Non-surgical Perio Treatment

Question 1

How can aetiological factors of periodontal disease be controlled?

Answer 1

Supra and subgingival biofilm can be disrupted via mechanical and chemical plaque control

Mechanical biofilm control can be carried out by professional and by patient

Question 2

How can subgingival biofilm be removed?

Answer 2

Mechnically: Debridement of the subgingival area by a dental professional. This can be done surgically and non-surgically.

Chemical: Antibiotics can be used

Question 3

What are the steps in patient perio treatment management?

Answer 3

History

Exam

Diagnosis

Provisional prognosis

Treatment plan

Question 4

What are the phases of the treatment plan?

Answer 4

Emergency phase

Risk management phase

Fundamental phase

Question 5

What happens during the fundamental phase of perio treatment plan?

Answer 5

Patient education: Inform and motivate the patient, awareness of PDs, modifiable risk factors.

Training in personal oral hygiene

Counselling on control of risk factors and oral hygiene instruction

Removal of defective restorations, overhangs, and/or any predisposing factors

Scaling and root debridement of teeth

Question 6

What is the role of the professional in maintaining patient oral health?

Answer 6

Oral health education / oral hygiene advice

Professional removal of predisposing factors: Calculus, overhangs, etc

Professional supra and sub-gingival plaque control: Debridement, chemotherapeutics

Question 7

What is the aim of scaling?

Answer 7

To remove plaque and calculus from the tooth surface and can be supra or sub gingival depending on the location of the deposits.

Question 8

What is the aim of root planing?

Answer 8

To remove calculus and softened cementum leaving a smooth and hard root surface. (The need for cementum removal has been questioned. making keeping root surface clean the primary aim)

Question 9

What is root surface debridement?

Answer 9

Term used to describe removing deposits from the root surface to leave the surface clean but without a specific aim of cementum removal

Question 10

What does the effectiveness of scaling, root planing, and root surface debridement depend on?

Answer 10

Probing depth

Skill of the operator

Root anatomy

Time available

Instrument sharpness

Question 11

What should be removed in debridement?

Answer 11

Aim to remove plaque, bacterial by-products, and calculus to create an environment compatible to periodontal health

Endotoxins and other bacterial products can be removed with gentle instrumentation

Cementum contributes to periodontal healing and should be preserved

Question 12

What hand instruments should be used for periodontal treatment?

Answer 12

Curettes

Hoes and files

Ultrasonic and sonic instruments (powered): Tip vibration and spraying/cavitation

Vibrations can be produced by an EMF or crystal transducer (Piezoelectric)

Question 13

What are the benefits of using ultrasonic instruments?

Answer 13

Effective for calculus removal and deplaque

Flushes out bacteria and by-products via fluid lavage

Anti-bacterial via cavitation

Ergonomic (light strokes only needed)

Less hand fatigue

Increased efficiency especially to remove bulk of heavy calculus deposits

Question 14

What are the benefits of using hand instruments?

Answer 14

Enhanced tactile sensitivity

Some are designed to be area-specific and are thus more adaptable to the tooth structure

Less tooth sensitivity

Water not required, no aerosols

Question 15

Should hand or ultrasonic instrumentation be used preferrably?

Answer 15

A combination of both is most effective.

Question 16

What is calculus?

Answer 16

Mineralized biofilm

Develops above or below the gingival margin (supra and subgingival)

Superficially covered by vital, non-mineralized biofilm

Question 17

Why should calculus be removed?

Answer 17

They act as plaque/biofilm retaining factors.

Question 18

When should scaling and debridement be performed?

Answer 18

When there is supra or subgingival calculus

Presence of marginal bleeding (gingivitis)

Probing depth of 4mm and more with signs of bleeding and/or calculus

Question 19

What are the steps for subgingival debridement?

Answer 19

1) Anaesthesia
2) Pocket mapping to check: Different depths, presence of calculus, concavities, sulci, root anatomy, pre-furcation and furcation involvement
3) Debridement
4) Probing to check
5) Irrigation (saline or chlorhexidine)
6) Haemostasis
7) Recommendations to patients

Question 20

What are the recommendations to make to patients following debridement?

Answer 20

Controlling plaque in the areas well

Possible pain so to use painkillers

Chewing discomfort

Dentine hypersensitivity - transient

Question 21

What are the potential complications that can arise from subgingival debridement?

Answer 21

Excessive bleeding

Soft tissue and papilla rupture

Instrument fracture

Question 22

How should post debridement assessment be done?

Answer 22

Immediate assessment - Resolution of visual signs of inflammation (Volume and edema/suppuration)

Mediate assessment - Subgingival probing, probing depth reduction, absence of BOP

Question 23

How does wound healing take place?

Answer 23

Through a long Junctional epithelium.

The LJE forms a barrier against biofilm and it is not more susceptible to further disease progression.

Question 24

What are the types of changes that follow non-surgical periodontal therapy?

Answer 24

Changes in microbiota

Hard and soft tissue clinical changes

Question 25

What effect does non-surgical periodontal therapy have on microbiota?

Answer 25

Shift in composition

Less gram -ve bacteria

Change in microflora assocaited with gingival health

Question 26

What are the hard tissue changes that follow non-surgical periodontal therapy?

Answer 26

Very little bone gain at sites with horizontal bone loss

Intrabony/vertical bony defects - some bone fill on x-ray

Question 27

What are the soft tissue changes that follow non-surgical periodontal therapy?

Answer 27

Amount of Pocket Depth reduction:

For PD 1 - 3mm: 0

For PD 4 - 6mm: 1.3mm

For >=7mm: 2.2mm

THESE ARE AVERAGE VALUES

Question 28

How long does healing take for reduced pocket depths?

Answer 28

Healing may take 9 - 12 months at deeper sites

Question 29

When should the re-evaluation phase be done?

Answer 29

6 - 8 weeks following the hygiene phase because that is how long it takes for tissue response and maturation.

Question 30

What should be observed during the re-evaluation phase?

Answer 30

Colour, form and aspect of the tissue.

Tissue tone (how easy is the tissue to probe)

Bleeding and exudates

Presence of subgingival plaque or calculus

Clinical probing depth and attachment levels and their changes over time.

Question 31

What are the possible outcomes of the re-evaluation phase?

Answer 31

1) All inflammatory responses have been eliminated as a consequence of successfully completed hygienic phase. Patient should be placed in maintenance and initiating the supportive phase of therapy.
2) Areas of persistent inflammation should be detected but at the same time deposits of residual calculus are found and considered to be accessible through instrumentation. Further selective scaling and root planing are performed.
3) Areas with persistent inflammation require open debridement for accessibility and visibility. In these cases periodontal surgery is indicated.

Question 32

What indicates resolution of inflammation?

Answer 32

No bleeding on probing.

Healthy gingival appearance; pink colour, firm consistency, regular gingival margins

Reduced probing depths: resolution of gingival oedema, gingival recession, reattachment or repair via formation of long JE

Question 33

What is the outcome that we ideally want to see?

Answer 33

Reduced Pocket Depths to <4mm

Easier for maintenance since easier access to shallow pockets

Good oral hygiene has more effect on shallow PD

Question 34

What should be done if some sites are still non-responsive following treatment?

Answer 34

Re-instrument residual sites or refer to a periodontist.