Overview of the Non-Surgical Periodontal Therapy

Objectives
o Describe indications, rationale, objectives and outcome of phase 1
periodontal therapy
o Define what is nonsurgical therapy
Scaling vs. Root planing
o reestablish periodontal health in patients by reduction of putative
periodontal pathogens
o Return periodontium to health
o Maintain health with professional and patient self-care
Non-Surgical Periodontal Therapy
o Includes all nonsurgical treatment and educational measures used to
help control gingivitis and periodontitis

o
The difference between Prophylaxis and SRP
o Prophylaxis
Patient with
Gingivitis
No attachment loss
present
Includes removal
of supra- and
subgingival plaque,
calculus and stains
Does not require
anesthesia
Done in one
appointment
o
o
o SRP
What
o
o
o

should be in phase I?
Oral hygiene instructions (D1330)
Tobacco cessation (D1320)
Caries control program

Patient with
Periodontitis
Attachment
loss/bone loss
present
Includes removal
of supra- and
subgingival plaque,
calculus and stains
May include
removal of
cementum
Does require
anesthesia
Requires more
than 1
appointment

o Management of secondary etiologic factors

o Prophylaxis (D1110) and/or
o Scaling and root planing (D4341 or D4342)
o Periodontal reevaluation (D0170)
o Decision for Periodontal maintenance interval (D4910)
Indications for Nonsurgical Therapy
o All patients with plaque-associated gingivitis or chronic periodontitis
o Even those patients go through nonsurgical therapy first, this phase of
treatment may minimize extent of surgery needed
o Surgery is indicated for patients with more advanced periodontitis
Goals of Nonsurgical Therapy
o Minimize bacterial challenges to patient
o Eliminate or control local risk factors for periodontal disease
o Minimize impact of systemic risk factors for periodontal disease
o Stabilize attachment level
Minimize Bacterial Challenge
o Controlling bacterial challenges requires:
Intensive educational training
Retraining in oral hygiene
Removal of hard and soft tooth deposits
Eliminate or Control Systemic Risk Factors for Periodontal Disease
o Eliminate or control systemic factors
Smoking
Diabetes
o Physician evaluations
o Smoking cessation programs
Minimize Impact of Local Risk Factors for Periodontal Disease
o Eliminate local risk factors
Replace defective restorations
Straighten malaligned teeth
Smooth rough surfaces
Stabilize Attachment Level
o Ultimate goal of nonsurgical therapy
o Attachment levels stabilize with control of local and systemic risk
factors
Rationale for Instrumentation
o Physical removal of microorganisms and by products to prevent and
treat periodontal infection
o Physical removal of bacterial plaque is the most effective mechanism
of control
o Subgingival plaque within pockets cannot be reached with a toothbrush
or floss
o Pockets must be instrumented to disrupt bacterial colonies
Rationale for Instrumentation
o Arrest progress of periodontal disease
o Induce changes in subgingival bacterial flora ie (from gram to gram
+)

Create an environment that permits gingival tissues to heal

Convert pocket from one with attachment loss to one where it remains
the same
o Eliminate bleeding
o Increase effectiveness of patient self-care
Definition of Scaling and Root Planing
o Scaling
Instrumentation of the crown and root surfaces
Removes plaque, calculus, and stains
o Root planing
Removes disease cementum that is permeated with calculus or
toxins
Instrumentation of root surfaces until smooth and glassy
Manual instrumentation is an essential skill for a dentist in order to
obtain good results form initial non surgical therapy
o Scalers
Anterior
Posterior
o Curettes
Universal
Site specific Gracey Curettes
o Power devices
Sonic
Ultasonics
Scalers
Are designed for removal of supragingival plaque, calculus and stains
CurettesAre designed for subgingival instrumentation
but can be used for supragingival scaling also
o Universal curettes
o Site specific Gracey Curettes
You should make a determined effort to overlap the instruments at
the line angles
Power Instruments
o Sonic and ultrasonics scalers are used for plaque, calculus and stains
from tooth and root surfaces.
Manual Instruments
o There are some studies that show manual instrumentation is more
effective than ultrasonic instrumentation in calculus removal
Power instruments have also been shown to access concavities and
furcation of the roots better that manual instruments
Comparison of hand instruments and ultrasonic scalers
o Calculus removed in a
Ultrasonic instruments
corono-apical direction
o Less fatiguing
Hand instruments
o Very light pressure
o More fatiguing
o More patient comfort
o Heavier pressure
o
o

Less patient comfort

Calculus removed in
apico-coronal direction

Calculus Detection and Removal Tips

Tactile detection using the ODU 11/12 explorer
o Tactile location of subgingival calculus with the ODU 11/12 explorer is
an important part of successful SRP
o To detect calculus effectively, light pressure and apico-coronal
movement of the ODU 11/12 explorer is recommended
Technique Tips
o Before you start SRP, review probing depths and radiographs
o Explore pockets with the 11/12 ODU explorer to locate calculus
o Start with the ultrasonic scaler.
o After removing supra and subgingival calculus with the ultrasonic
scaler, re-examine the pockets with the 11/12 ODU explorer.
o Use hand instruments to obtain a clinically smooth surface
Sites where calculus is left after SRP
o Under the contact point
o On interproximal surfaces
o At CEJ
o At the line angles
o Deep in the pocket
o In the furcation
Tissue Healing Post SRP
o End point of instrumentation is to convert the soft tissue to health
What is the effect of scaling and root planing on the subgingival
biofilm?
o A significant reduction in numbers of bacteria (> 90%) can be achieved
o The reduction in microorganisms is temporary ~2-3 months
o Numbers of bacteria return to pretreatment levels more quickly in deep
pockets compared to shallow pockets
o Scaling and root planing is only partially successful
in removing all subgingival calculus.
o More calculus is left in deep pockets than in shallow pockets

Healing After Root Planing

o Primary pattern is through formation of a long junctional epithelium
Can result in reduced probing depths
o No formation of new bone, cementum, or periodontal ligament
o After treatment tissue heals by forming a long junctional epithelium
o Results in (was 6) 2mm probing depth
o NO formation of bone, cementum, or periodontal ligament fibers.
Assessing Tissue Healing
o Tissue healing does not occur overnight
o Usually assessed at least 1 month after instrumentation

Reevaluation should be scheduled 4 to 6 weeks after completion of

instrumentation
Nonresponsive Sites
o Nonresponsive sites show continued loss of attachment, inflammation,
and bleeding
o Sites should be reevaluated with an explorer for presence of residual
calculus deposits or roughness
o Pockets too deep to remove the residual calculus and therefore surgery
may be indicated
Successful periodontal debridement always results in the complete removal
of cementum form the exposed root surfaces.
True
False
What type of healing occurs following successful root planing?
o Connective tissue attachment
o Epithelial attachment (repair)
o Bone attachment
o Osteoblast attachment
The main objective of root planing is:
o To remove chronically inflamed tissues
o To change the bacterial microflora
o To provide optimally smooth root surfaces
o To eliminate pockets
o