5. Non-Surgical Periodontal Treatment Flashcards
What is the Goal of Treatment in Periodontitis?
Elimination of the etiologic factor
Microbial ____
____ host
Elimination of the local contributing factors \_\_\_\_ Pockets \_\_\_\_ - Crown margins Cervical enamel projections \_\_\_\_ groove
Control of the systemic contributing factors
____
Diabetes
____
plaque susceptible calculus overhangs distopalatal
smoking
drugs
Treatment Modalities for Periodontal Disease
____
Local Delivery or Systemic Antibiotics
____
Periodontal Maintenance
scaling and root planing (SRP)
surgical treatment
What is the Goal of Treatment in SRP?
Elimination of the etiologic factor
- ____
Elimination of the local contributing factors
- ____
microbial plaque
calculus
What is the Sequence of Treatment in Periodontal Disease?
- ____ Treatment (non-surgical)
- Re-____
- ____ Treatment (surgical)
- Re-____
- Periodontal ____ (recall)
- Done first. Includes SRP, initial therapy, nonsurgical therapy
- 4-6 weeks later, do reevaluation to see the pt’s response to initial therapy
- If needed, Phase 2 (surgical trx)
A. Whether surgical or nonsurgical, our therapy needs to be evaluated - Reeval part of surgical trx as well. Happens based on what type of therapy (3 mo, 6 mo, 1 year, it depends if regenerative therapy was used or not)
- Perio maintenance is important. In this environment where phase 1 to 3 may take months to years (due to your or their schedules/ school factors), perio maintenance needs to happen after phase 1 and every ____ months.
For example, if we do phase 1 and then we identify a quadrant that needs extra surgical therapy, the rest needs to be ____ until then and the pt needs to be on perio maintenance. Especially in dental school environment, this is where we ____ our patients
phase I evaluation phase II evaluation maintenance
3
maintained
fail
What is Included in the Phase I Treatment?
- Oral ____ Instructions
- ____
- ____ Defective Restorations and Crowns
- ____ of Carious Lesions
- ____ (____ weeks)
hygiene scaling and root planing recontouring management re-evaluation 4-6
What is Scaling and Root Planing?
- Scaling: Removal of ____- and ____gingival plaque and calculus
- Root Planing: Removal of residual embedded ____ and portions of ____ from the roots to produce a smooth, hard, clean surface
Used to be aggressive in the past to the point where cementum would be eliminated leading to sensitivity
We aren’t that aggressive these days (we still want it as smooth as possible to reduce plaque retention), but we don’t want to remove all of the ____. If we remove all the cementum, there will still be bacteria there and in the tubules.
Since we cannot remove all of it, we want to be less invasive and produce as smooth of a surface as possible
supra sub calculus cementum cementum
Scaling and Root Planing
This particular case seen here (from Carranzas textbook). What looks like severe periodontitis (lots of calculus deposits both facial and probably lingually), there is a lot of swelling, erythema, and edema of gingiva.
With ____ alone and no ____ therapy, the local factors have been eliminated (no supragingival calculus seen and likely none subgingival).
The quality of the gingival tissue (color, texture, contour appears more healthy than initially - indicates less subgingival calculus)
SRP
surgical
Scaling and Root Planing
Lingually, you can see calculus deposits clinically and radiographically if this heavy (indicates they have been here a long time)
Something you can use as a tool to ____ to patients. When you have visible calculus deposits you can show, but you can use a radiograph to show subgingival calculus as an educational tool - What/where it is and why it needs to be removed
communicate
Is Non-Surgical SRP an Effective Treatment?
• Long-term Randomized Controlled Clinical Trials w/ Split Mouth Design
• Minnesota studies: SRP - MWF, 6.5 years
• Michigan studies: SRP - SC - APF - MWF, 8 years
• Gothenburg studies: SRP - APF - MWF w/ or w/o OS, 14 years
• Aarhus studies: SRP - APF - MWF, 5 years
• Michigan-Tucson-Houston studies: SRP - MWF - APF w/ OS, 5 years
• Nebraska studies: CS - SRP - MWF - APF w/ OS, 7 years
You do SRP to most pts you see in clinic . Everyone has some sort of plaque removal, but if pt has periodontal disease, plaque removal inclues SRP.
Is this therapy done for bascially everyone with periodontitis effective? We have (1) in perio. Highest level of evidence that we can have. Shows that nonsurgical SRP can be very you trx These studies have been performed around the world (in US and Europe) and have compared nonsurgical therapy (SRP) with you therapy (includes modified widman flap (MWF), subgingival curettage (SG), osseous surgery (OS), Apically positioned flaps (AP), and coronal scaling prophylaxis (CS)). these studies have gone over long term - longest is 14 years (Gothenburg)
effective
surgical
Is Non-Surgical SRP an Effective Treatment?
- All ____ modalities were effective in halting disease progression
- Overall, no significant difference in ____ between treatments
- Overall, no significant difference in ____ between treatments
- Differences between treatments were noted mainly in ____
- Key to success is ____ month recall
Non-surgical SRP is an ____ treatment for periodontitis, even for severe cases
These studies have found that all trx modalities were effective in halting disease progression except for ____ (ineffective and inappropriate trx for periodontitis)
Includes nonsurgical and surgical
Looking at mean data, no significant difference between probing depth and clinical attachment levels (PD and CAL) betwen trx
Differences noted in different groups of teeth were evaluated, eg. Molar respond better in surgical trx
Key to success whether non-surgical or surgical is ____!
treatment PD CAL molars 2-3 effective
CS
Here is his FMX - bone loss that is horizontal
Ranging from 20% to 50 to 60% (underlined on anterior teeth)
Here, we have a loss of ____in certain areas (a hallmark of periodontitis), significant, radiographic calculus deposits (can be sued to educate pts)
Here we have SRP - the only procedure performed here. The right is the reevaluation. These top photos are perio charts (different that those we see in axium).
How that there is red - BOP, green spot, Probing more than 4 mm.
After SRP, pt has minimal ____ and no ____ more than 4 mm - deep areas are improved with SRP alone
crestal lamina dura
BOP
pockets
we have something that could be considered regeneration (probably not), but it is more ____ bone appearing radiographically
dense
What are the Instruments Used for SRP?
• ____ and Curettes
• ____ Instrumentation
SRP can be very effective but in the details, you can say that some people aren’t doing it correctly. The ____ are important (how we do it is important to get desired outcomes to say that they’re as effective as surgical therapy)
These following slides cover some questions whose answers explain how to do a proper SRP
scalers
ultrasonic
details
Are Ultrasonics or Hand Instruments More Effective ?
51 pairs of contralateral single-rooted teeth with PD = 5-7 mm
Randomized controlled clinical trial
____ design
Control: SRP with ____ instruments only Test:
SRP with ____ instruments only
PD, BOP assessed at baseline and ____ weeks
split-mouth
hand
ultrasonic
8
re Ultrasonics or Hand Instruments
More Effective ?
• No ____ between the two methods in any of the clinical parameters measured
• Somewhat less ____ required for ultrasonic instrumentation
Hand instrumentation used to finish to make sure that there is smooth, clean surface.
Ultrasonics don’t have as good of a ____ sense as hand instrumentation. When it comes to clinical outcomes, it doesn’t matter which one you do (but we use both)
difference
time
tactile
How Much Time is Required for SRP?
20 patients with generalized severe chronic periodontitis
Randomized controlled clinical trial
____ design
Control: SRP performed by one experienced operator Test: SRP performed by another experienced operator
6 operators: periodontists and hygienists with ____ years of professional experience
PD, BOP assessed at baseline and ____ months
Split-mouth - ____ of the mouth receives one trx, and a different ____ receive a different trx (a quadrant or a half of the mouth, etc). This takes away ____ (different host factors)
split-mouth
3-14
24
part
part
host variability
How Much Time is Required for SRP?
- ____ minutes per non-molar tooth required by experienced operators to achieve a biologically compatible root surface
- No less than ____ hour per quadrant
10
1
How Much Time is Required for SRP?
- Review of longitudinal studies comparing surgical and non- surgical treatment
- ____ hours for FM non-surgical SRP required by experienced operators
- ____ appointments for FM non-surgical SRP
5-8
2 to 8
Can FM SRP be Completed in One Appointment?
Full mouth disinfection protocol
FM SRP within ____ hours
____ irrigation of pockets and tongue
____ rinse for 2 weeks
24
chlorhexidine
chlorhexidine
Is Full Mouth Disinfection More Effective than Quadrant SRP?
Quirynen’s group: FMSRP is more ____ than QSRP Kinane’s group: FMSRP is equally ____ as QSRP
Consensus: Clinician’s Choice
Full mouth disinfection is ____ as effective as QSRP and we have both options. Clinician (and patient’s) choice for trx.
If pt cannot come by as ____, may want to do full mouth disinfection. If pt can’t stay in chair for long time, may want to break down, but either works for the patient and works well.
effective
equally effective
at least
often
Is Repeated SRP More Effective than a Single Round?
Is Repeated SRP More Effective
than a Single Round?
13 patients with generalized severe chronic periodontitis
Randomized controlled clinical trial
____ design
Control: single SRP session
Test: repeated SRP after ____ and ____ months
PD, CAL, BOP assessed at baseline and ____ months
split-mouth
3
6
24
Is Repeated SRP More Effective than a Single Round?
• Repeated reinstrumentation of the same teeth did ____ yield a better result than one ____ SRP procedure
Emphasis on “thorough”
If you remove calculus that you missed the first time, this is not considered repeated SRP. If you don’t do a good job 1st time, this isn’t what we are talking about.
If it’s the best quality, doing it every 3 months will not improve outcomes 2 years later.
not
thorough
Is Pocket Irrigation with Chlorhexidine Beneficial?
14 patients with generalized severe chronic periodontitis
Randomized controlled clinical trial
____ design
Control: SRP alone
Test: SRP plus daily pocket irrigation with ____ 2%
PD, CAL, BOP, microbiological testing at baseline and ____ weeks
Chlorhexidine is antimicrobial but you have to consider cost and benefit. Cost = money and time. Irrigation of each pocket - is it reasonable amount of time for something that may not be beneficial.
Done irrigation daily - time and pt ____. Pt has to do this irrigation in every pocket every day. If we think pt complies, then we will see what happens with clinical measurements
split-mouth
chlorhexidine
24
compliance
Is Pocket Irrigation with Chlorhexidine Beneficial?
• Pocket irrigation with chlorhexidine is no more ____ than thorough SRP alone
beneficial
Summary on Non-surgical SRP
• ____ is an effective treatment for periodontitis
• ____ hours required for FM SRP
• No ____ between hand instruments and ultrasonics
• No ____ between one thorough SRP procedure and repeated reinstrumentation of the same teeth
• No additional ____ of pocket irrigation with chlorhexidine
• No ____ between FM disinfection and Q-SRP
non surgical SRP 5-8 difference difference benefit difference
What are the Steps for a SRP Appointment?
- ____
- SRP with Ultrasonics
- SRP with ____ Instruments
- Check (visual and tactile)
- ____
- Polishing
Local is needed because in SRP you go ____. Interfering with soft tissue (hurts) and root of the tooth, removing plaque anc calculus from cementum and cementum (also hurts - more or less). This isn’t painless.
It’s not a matter of how much pain pt can take. If they do hurt and they are uncomfortable/moving that doesn’t allow you to do the SRP correctly (cannot go deep enough/ do what you need to do). May keep us from doing what we need to do for our pts.
- Mostly ____ to make sure smooth surface is achieved and calculus is removed. Check this visually and tactilely. You dry and look at it. (Look at enamel and cementum). Tissue/ pockets are usually loser than before and use air-water syringe to irrigate well and blow air in the pockets and see deep in the margin with magnification to see if there is calculus. You can also use calculus detection explorers to see if calculus left on root.
- Flossing. Important because you cant reach ____ with instrument (mechanical (best is ____) or ultrasonics), you cannot reach plaque here.
- Polishing removes plaque you missed supergingivally and stain but helps with hemostasis afterwards
local anesthesia
hand
flossing
subgingivally
curettes
contact point
scaler