non-surgical therapy

Question 1

How much PD reduction and CAL gain can you get from SRP

Answer 1

Cobb
-4-6mm PD: reduced 1.29mm, gain 0.55mm
->7mm PD: reduced 2.16mm, gain 1.79mm

Question 2

How effective is SRP

Answer 2

-Stambaugh: effective instrumentation limit is 6.21mm
-Waerhaug: 90% had plaque and calculus remaining in pockets >5mm

Question 3

what factors affect the efficacy of SRP

Answer 3

-Quality of root debridement
-host response to therapy
-PD: surgical is more effective for PD>4mm (Brayer)

Question 4

Is it more effective to do SRP or FMD?

Answer 4

-Quirynen: FMD had greater PD reduction of 1.5mm and a gain of 2mm (for pockets >7mm) and a greater reduction in spirochetes. No difference between the use of chlorhexidine though.
-Santuchi: No significant difference

Question 5

What is more effective - scalers or ultrasonic?

Answer 5

-Dahiya 2011 (using scanning electron microscope): Manual = ultrasonic
-Hallmon and Rees 2003: systematic review; Manual = mechanical for perio parameters and instrumentation time

Question 6

What is more effective for cleaning FURCATIONS - scalers or ultrasonic?

Answer 6

-Bower: furcation is 1mm 81% of the time and <0.7mm 58% of the time so the ultrasonic would fit better in grade 2/3 furcation than Gracey curette
-Parashis 1993: ultrasonic>manual
-Leon and Vogel 1987:
-Grade 1: scalers=ultrasonic
-Grade 2/3: ultrasonic > scalers

Question 7

Cavitron versus piezo

Answer 7

-Both are ultrasonic
-Cavitron has fewer cycles/second and tip moves elliptical
-Piezo is linear movement

Question 8

Does contaminated cementum need to be removed?

Answer 8

-Mombelli 1995:
No
-similar results after 1 year
-reduction of microbes was more important

Question 9

Is irrigation recommended/required?

Answer 9

-position paper by AAP: insufficient evidence; controversial
-Hallmon and Rees: systematic review; similar outcomes to just manual instrumentation

Question 10

What about lasers? AAP statement

Answer 10

-controversial and minimal evidence

Question 11

What about lasers? -Slot et al:

Answer 11

effect was comparable with SRP

Question 12

What about lasers? -Zhao et al:

Answer 12

Er:YAG led to sig greater short term decrease in PD, but was clinically effective to SRP after 3 months

Question 13

What about systemic antibiotics?

Answer 13

Haffaje:
-systematic review
-adjunct use leads to greater CAL gain
-Esp with aggressive periodontitis

Question 14

What about locally delivered antibiotics?

Answer 14

-Hanes and Purvis: systematic review; greater CAL gain and reduction in PD with minocycline gel, chlorhexidine chips, and doxycycline gel in conjunction with SRP compared to SRP alone.

Question 15

What about powders?

Answer 15

-Wennström: split-mouth study (SRP alone versus SRP and air polishing with glycine powder). Both improved BOP, PD, and CAL, but there were NO additional benefits from air polishing at 2 months
-Flemming: subgingival adjunctive use of glycine powder air polish led to significantly lower total bacterial counts at 10 days and lower total P gingivalis count at 90 days compared with SRP alone.

Question 16

What about SRP by quadrant (1 every week for 4 weeks) or FMD (full SRP in 24h)?

Answer 16

-Eberhard: Cochrane review; no additional benefit for FMS or FMD over SRP
- Santuchi 2016 – no sig difference
- Lang 2008 – systematic review; sig reduction in PD (0.2mm) but was not clinically relevant
-no clear superiority at clinical level and a bit controversial, but if systemic antibiotics are needed then FMD may be treatment of choice and if pt has time limitations

Question 17

How effective is NSPT?

Answer 17

-more remaining plaque and calculus in: deeper pockets and teeth with furcations
Waerhaug:
-PD<3mm = 83% of surfaces were plaque-free
-PD>3mm = 44% of surfaces free of plaque-free
-PD3-5mm: high chance of leaving calculus
-PD>5mm: 90% chance; only 11% of surfaces were plaque-free

Stambaugh:
Plaque remained on teeth with mean PD of 7.69mm
Curette efficiency was 3.73mm
Curette limit was (average) 5.52mm, with a max of 6.21mm

Question 18

If you have a residual deep pocket, will you try to keep scaling or go surgical?

Answer 18

Badersten
-repeated SRP q3m did not lead to any clinical improvements after the first 3 cycles

König
-2nd round of NSPT 5m later lead to even more CAL gain and reduced need for surgical intervention

Question 19

Non-surgical versus surgical therapy?

Answer 19

Becker
-after 5 years, no sig difference in SRP, osseous, and MWF

Heitz-Mayfield 2002:
-meta analysis
-PD 4-6mm: NSPT => less PD reduction and more gain in CAL
-PD >6mm: Surgical => higher PD reduction and more gain in CAL

Caffesse 1986:
-clinical study
-more calculus and plaque if non surgical and also if there are grooves, fossae, or furcations
PD 1-3: 86% calculus free for both
PD 4-6: 43% (non surg) versus 76% (surg)
PD >6: 32% versus 50%

Question 20

Critical probing depth:

Answer 20

-Lindhe 1982:
-PD <2.9mm – SRP leads to CAL loss
PD <4.2mm – surgical SRP leads to CAL loss

Heitz-Mayfield 2013:
PD>5.4mm – surgical has more CAL gain

Therefore, from 2.9-5.4mm you should do SRP. For PD >5.4mm you should do surgical.

Question 21

How effective is SRP in furcations?

Answer 21

-Fleischer: experienced operators had calculus-free surface only 68% of the time

Question 22

When would you use a surgical modality vs a non-surgical modality?

Answer 22

• Level of BOP
• PI

Question 23

how does the tissues heal after SRP

Answer 23

• Waerhaug
  -some of the remaining pocket epithelium will give rise to the reformation of the junctional epithelium (takes 2 weeks)

The initial pocket depth reduction following SRP (about 1 week) is related to increased gingival recession, while the secondary pocket reduction (after 3 weeks) is due to clinical attachment gain.

-Caton and Zander: formation of a long junctional epithelium (LJE) rather than new connective tissue (CT) attachment. However, this LJE was demonstrated to be no different in resistance to plaque or disease progression.