Non-surgical Periodontal

Therapy

Dr. Cheng Zi Hui

Unit Pakar Periodontik, KPBJ 1
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Mechanical Hand Instrumentation
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2 types:
- Straight blade
- Curved blade

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 Curettes

Instruments of choice for root planing

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The root cementum is only between 0,03 and 0,1 mm thick in the coronal third of the root. Therefore 10-20
strokes with a curette or 5-10 rotations with a 15 micron diamond bur may result in the complete removal of the
root cementum. This can lead to an invasion of subgingival microflora in the dentinal tubules which may result
in an infection of the pulp. Additionally, microflora and their toxins in infected root canals may go the other way,
which will lead to disturbances in the healing of the periodontitis.
Ref. Prof. Per Axelssons book Professional Mechanical Tooth Cleaning (PMTC), Finishing and Minimally
Invasive Treatment of Caries and Periodontal Diseases – Materials, Methods and Effects”.

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Ultrasonic Debridement
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Supragingival & Subgingival
Irrigation
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How did the literature find the efficacy of
each method? Recommendations?

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 Mechanical instrumentation
• effective for majority of mild to moderate
chronic periodontitis (CAL <5mm)
• reduce probing depths, gain clinical
attachment, inhibit disease progression
Initial pocket depth Mean pocket depth Gain of clinical
reduction attachment
4-6mm 1.29mm 0.55mm

>7mm 2.16mm 1.29mm

Cobb: probing depth reduction usually was greater at sites with larger initial probing depths -
gain of clinical attachment and recession
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• Most healing occurred after 6 weeks but
repair can continue for 9 months
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• Most clinical trials (which often show that
nonsurgical and surgical therapy achieve
equivalent results) usually did not provide
fair comparison, esp at PPD >6mm
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• Hujoel et al. reviewed 10 studies and
reported there only 14% chance of
achieving fair assessment btw nonsurgical
and surgical therapy, as too few deep sites
were included 94
• Clinicians need to consider these factors when contemplating
nonsurgical therapy:
- efficacy of SRD
- predictability of bone fill in an angular osseous defect
- bacterial suppression
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• Caffesse et al. demonstrated that when pockets >5mm,
clinicians often failed to adequately debride root surfaces and
removed deposits completely only 32% of the time
• Cobb found that limited bone fill occurred after root planing in
cases of angular osseous defects
• Laurell et al. found that more bone deposited after OFD with
bone grafting of GTR
• Nonsurgical therapy also not effective in suppressing A.A.
because this bacterium is tissue-invasive. Therefore, if patients
with aggressive periodontitis who do not respond to conventional
therapy, might be necessary to perform a microbiological test to
determine appropriate antibiotics to be administered
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 Conclusion
• Mechanical therapy is effective for majority patients with
mild-to-moderate chronic periodontitis
• Before selecting definitive tx method, need to consider
the severity of the periodontal condition, magnitude of
probing depths, desired outcomes for each patient and
evaluate the potential of mechanical instrumentation
• In general, mechanical instrumentation has been
successful in stabilising clinical attachment levels for
most patients with mild-to-moderate periodontitis
• However, if bone fill or major probing depths reductions
are desired outcomes, then surgical procedures may be
needed
• Most importantly, after nonsurgical or surgical tx, need to
be monitored periodically to determine if disease
progression has occurred 96
 Ultrasonic Debridement
• Numerous studies shown that ultrasonic achieved
similar results to root planing
!Initial probing reduction after root reduction after ultrasonic
depth planing debridement
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>4mm 1.20 - 2.3 mm 1.70 - 1.9mm
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• Ultrasonic debridement will not cause over
instrumentation of the roots which will cause
dentinal hypersensitivity
• Less chair time and operator fatigue
• However, root planing attains smoother root surface
at microscopic level (but no significant difference)
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• Most studies reported no benefit from using CHX as irrigant
via ultrasonic
• However, other studies noted an improved results when
povidone iodine (PVP-I) eg. Betadine, Purdue Frederick is
used at deep sites >6mm
• PVP-I sold commercially as 10% concentration (1/10 is iodine)
• Clinicians can dilute by using 3 parts of water to 1 part PVP-I,
resulting in a 0.25% iodine concentration (min bactericidal
concentration needed to kill P. Gingivalis in 5 mins
• Problems with ultrasonic include aerosols which develop
within several feet of the operator and remains in the air for
30 mins
• Clinicians should wear a mask, use high speed suction and
ask patient to pre-rinse to reduce amount of bacteria in the
saliva
• Overall, ultrasonic is as effective as root planing and the
addition of medicaments as irrigant in deep probing depths
may provide some benefit 98
 Supragingival Irrigation
• Several studies shown that irrigation with
medicament achieve better result than
rinsing with antimicrobial agent
• A study shows that 0.02% CHX delivered
with an irrigator achieve similar result to
0.2% (can dilute 0.12% CHX m/w with 5:1
water:CHX)
• supragingival irrigation good as adjunct,
NOT to be used as substitute for
toothbrushing 99
6 different studies show gingivitis reduction ranged from 6.5% to 54.0%
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 Subgingival irrigation
• 8 studies indicated that irrigation did not enhance
result attained with root planing alone
• 6 other studies noted an additional effect, but only
minimal improvement
• 1 study buy Christersson et al. noted that prolonged
irrigation (5 mins each tooth) with high concentration
of tetracycline (10%) used with root planing enhanced
gain of clinical attachment compared with root planing
alone (1.8mm vs 1mm). However after 6 months no
significant difference
• Overall, subgingival irrigation usually does not provide
any reduction of inflammation, probing depth
reduction or clinical attachment gain 101
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CONCLUSION

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