Chapter 21: Response to NonSurgical Therapy
NonSurgical Periodontal Therapy
initial phase is control of the supra gingival microbial biofilm and disruption or removal of sub gingival gram negative microbiota
it is essential to control the supra gingival microbial activity through oral hygiene self care and sub gingival biofilm removal
sub gingival debridement decreases the number of periodontal pathogens such as P. gingivalis and P. intermedia
therapy based on returning the gingival tissue to a healthy, non inflamed state
Terminology
scaling = the mechanical removal of supra and subgingival dental biofilm, calculus, and stains (tooth accumulated materials ) from crown and root surfaces
root planning = definitive treatment procedure designed to remove cementum or surface dentin that is rough, impregnated with calculus, or contaminated with toxins or microorganisms
periodontal debridement = removal of any foreign material, including dental biofilm, its by- products and toxins, calculus, and diseased or dead tissue, from coronal tooth surfaces, root surfaces, sulcus or pocket, and periodontium (supporting bone)
Deplaquing - mechanical disruption of non attached, free floating sub gingival biofilm and its by products from the sulcus or pocket
prophylaxis = removal of biofilm, calculus, and stains from the exposed and unexposed surfaces of the teeth by scaling and polishing as a preventative measure for the control of local irritants
Periodontal Debridement
dental hygienist should strive to remove as much sub gingival calculus as possible because it can affect biofilm accumulation
remains the foundation of nonsurgical periodontal therapy
One clinical study reported that in the presence of supra gingival biofilm, a sub gingival microbiota containing greater than 5% spirochetes and motile rods was reestablished 4 to 8 weeks after periodontal debridement
purpose: to treat and resolve inflammation in the periodontal soft tissues by removing irritants, which are supra gingival and sub gingival biofilm and calculus
indicated at sites showing 1) signs of gingival inflammation 2) elevated levels of bacterial pathogens 3) progressive attachment or alveolar bone loss
Outcomes : preservation in the form and function of dentition
care in selecting sites that will benefit from sub gingival debridement is essential in the prevention of CAL
Subgingival Microbiota
After debridement the number of gram negative microorganisms decreases, especially spirochetes and the number of gram positive rods and cocci increases . this may be ineffective in eliminating Aggregatibactor actinomycetemcomitans .
Perio debridement procedures
decreased probing depths primarily due to gingival shrinkage may cause gingival recession and longer looking teeth that may respond with hypersensitivity
ER:YAG laser, selectively removes calculus , may cause less damage to the cementum
Subgingival Debridement
goal: a root surface free of biofilm, calculus, and endotoxins to enable soft tissue healing
smoothness is not adequate for tissue healing Teeth with furcations have higher frequency of residual calculus
Endotoxins are highly toxic compounds that are capable of penetrating the JE and entering connective tissue resulting in destruction of periodontal tissues. The endotoxins activate the inflammatory response which causes loss of connective tissue attachment from the root surface, apical migration of JE and bone loss
Healing response and Outcomes of therapy
In disease : The probe penetrates the tissue apical to the JE (pocket), giving deeper probe readings. This occurs because the connective tissue of the gingival tissue contains less collagen and more inflammatory cells
In gingivitis : the tissues will heal with approximation of the JE to the tooth surface
In periodontitis: After root planning, the tissues heal by formation of a long JE attachment to the root surface
healing will most likely occur by repair (long JE) rather than regeneration
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Tissue Response
visual inspection for inflammation and tissue color can be evaluated after one week
Re-probing recommendations range from a minimum of 4 to a maximum of 8 weeks after periodontal debridement to allow for tissue healing, waiting longer than 6 weeks may augment the response
If results of initial therapy show improvement, but with some residual 5mm probing depths, the patient should be placed on periodontal maintenance and reevaluated in 2 to 3 months because this is about how long it takes for bacteria to repopulate subgingivally after debridement
Shift should be from gram negative to gram positive species such as cocci or non-motile bacteria
Lasers
Approved by FDA, but ADA states that clearance by the FDA may not be enough to ensure safety, efficacy, or effectiveness for marketed lasers in all cases
Er:YAG wavelengths are highly absorbed in both water and hydroxyapatite which permits it to be used for soft tissue incisions , curettage, and scaling of root surfaces, and bone reconturing during flap surgery
The CO2 laser should avoid contact with teeth
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shown effective for root debridement
Reflection Since I started seeing patients they have all been deposit 3's. While they don't have excessive bone loss, I have witnessed the inflammatory response due to sub/supra gingival calculus, including gums that bleed excessively when probed. I can't wait to be able to treat these types of patients. I was so upset when I found out that I cannot yet see them as patients. Seeing the build up of calculus on teeth makes me excited to educate my patients about oral hygiene and proper home care.