Diana Howsare

October 3, 2020

Periodontal Disease
Periodontal Treatment

Periodontal disease is collectively any disease of the periodontal tissues such as the alveolar

bone, periodontal ligament, cementum, and gingiva. These diseases not only have an affect on

the tooth and their surrounding structures, but on the body as a whole. Clinically these diseases

will manifest as inflamed or receded gingiva, increased probing depths, and alveolar bone loss.

Periodontal disease is predominantly caused by bacteria present in the oral cavity particularly in

biofilm. Some of the primary bacteria involved in these infections are Porphyromonas gingivalis,

Tannerella forsythia, and Aggregatibacter Actinomycetemcomitans. In addition to bacteria, there are other

factors and determinants that play a role in the disease. Diabetes, smoking, immunosuppression,

medications, hormones, age, and gender are a few; some of which can be controlled by the

patient and some of which cannot.

While periodontal disease is not reversible, there are treatments which can stabilize the

disease. One of the most common methods is non-surgical periodontal therapy also know as,

periodontal debridement or scaling and root planing. This can further include chemotherapeutic

agents such as antibiotics. Other methods of treatment are periodontal surgeries including

procedures for the following: pocket reduction or elimination, osseous defects, mucogingival

defects, regeneration of the periodontium. One, or a combination of treatments is effective a

majority of the time, with only 8-14% of patients developing refractory periodontitis after

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treatment for chronic periodontitis (Clark, 2020). A key component in treatment and success no

matter which method is used however, is home care and plaque control. Many of the treatments

are centered around doing just that, or making it easier and more effective for the patient to

control biofilm on their own. Because the bacteria leading to the disease processes preside in the

biofilm, without effective removal daily and throughout treatment, the effectiveness of the

treatment is going to suffer. This could lead to ineffective treatment and continued progression of

the disease.

As stated before, scaling and root planing is one of the most common treatments and is

often used for less severe periodontal disease. As any treatment for periodontal disease, the scaling

and root planing route of treatment starts off with controlling any risk factors possible and

altering patient behaviors to be the most beneficial for successful treatment. Given the deeper

pockets and/or more exposed tooth structure with periodontitis, local anesthesia can be used for

patient comfort and ease of treatment for the clinician. Tactile and visual evaluation of the teeth

designated for treatment is then used to develop a plan. For scaling and root planing, either hand

instruments can be used, or a combination of hand instruments and an ultrasonic scaler. Using

an ultrasonic scaler does come with the added benefit of also irrigating the sulcus of plaque and

calculus. Even with the use of an ultrasonic scaler, hand instruments are necessary for scaling and

root planing. The clinician will use them to very thoroughly scale every surface of the tooth,

making sure to remove all off the plaque and calculus. The root surface will also be debrided,

leaving the cementum a smooth surface that will limit bacterial formation and aid in healing.

Depending on the number of teeth needed treated, this could take multiple appointments. After

the scaling and root planing is completed, a chemotherapeutic agent such as chlorhexidine,

doxycycline, or minocycline can be placed in the pocket to reduce the current bacteria in the

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pockets and help prevent new bacteria from colonizing during the healing process. These agents

are not a component of scaling and root planing itself, but an adjunctive treatment that often

goes along with it. After the scaling and root planing treatments are complete, the patient should

have a follow-up appointment in four to six weeks. This appointment is to re-evaluate the patients

condition and ensure the treatment was successful or adjust the treatment plan as necessary.

Probing levels, bleeding, and plaque indexes are some of the methods that can be used to

evaluate for effective treatment. At each appointment it is very important to stress the importance

of them having good home care. Not only during the treatment and healing period, but to

continue in the future to help maintain the level of disease and not let it progress. A dental

hygienist can perform all of these necessary components of treatment for non-surgical scaling

and root planning for a patient. The patients that are ideal candidates for this method of

treatment are those with less severe periodontitis. Research showed that 74% of patients with

initial probing depths of more than 9 mm compared to 26% of patients with initial probing

depths of less than 9 mm were able to achieve pocket depths of 5 mm or less after the non-

surgical treatment (Van der Weijden, Dekkers, & Slot, 2019). While less severe cases are ideal,

deeper probing depths still can be successfully treated. Overall this treatment method costs

around $150-250 for up to a quadrant of teeth.

Scaling and root planing can be very beneficial to a patient in a variety of ways including

but not limited to the following: improved health of periodontal tissues and overall health,

improving ease of maintenance, effectiveness, less invasive, and potentially lower cost and time

than surgical methods. By removing the plaque and calculus and smoothing the root surface, not

only is the volume of bacteria reduced, but the ability to maintain this is improved. The smooth

tooth surface is more resistant to new accumulation of biofilm and beneficial to the healing

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process of the gingiva. This will lead to decreased probing depths, less bleeding, lower plaque

scores, and healthier tissues in general when successful. Once the tissues do heal, that level of

health could then potentially be maintained for the rest of the patients life—which is great news

for the patient. Successful treatment is always the goal but no treatment has perfect success rates.

Myneni and Cobb (2018) report, however, that only about 10% of patients are not able to

achieve the desired outcomes with non-surgical treatment alone. Being able to avoid surgical

treatment options comes with the benefit of shorter treatment time and a less invasive option

which is beneficial to patients. While scaling and root planing may be quite expensive for each

quadrant of the mouth the patient needs treated, the overall cost would still be less than surgical

methods. Overall this is the treatment of choice for many patients because it’s effective, less

invasive, and saves the patient time and money over surgical methods.

There are some downfalls to scaling and root planing, however, such as patient compliance,

unsuccessful outcomes, cost, loss of tooth structure, and post-op sensitivity. One of the key

components is the level of patient compliance needed for success. While this is the case with all

treatments, needing the patient show for appointments, come in more often for maintenance,

possible lifestyle changes and have very good home care are all components to treatment that can

lead to unsuccessful treatment if not fully achieved. Even with excellent patient compliance

sometimes the treatment is still considered unsuccessful. Treatments are considered unsuccessful

if they do not reach the desired outcomes. This is often measured by re-evaluation such as “a

decreasing plaque index ≤ 10%, bleeding on probing ≤ 20%, probing depths ≤ 4 mm, mean

gain and stability of CAL, maintenance of alveolar bone height, and preservation of form and

function of dentition” (Myneni & Cobb, 2018). While different studies and research show

different results, a study by an der Weijden, Dekkers, and Slot only had a success rate of 47% on

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molars (2019). This can be discouraging especially for a patient who is paying for the treatment.

On top of the normal fee for just a quadrant of treatment, if a chemotherapeutic agent is used

such as Atridox, there is an additional fee which can add up significantly. Another component to

consider is the loss of tooth structure for the patient. While not much, some cementum is scaled

off in order to make the surface smooth. This treatment can also result in sensitivity. The

sensitivity typically resolves within a few weeks, but can cause discomfort for the patient.

To have the highest possibility of successful periodontal treatment with scaling and root

planing there are expectations of both the patient and the dental hygienist. The success of

treatment is linked with the patients dedication and motivation to improve their health. The

patient needs to be informed on the disease process and treatment plan. This will give them the

opportunity to consent to treatment and understand the consequences if not treated or

unsuccessful treatment. The patient is also expected to diligently maintain their oral health and

biofilm control in addition to overall health. If the patient does all of this and continues to come

to appointments and actively participates in their treatment process, favorable outcomes are more

likely. A lot of the patients expectations are connected to the dental hygienists expectations. The

dental hygiene process of care is followed for all treatment types, and this is no different. The

dental hygienist is expected to assess, diagnose, plan, implement, evaluate, and document the

patient’s care. After the dental hygienist has determined with the patient that scaling and root

planing is going to be the treatment of choice, risk factors and determinants should be reviewed

and controlled when possible. This can involve the dental hygienist encouraging the patient on

this from seeking medical care for uncontrolled diabetes to receiving smoking cessation. The

clinician is then expected to follow through with the treatment including reevaluations and either

maintenance or referring them to surgical treatment methods. These follow up appointments are

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where the patients regular dental care visits will differ. Not only should the patient come in for a

four to six week reevaluation after the treatment, but if it was successful they will continue to be

on a periodontal maintenance program for the rest of their life. This will entail appointments

often being every three to four mouths as opposed the common six months. A patient can stay on

this maintenance for the rest of their life and the level of periodontal health could never change.

This is dependent partially on the home care the patient is doing both during and after

treatment. The dental hygienist needs to use motivational counseling to encourage the patient to

alter their home care. This can include establishing a routine for home care lessons like brushing

and flossing, but also learning how to use new products such as interdental brushes, rubber tip

stimulators, water irrigators, and tongue scrapers. For example, even just string floss may not be

effective, as it would with a healthy patient, because of the loss of interdental papilla. Rubber tip

stimulators and water irrigators can both be used by the patient to stimulate the gums and

provide plaque control. While all of this an expectation of the dental hygienist to inform the

patient, it falls into the patients hands what they choose to do with it. A key component in

determining the success of treatment comes back to patient compliance. While there are a lot of

roles the dental hygienist plays in the treatment that also effect the outcome, there is only so much

the clinician can do to get the patient on the right track to healing. If the patient doesn’t do

anything on their end and isn’t compliant, treatment can only go so far. Periodontal treatments

require a lot from the patient regarding home care and treatments. Not being treated, not

showing up for appointments, and not executing home care are just some of the compliance

issues that can hinder the patients treatment. Overall, however, if everyone does their part

throughout the process of care then the patient can look forward to improved periodontal health.

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 References

Boyd, L. D., Wilkins, E. M., & Wyche, C. J. (2017). Clinical practice of the dental hygienist. (12th ed.).

Wolters Kluwer.

Clark, S. (2020). Perio PPT. [PowerPoint slides]. talon.kirkwood.edu

Lavigne, S. E. (2020). The 2018 AAP/EFP classification of periodontal & peri-implant diseases.

dentalcare.com. https://www.dentalcare.com/en-us/professional-education/ce-courses/

ce610

Myneni, B. D., Cobb, C. M. (2018). 7 Steps to the nonsurgical treatment of periodontitis.

Dimensions of Dental Hygiene, 16(11), 39–42. https://dimensionsofdentalhygiene.com/

article/7-steps-to-the-nonsurgical-treatment-of-periodontitis/

Perry, D. A., Beemsterboer, P. L., Essex, G. (2014). Periodontology for the dental hygienist. (4th ed.).

Elsevier.

Van der Weijden, G. A., Dekkers, G. J., & Slot, D. E. (2019). Success of non‐surgical periodontal

therapy in adult periodontitis patients: A retrospective analysis. International Journal of

Dental Hygiene, 17(4), 309-317. https://doi.org/10.1111/idh.12399

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 For the patient to successfully comply, they need to be informed and consent to the

treatment which is where one of the roles of the dental hygienist comes in.

DHYG

explain tx to pt and receive consent on the planned tx

inform pt of their expectations

encourage patients to do what they can to achieve or maintain a healthy lifestyle: seek

medical care for uncontrolled diabetes or smoking cessation for a smoker

homecare, appt compliance,

develop tx plan, treat, re-eval, maintenance, prepared for side effects/sensitivity, pt

motivation, OHI

POI, tooth sensitivity, home care

recall length

increased, string floss may not be enough interdental brushes, rubber tip stimulators,

brushing on gingival third of tooth not just crown, irrigation, tongue

https://dimensionsofdentalhygiene.com/article/7-steps-to-the-nonsurgical-treatment-of-

periodontitis/

https://onlinelibrary.wiley.com/doi/full/10.1111/idh.12399

https://doi.org/10.1111/idh.12399

https://www.dentalcare.com/en-us/professional-education/ce-courses/ce610/conclusion

Boyd, L. D., Wilkins, E. M., & Wyche, C. J. (2017). Clinical practice of

the dental hygienist. (12th ed.). Wolters Kluwer.

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