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
What is the Sequence of Treatment in Periodontal Disease?
- Re-evaluation
Now you need Reevalulation ____ weeks later.
You may be confused between reeval and recall. Reevaluation - evaluation ____ weeks after initial trx
Recall - maintenance every ____ mo
4-6
4-6
3
Additional Treatment Following Re-evaluation
Active therapy should continue until all areas of unresolved disease have been eliminated
NON-SURGICAL Isolated \_\_\_\_ with residual inflammation • Sites with PD < \_\_\_\_ mm • Detectable calculus that can be \_\_\_\_ • \_\_\_\_ contributing factors
SURGICAL • Many sites with residual \_\_\_\_ • Sites with PD ≥ \_\_\_\_ mm • Tenacious calculus that cannot be \_\_\_\_ • \_\_\_\_ contributing factors
sites
5
removed
correctable
inflammation
5
removed
local
hy is Long-Term Use of Antimicrobials (chlorhexidine) Not Recommended?
- ____ of teeth, some restorative materials and tongue
- Increased ____ formation
- ____ alteration
- Oral mucosal ____
staining
calculus
taste
erosion
Local Deliver Chemotherapeutics Commercially Available in the US
- Actisite ®, TCN HCl fibers
- Arestin ®, MINO HCl 1mg microspheres ($11-16/cartridge/pocket)
- Atridox ®, DOXY HCl 10% polymer gel ($40-60/500ml syringe)
- PerioChip ®, CHX gluconate 2.5mg
Actisite - commercially was available. Tetracycline ____
Arestin - (minocyclin), ____ (powder form in cartridge that you can inject into pocket), one of
top 2 local delivery antibiotic (Ab). 1 pocket/cartridge. 1 cartridge = $11-16. Need to think about ____ for pt - if you have generalized pockets, does this make sense
Atridox - 2nd local delivery Ab that is commercially available in the US. ____ gel in a syringe. Each can treat ____ pockets. Cost listed for math
PerioChip - chlorhexidine ____ to be placed in pocket. Not ____ friendly to put in pocket and would fall out. Effective, not user friendly, not used much any more
fibers
microspheres
cost
doxycycline
10
chip
user
Are Local Delivery Chemotherapeutics Safe and Effective?
• Systematic review and meta-analysis of 32 studies
• Minocycline gel and minocycline microspheres, when combined with
____ have a statistically significant ____ effect on PD reduction
• Chlorhexidine chip and doxycycline gel, when combined with ____
have a statistically significant ____ effect on CAL gain
• No significant ____ events observed with any of the local drug delivery systems.
adjunctive
SRP
adjunctive
SRP
When is Local Delivery Indicated Following SRP?
- Consensus report of the 2003 Workshop
- ____ evidence to support the benefit of the adjunctive use of minocycline gel and microspheres, chlorhexidine chip and doxycycline gel
- The clinician’s decision on the use of adjunctive local drug delivery should be based on ____ judgment, the ____ of treatment and the patient’s ____ and preferences
moderate
clinical
phase
status
When is Local Delivery indicated Following SRP?
Based on the literature, as well as cost and benefit:
____ sites that do not respond to SRP or surgical treatment after all local etiologic factors have been ____
Individual ____ sites during periodontal maintenance
Emphasizes “Individual sites”.
If pt doesn’t respond to ____ or surgical trx (this at any point during pt’s trx).
These sites are good candidates for utilizing local delivery chemotherapeutics.
Make sure etiologic factors have been ____. If there is still calculus in pockets, Ab placed on top will not do ____ (especially in long term)
Sites that you have seen and treated and pt is on maintenance, you will have sites that will get worse. As long as you don’t have ____ during perio maintenance, this is a good indication to use these local delivery devices on refractory sites
individual
removed
refractory
SRP
removed
much
calculus
Systemic Antibiotics in Periodontal Disease
This shows a diagram from the Carranza textbook. The white bars are Ab (systemic mostly, some local). Start at ____ and pink boxes are surgery. Phase 1 happens first and we see if there is resolution, then we consider ____ (not considered before SRP is ____).
SRP
antibiotics
done
Why are Systemic Antibiotics Contraindicated without prior SRP?
Reduced marginal inflammation with residual apical calculus can lead to :
‣ ____
‣ ____ formation
Systemic Ab’s are contraindicated without prior SRP because without SRP there are deep pockets with residual apical calculus in pockets. When pt takes Ab, there is reduction in inflammation, this can allow soft tissue to tighten around teeth and cause:
____ (false negative results, less BOP, tighter tissue around the tooth but there is still calculus)
periodontal abscess formation - when soft tissue is tighter but calculus under the gingival margin, this leads to abscess because extra ____ fluid has nowhere to go in a tight sulcus/ pocket.
If we use adjunctive systemic antibiotics, we have to use them right after SRP completed or in conjunction with SRP after it has been completed OR (as seen in Carranza’s diagram) you can use at different points in trx but after initial SRP is done.
disease masking
periodontal abscess
disease masking
gingivocrevicular fluid
Should Systemic Antibiotics be Routinely Used
in Periodontal Disease?
12 Swedish patients with generalized severe chronic periodontitis
____ month randomized controlled clinical trial
No ____ vs ____ alone vs ____ alone vs ____
PD, CAL, BOP and ____ microscopy assessed at ____, 2 and ____ months
Ongoing question from the late 70s that’s coming up again since 2010. reads question
One could think that this is a disease of mainly bacterial origin, Ab kill bacteria, and should be used and won’t be bad. For a long time we didn’t use Ab’s routinely (possibly for some cases)
In the late 70’s, Max Listgarten (who was faculty here :O) asked this question when in Sweden reads bullet points
6 treatment SRP TCN SRP + TCN plaque baseline 6
Should Systemic Antibiotics be Routinely Used in Periodontal Disease?
- No significant difference in ____ measurements between test groups
- Once an antibiotic regimen is discontinued, the pathogenic bacteria rapidly ____
clinical
return
Should Systemic Antibiotics be Routinely Used in Periodontal Disease?
47 patients with generalized severe chronic periodontitis
____month randomized controlled clinical trial
FM ____ + placebo vs FM debridement + ____,
____ for 1 week
PD, CAL, and BOP assessed at baseline and ____ months
For a long time, we haven’t routinely used Ab in trx of periodontal disease. It was a yes/no question. Should we use SRP or Ab’s in every case
In the early 2000’s, new research shows cases that benefit from thoughtful use of Ab (not indiscriminate use)
This research is from Switzerland reads bullet points
Certain rationale about using a wide spectrum Ab combined with one that targets Gram -
6 debridement amoxicillin metronidazole 6
Should Systemic Antibiotics be Routinely Used in the Treatment of Periodontitis?
Results of study. Well-designed but had an issue…This was a 6 mo study with NO perio ____. They should have known that maintenance is the key to success.
They should know from Listgarten that when you discontinue Ab, ____ effect goes away. if you don’t maintain the outcome, there’s no ____ (same with SRP alone)
maintenance
additive
maintenance
Should Systemic Antibiotics be Routinely Used in the Treatment of Periodontitis?
No significant difference in average ____ measurements between test groups
PD > ____ mm significantly ____ in antibiotics group at 6 months
They did site specific analysis and found that when residual probing depths of 4mm+ (our cutoff for surgical trx), they found ____ proportions of this site in the Ab group in 6 mo
If you can do SRP AND give antibiotics you are lowering number of sites that require ____ at 6 mo.
clinical
4
lower
lower
surgery
What is the Most Efficient Protocol for the Non-Surgical Treatment of Periodontitis?
Issues with the study: no perio ____ at all, and the study only lasted 6 months (not very long).
There are studies that last 14 years, comparatively this study didn’t last very long.
Years ago they conceived a similar but different study (Penn Initial Phase Efficiency Study) - now is nearing completion (done on April 1st). they are looking at 2 different types of protocols for nonsurgical trx of perio disease.
Conventional = ultrasonics, hand instruments, whatever is necessary
The other group has only ultrasonics (no ____ instrumentation), and in 1 visit, and with adjunctive Ab
Looking at clinical and microbiological testing and blood sample for immune indices.
The concept is not to compare multiple v 1 visit or Ab v no Ab nor ultrasonics v non-ultrasonics. The concept is to look at ____ very different protocols.
There are many issues for skipping the initial phase ____ (even though it would save pt time and money for SRP)
maintenance
hand
2
SRP
When are Systemic Antibiotics Indicated for Periodontal Disease?
Periodontal Abscess with ____ manifestations
____ and Periodontitis
____ with Aa (former LJP)
____
Always in conjunction with ____ debridement
- Include fever, malaise, lymphadenopathy
- In NUG or NUP
- Formally localized periodontitis or former Localized Juvenile Periodontitis. Does not exist any more these days but has characteristics (molar incisor pattern) that helps us decide this was formerly LAP/LJP
- Very few cases. Mechanical debridement (surgically/non surgical) are effective, but if pt has compromised ____ with refractory sites, that’s a place we can use additional Ab.
Remember: No mater what we do with Ab, we use IN CONJUNCTION ____ debridement If not, you can mask ____ and create potential of____
periodontal abscess
necrotizing ulcerative gingivitis
localized aggressive periodontitis
refractory periodontitis
mechanical
immune system
mechanicak
disease
periodontal abscess
Antibiotic Regimens for Periodontal Abscesses
Amoxicillin
____ g (loading dose)
____ mg q8h x 3 days
evaluation for continuation or adjustment
Azithromycin
____ g (loading dose)
____ mg qd x 2 days
Clindamycin
____ mg (loading dose)
____ mg q6h x 8 days
These are the regiments for perio absces for pt (mostly ____ or ____- or clinda- if allergic)
1.0 500 1.0 500 600 300
amox
azithro
What is the Goal of Treatment in Periodontitis?
- elimination of the etiologic factor
- ____ host
One of the 2 major etiological factors is ssceptible host. What we do targets the microbial plaque (obvious and easy part, but the other part is the susceptible host). Besides eliminating the susceptible host themselves which we don’t want to do (note from me: oh gosh), there is very little ____ available (only 1 with FDA approval that targets this part of the equation)
treatment
Host Modulation in Periodontal Disease
When this part is affected, we have the best chance for improvement of pt perio health.
Reducing ____ burden we always do, we also modify risk factors like ____, diabetes, and local contributing factors improves our chances of getting resolution of disease.
If we can change host response, we get this triangle in the circles here - the best outcomes. We only have 1 ____ currently available
bacterial
smoking
treatment
Systemic Host Modulation Agent Commercially Available in the US
- Periostat ® 20 mg
- Subantimicrobial Dose ____ (SDD)
- ____ inhibitor, not ____ properties
- ____ + ____ mg bid, for 3 to 9 months
This is Doxycyclin 20 mg. The anitmicrobial dose is ____ mg. The effects of this drug periodontally are not due to antimicrobial effect. The dose of this drug are subantimicrobial and do not ____ bacteria.
This inhibits MMP’s (____ enzymes secreted). no antimicrobial effects (repeats this several times)
Periostat is an adjunct (not by itself). Evaluated with SRP in dose as listed on the bottom.
____ months becausee this is as long as studies have gone (no evidence that it can be used longer)
doxycycline MMP antimicrobial SRP 20
100
kill/attack
host
3-9
Is SDD Safe and Effective as an Adjunct to SRP?
190 patients with generalized chronic periodontitis
Multi-center randomized controlled clinical trial Control: SRP + placebo
Test: SRP + SDD
No ____ provided during the trial PD, CAL, BOP at baseline, 3, 6, and ____ months
maintenance
9
Is SDD Safe and Effective as an Adjunct to SRP?
These are what they found. These are clinical parameters they looked at, ____ gain and ____ reduction and the difference in the 2 groups.
Looking at the stratification of the sites based on the initial probing depth 0-4 shallow, 4-6 mm moderate, 7+ mm
Looking at CAG and PD reduction results - differences are ____ of a mm. In the deepest sites, there are 0.38 mm in CAG and 0.48 PD reduction. The outcomes are statistically ____ between the 2 groups.
We have to consider that though these are statistically significant, are they clinically ____. Does it make sense to keep a pt on systemic medication for their whole lives for 0.5 mm difference
clinical attachment
probing depth
fractions
significant
relevant
When is SDD Indicated as an Adjunct to SRP?
SDD in combination with SRP provides a defined but ____ improvement in periodontal status
____ is a potential issue
Beneficial in patients with increased ____
Only host modulating agent that we have right now, creates a defined benefit (statistically significant) but has limited improvement
Compliance - need to take ____ times a day indefinitely (could be an issue)
Need to keep in mind that this may not be for the whole population. The 1/2 mm improvement may not benefit most pts but for those with increase susceptibilty or refractory or without good outcomes from traditional trx, maybe these are good candidates for additional tools to help.
limited
compliance
susceptibility
2
Are LASERs Effective as Adjuncts to SRP?
2010 AAP Statement on the Efficacy of Lasers in the Non-surgical Treatment of Inflammatory Periodontal Disease
Laser Mediated Sulcular and/or Pocket Debridement “____ evidence to support use of a laser
for the purpose of subgingival debridement, either as a monotherapy or adjunctive to SRP”
The next group of trx that has been discussed are LASERS. Not LANAP - we are talking about lasers in general with SRP
Are they good/not - should we use them or not?
The AAP looked at all of the literature on lasers and issued a report. The literature on lasers is poor because research available are not good, experiments are not well designed, not published in high impact journals. There is literature out there, but not high quality.
To assess the quality of the literature, they issued this statement and looked at the use of lasers in 3 different ways with SRP as adjuncts.
This is the first type (underlined) - she read the description under
Minimal evidence doesn’t mean it’s not good, but it is minimal. Either low quality or low volume research. Cannot say in evidence based manner if it is or is not effective
minimal
Are LASERs Effective as Adjuncts to SRP?
2010 AAP Statement on the Efficacy of Lasers in the Non-surgical Treatment of Inflammatory Periodontal Disease
Reduction of Subgingival Bacterial Levels
“lasers, as a group, to be ____ and inconsistent
in their ability to reduce subgingival microbial loads beyond that achieved by SRP alone”
unpredictable
Are LASERs Effective as Adjuncts to SRP?
2010 AAP Statement on the Efficacy of Lasers in the Non-surgical Treatment of Inflammatory Periodontal Disease
Scaling and Root Planing
“Er:YAG laser has been shown, in ____, to remove ____ …potential for root surface ____…
Clinical data on attachment level changes when compared to SRP alone is ____ ”
vitro
calculus
damage
conflicting
imitations of Non-surgical SRP
- 7 teeth planned for extraction with 42 pockets with PD = 2-10mm
- SRP performed with ultrasonic and hand instruments
- PD recorded initially and post-extraction from a groove placed at GM
- Root surface assessed for residual plaque and calculus, and signs of instrumentation under ____
on-surgical therapy has been shown to be effective therapy with or without adjunct - SRP alone can be very effective, but we have to recognize the limitations.
It’s great to perform treatment, but when it comes to us not being specialist in the area, know we have limitations and accept them and work to improve them or refer to someone who can do it better.
In nonsurgical SRP, know there are limitations as well. There is good research over the years to understand the limitations, which is where the ____ mm threshold comes from. Know the literature - she says it’s important to understand the limitations of Non-surgical SRP
There is a classic study in regards to limitation done by Stambaugh in the early 80’s. Reads the slide.
Teeth were extracted regardless, this was for experiment, not to save the teeth.
Groove was used to measure PD before SRP and after the extraction. They wanted to see how deep the instuments could reach while the tooth was in the mouth.
After SRP, extracted the teeth and looked at root surface
5
Limitations of Non-surgical SRP
Instrument limit
the max pocket depth the instrument tip can verifiably reach ____ mm (2-10 mm)
Curette efficiency
the max pocket depth where a plaque- and calculus- free-surface can be established
____ mm (1-6 mm)
- 52
3. 73
imitations of Non-surgical SRP
% tooth surfaces completely calculus - free classified
according to PD following different treatment modalities
A similar but differently designed experiment by Caffesse and colleagues - didn’t extract teeth. Compared the effect of instrumentation when SRP was performed nonsurgically vs SRP with open flap procedure.
Open flap, theoretically you can see everything and remove it, but this wasn’t exactly. Stratified data according to initial probing depths. Shallow, moderate, and deeper (6+mm).
If we focus on 1-3 mm, you are never ____% effective in removing calculus. You should be aiming for as biologically compatible surface as possible. Get bacterial load low enough that the host can fight it. You cannot remove all the bacteria. There is also no difference between flap procedure and close procedure
In moderate pocket depths (4-6 mm), when you elevate flap, you are ____ your chances of getting plaque and calculus free surface, but not 100%
If pocket greater than 6 mm, you have better chances with the flap, but you’re still not going over ____%. Why is it so hard? If you have pockets that deep, pt has a lot of attachment and bone loss and likely furcation involvement. Even if you lift the flap, you cannot remove 100% of the plaque.
Strive for the best outcomes, but you’re never 100% able to remove calculus. When you go past 4mm, you have better chance of plaque removal by elevating the ____ in comparison to nonsurgical.
100
double
50
flap
Limitations of Non-surgical SRP
This is a pt that she treated in residency pt had SRP done by predoc students. Residual pockets of ____ mm found. Pt sent to grad perio, found some leftover calculus. The patient came back for reevaluation and there were still resideual pockets and BOP. Decided to do surgery - an apically positioned flap with osseous surgery planned for the area. Flap was elevated - she refers to the area of bone interproximially between the two teeth (underneath the green bracket)
The mesial furcation of 1 is exposed and number 2 has some calculus in the ____ (this is difficult to remove without flap (even when the flap is elevated it’s difficult). Even without super deep pockets, you may need surgery to remove the inflammatory factor in the region
5-6
furcation
imitations of Non-surgical SRP
• 82 periodontal patients from Nebraska
• ____-year randomized controlled clinical trial
• ____ design: ____, SRP, MWF, APF
• Unstable sites: ≥ ____mm CAL loss from baseline
• Data stratified according to PD at baseline
7
split-mouth
prophy
3
Limitations of Non-surgical SRP
Breakdown sites / year for sites with PD ≥ ____ mm following different
treatment modalities
____ > ____ > ____
5
SRP
MWF
APF
Limitations of Non-surgical SRP Breakdown rate in furcation areas following different
treatment modalities
____ > PROPHY > ____ > APF
SRP
MWF
Additional Treatment Following Re-evaluation
Active therapy should continue until all areas of unresolved disease have been eliminated
SURGICAL
- Many sites with residual ____
- Sites with PD ≥ ____ mm
- Tenacious calculus that cannot be ____
- Local ____ factors
inflammation
5
removed
contributing
Treatment Modalities for Periodontal Disease
3. Surgical Treatment \_\_\_\_ Modified Widman Flap (MWF) \_\_\_\_ Guided Tissue Regeneration (GTR) \_\_\_\_
open flap debridement (OFD)
apically positioned flap (APF)
laser-assisted new attachment procedure (LANAP)
What are the Advantages of Surgical Periodontal Treatment?
- ____ of the root surface in order to achieve a plaque- and calculus- free surface
- ____ reduction or elimination
- Improved ____ for oral hygiene and maintenance
- ____ of lost periodontal structures
- More accurate determination of ____
- Improved environment for ____ dentistry
visualization pocket access regeneration prognosis restorative
Guided Tissue Regeneration (GTR)
• GTR involves bone grafting in areas that are graftable - typically ____ bony defects or ____ defects
vertical
furcation
Laser-Assisted New Attachment Procedure (LANAP)
- The difference is that here we are not using a scalpel to make an incision but rather a ____ to de-epithelialize the pocket lining.
- We are still using ____ to do sub gingival SRP as seen in the pic below
- We are using different settings on our laser instead of suturing in order to create a ____ clot and hence a new attachment between the soft tissue and the tooth
- The final step in this procedure is some ____ adjustments if needed.
- Final point: it is surgical but no scalpel used and no sutures
laser
curettes
fibrin
occlusal
What are the advantages of Surgical Periodontal Treatment?
• 1 - No matter what type of surgical flap procedure we do this is our main goal
• 2 - We want to eliminate pockets, have a sulcus that is no more than ____ mm,
sometimes this cannot be achieved, so then we will settle for a reduction as long as the etiologic factors are removed.
• 3 - A shallower pocket will allow the hygienist to clean better and easily during
maintenance as well as the patient will be able to clean easily at home
• 4 - The flap will allow us access to perform ____ procedures
• 5 - This is not the primary goal. When we elevate the flap we can see the bone level around the tooth, and the actual configuration of defects and determine the prognosis more accurately. for example a furcation defect which is seen ____
not radiographically. Sometimes with clinical measurements we over or under estimate the defect. With the flap elevated we can see exactly where the bone is and if the prognosis is favourable or not
• 6 - this refers to surgical periodontal procedures such a crown lengthing so that there is enough tooth structure to work. Mainly perio/prosth cases.
3
regenerative
clinically
