surgical therapy is almost complete at 3 months.
 Patients also need the opportunity to improve their plaque control skills to both reduce
inflammation and adopt new habits.
 At re-evaluation the effectiveness of treatment previously carried out is evaluated and the
nature of further therapy, if needed, is established.
 Measurements are made at baseline and again at 3 months as a method of evaluation of
periodontal status, effectiveness of therapy and to estimate prognosis.
 Measurements include:
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plaque scores,
bleeding on probing,
suppuration on probing,
probing pocket depth,
recession,
clinical attachment level,
assessment of mobility.
Healing
 Healing of the gingival epithelium consists of the formation of a long
junctional epithelium rather than new connective tissue attachment to the
root surfaces.
 The attachment epithelium reappears 1 to 2 weeks after therapy. Gradual
reductions in inflammatory cell population, crevicular fluid flow, and
repair of connective tissue result in decreased clinical signs of
inflammation, including less redness and swelling.
 One or two millimeters of recession is often apparent as the result of tissue
shrinkage
 Transient root sensitivity frequently accompanies the healing process.
Although evidence suggests that relatively few teeth in a few patients
become highly sensitive, this development is common and can be
disconcerting to patients.
Average changes after non-surgical
treatment
Mean changes generally observed in
studies
a) in improvements in plaque and
bleeding scores for sites of
different initial probing depths
b) in probing depth, probing
attachment levels, and gingival
recession after a single episode of
supra- and subgingival
instrumentation
Interpretation of probing
measurements at re-evaluation
 On average the change in pocket depth seen following treatment for deeper
pockets is a combination of recession at the gingival margin due to resolution
of inflammation and a tightening of the junctional epithelium at the base of
the pocket.
 Moreover the reduced bleeding on probing scores found after treatment may
reflect the increased resistance to probe penetration into the connective
Effects of non-surgical treatment
on microbiology
 A re-emergence of species of the red and orange complex 3–12
months post debridement may be associated with ongoing
attachment loss at these sites
(Haffajee et al. 2006).
 In the absence of appropriate home care, the reestablishment of
the pretreatment microflora as well as the rebound of clinical
improvements due to treatment will occur in a matter of weeks
(Magnusson et al. 1984; Loos et al. 1988; Sbordone et al. 1990).
 In the absence of professional maintenance an increase in the
prevalence and counts of periodontopathogens is to be expected
(Renvert et al. 1990; Shiloah & Patters 1994).
Re-evaluation
 Many patients can have their periodontal disease controlled with phase I
therapy and not require further surgical intervention.
 In patients who do need surgical treatment, phase I therapy is advantageous in
that it also provides tissue with reduced inflammatory infiltration, thus
improving the surgical management of the tissue and improving the healing
response.
 In the re-evaluation visit , consider surgery if:
 Patients with 5 mm or more of attachment loss and with pockets present
after phase I treatment.
 Those patients who do not demonstrate the ability to have 20% or less of
tooth surfaces free of plaque are poor candidates for successful surgical
outcomes and should be closely monitored on a recall maintenance
program until plaque control is established.
Re-evaluation
 If no response to conventional non-surgical therapy
(scaling and root planing/debridement) consider:
 Antibiotics/antimicrobials
 Repeat periodontal debridement
 Periodontal surgery
 Traditionally non-surgical treatment of periodontitis involves a series
of appointments separated by perhaps a week or more. Each
appointment typically involves root debridement of a quadrant
depending on disease severity.
 In 1995 Quirynen et al. introduced the concept of total mouth
disinfection as a new treatment strategy. It involved:
 Full-mouth scaling and root debridement within a 24-hour treatment
period,
 Subgingival irrigation (repeated three times within 10 minutes) with 1%
chlorhexidine gel,
 Tongue brushing with 1% chlorhexidine gel,
 Mouth rinsing with 0.2% chlorhexidine.
 This full mouth disinfection protocol aimed to reduce the bacterial
load in pockets and intraoral niches to minimize the risk of reinfection
of the treated pockets from areas harbouring pathogenic bacteria.
 Recent studies suggested both the one appointment and staged or
multiple appointment treatment strategies work well, microbial
parameters were not significantly different after 8 months, regardless
of treatment modality and the risk of recurrence of periodontal
pockets was no greater for either modality.
 Staged therapy permits the advantage of evaluating and reinforcing
oral hygiene care, and the one or two appointment therapies can be
more efficient in reducing the number of office visits the patient is
required to attend.
Response of Furcation sites to nonsurgical treatment
 Patient-performed home care and professionally performed
subgingival debridement become more difficult.
 Sheltered anatomic site for anaerobic and virulent microbes.
 Sites with furcation involvement consistently demonstrated higher
microbial counts and greater proportions of suspected
periodontopathogens.
 Generally clinical improvement was found to be less pronounced in
furcation sites than in other locations
(Loos et al. 1989)
 Consequently, teeth with furcation involvement may be viewed with
some caution with respect to long-term prognosis.
When to refer?
 The rationale behind the 5-mm
standard is that the typical root
length is about 13 mm and the
crest of the alveolar bone is at a
level approximately 2 mm
apical to the bottom of the
pocket. When there is 5 mm of
clinical attachment loss the
crest of bone is about 7 mm
apical to the cementoenamel
junction, therefore only about
half the bony support for the
tooth remains.
When to refer?
 Specialist care can help preserve teeth in these
cases by eliminating deep pockets and
regenerating support for the tooth.
 the treatment of periodontal diseases is generally
successful in patients with 6- to 8-mm probe
depths. Success rates diminish when probing
depths are 9 mm or greater, so early referral of
advanced cases is likely to provide the best results.
Reasons for referral
 In addition to the 5-mm standard and evaluation of probe depths, the following factors
must also be considered in the decision to refer:
I. Extent of disease and generalized or localized deep involvement. Extensive bone loss,
even in localized areas suggest the need for specialized reconstructive techniques.
II. Root length. Short roots are more seriously jeopardized by 5 mm of clinical attachment
loss than long roots.
III. Hypermobility. Excessive tooth mobility suggests contributing factors and a more
guarded prognosis.
IV. Difficulty of scaling and root planing. The presence of deep pockets and furcations
makes instrumentation much more difficult and results can often be improved with
surgical access.
V. Restorability and importance of particular teeth for reconstruction. Long-term
prognosis of each tooth is important when considering extensive restorative work
VI. Age of the patient. Younger patients with extensive attachment loss are more likely to
have aggressive forms of disease that require extensive therapy.
VII. Lack of resolution of inflammation after scaling and planing. If inflammation persists,
further therapy is often necessary to gain the most positive results.
 S/RP is an essential part of non-surgical periodontal
therapy ,yet dose not result in complete removal of calculus
.
 Patient motivation and cooperation is important in success
treatment outcomes .
 Self performed OH should be applied regularly and
modified if needed .
 Re-evaluation provides a check for treatment success and
patient’s level of cooperation .
Thank you