NON SURGICAL THERAPY Flashcards
Define non surgical therapy
- Plaque control
- Supra and sub gingival scaling, root planing
- Adjunctive use of chemical agents
- Re-evaluation
- Periodontal maintenance
- Re-treatment
** non surgical therapy may be definitive but often you need to perform surgical therapy
Non surgical therapy-Effects on single rooted teeth
1.SRP< PD reduction and slightly greater CAL compared to surgical therapy
2. No correlation between OH and recurrence, suggesting subgingival scaling at frequent recalls important
3. Deeper site >BoP
4. Single session of SPT as effective as multiple sessions.
5. Not necessary that deeper sites are harder to maintain..?
6.Most of the effect is from SPT and not OH
7. Surgery is better at reducing PDs than SRP and eliminating pockets, more patients in SRP group showed advanced disease progression
8. Single rooted teeth respond better to non surgical than multi rooted teeth
Non surgical therapy -Effects on multi-rooted teeth
- Molar furcation sits-poorer response than non molar and molar flat sites
- Lost teeth: Mx 2nd molars, Mnd 2nd molars, Mx 1st molars
3.Deeper pockets better managed with surgery - At 8years no difference in PD reduction and increase CAL for any single therapy (sub g curettage, PE, MWF)
Long term effect of 4 surgical therapies and non surgical therapy ( Mailoa et al 2015 J PERIO)
- Shallow (1-3mmPD) - Surgery- significantly higher CAL loss than SRP
- Moderate (4-6mm)- MWF- significantly higher PD reduction than SRP
- Deep (>or = 7mmPD)- Osseous surgery, significantly higher PD reduction than SRP
Does plaque control matter in those receiving NSPT?
Patients with imperfect plaque control fare just as well as those with high plaque scores. Sub-gingival instrumentation is absolutely essential at maintenance visits.
What are the clinical characteristics of sites with continued probing attachment loss?
- high BoP
- 20-30x less AL in well maintained pts than untreated patients
What is the frequency and localization of sites with continued increased probing attachment loss?
Non surgical treatment- influential factors
PD decreases and BI decrease mainly influences by baseline PD, AL and mobility, tooth type and maintenance frequency
Endpoints of Root planing?
- Excellent OH (supra and sub g)
- Pink and firm gingiva
- PD<5mm
- No BoP
- Calculus not detectable on exploration/ probing
- Reduced mobility
Root planing effectiveness?
- PD reduction and CAL gain related to the initial level of disease severity
- You can expect to have residual pockets with 7mm PDs
Critical Probing Depths (Lindhe 1982)
<2.9= AL
2.9-4.2= SRP; surgery will cause AL
4.2-5.5= both SRP and surgery work
>5.5 =benefit from surgery
Basic Treatment Planning for PDs
1-3mm= supragingival scaling
4-6mm= SRP /surgery
> than or =7mm = surgery
Full mouth debridement vs quadrant wise, difference?
No significant difference
(Cochrane Database- modest favouring of full mouth disinfection) other systematic reviews show no difference
What are limitations of SRP?
Calculus
Mineralized plaque permeated with calcium phosphate crystals supplied by saliva and GCF
Subgingival calculus indicates chronic inflammation.
Common sites for residual calculus?
- CEJ
- Flutes
- Line angles
- Resorption bays, carious defect, interradicular areas, deep PD, below contact areas
*sig correlation between amount of residual calculus and increased PDs
Instrument efficiency
Removal of all subgingival calculus average depth of 3.73mm
Residual calculus and PD
Amount of residual calculus after instrumentation correlated to increasing PDs
Residual PD: Scaling vs Scaling +Flap
1-3mm (86% vs 86%)
4-6mm (43% vs 76%)
>6mm (32% vs 50%)
Experience and calculus removal
Experienced operators were able to remove more calculus in both closed and open flaps.
Furcations most difficult; but even with flaps, 68% residual calculus
Ultrasonic vs hand instruments
Both equally effective; combination of both was superior for subg calculus removal
Evidence for using subgingival irrigation during scaling and root planing?
Chlx, saline, H2O2, povidone iodine, TCN, metronidazole= Insufficient evidence
What is the beneficial effect of adjunctive systemic antibiotics with SRP
Amox+metro in non surgical phase resolved disease quicker and reduced need for additional surgical intervention- use clinical judgement (side effects, abx resistance, perio benefits)
Insufficient evidence to use systemic abx as a monotherapy
What is the beneficial effect of using subgingival locally delivered abx?
-limited benefit; not recommended to use routinely, use when conventional treatment has not been ideal.
- use with SRP showed decrease in PD, and increase in CAL
Local and systemic abx and non surgical treatment of smokers
additional decrease in PD and gain in CAL
Adjunctive use of host modulators in non surgical periodontal treatment
- Statin gels 1.2%- sig decrease PD (infrabony defects)
- Systemic LDD- improved PPD decrease
3.Probiotics-limited clinical benefits - Bisphosphonates and Metformin gels- potential, but needs confirmation
When to re-evaluate your therapy?
4-8 weeks = ideal time (adequate time for improved OH, decrease in BoP, edema, redness)
Too soon= over treatment
Too long= disease progression and return of pathogenic flora
What is the value in re-evaluation
- assess improvements following initial therapy
- OHI compliance
- Assess tissue condition prior to surgery (not too friable)
- identify progression of disease in a timely manner
- identify need for possible re-treatment
Maintenance goals
- Minimize recurrence and progression of periodontal disease in patients
- Prevent tooth loss by monitoring dentition
Recall intervals
3-4months= successful
Prophy bi-weekly for 2-3month after active treatment (surgery)
**tailor to pt needs
spirochete, motile rods repopulate pockets in 4-8 weeks.
Maintenance and tooth retention
87-92% tooth retention
Maxillary molars most often lost, and mandibular canines often retained.
Furcation involved teeth lost 3-5x often as other teeth
Maintenance compliance
complete compliance 16-32%
erratic compliers required more surgical interventions
non compliers= male, <40yo, non sx patients
**compliant pts lose fewer teeth than non compliant pts
Tooth retention with maintenance
Treated and maintained patients lost teeth 0.11 tooth/yr/pt (years to lose 1 tooth =9.1)
Treated but NO maintenance lost 0.22 teeth/yr/pt (years to lose 1 tooth= 4.5 years)
Diagnosed, untreated pts lost 0.36 teeth/yr/pt (years to lose 1 tooth =2.8 years)
Causes of treatment failure
cannot maintain adequate home care
inappropriate patient selection
incomplete diagnostic procedures
treatment difficulties
unsupervised healing
absence of maintenance therapy
When do you decide to retreat?
not before adequate history and trial of conservative therapy
Signs of disease recurrence
- BoP
- Increasing PDs
- Radiographic Bone loss
- Progressing mobility
SPT interval of 2months
Stage III or IV
Poor OH
Uncontrolled or recurrent disease
SPT interval of 3months
Adult orthodontic patients
Pregnant women
Diabetic patients
Smokers
>50yo with active perio
High stress
Early to mod perio
Moderate perio who do not see periodontist
SPT intervals of 4 months
Teens/young adults
Mod disease with excellent OH
Non bleeding 4-5mm periodontal pockets and good OH
SPT intervals of 6 months
Healthy patients with 1-4mm non bleeding PDs
Pediatric pts
Gingivitis patients with improving OH and high motivation
Brushing techniques
Bass- brush head parallel to occlusal plane, bristles at GM apically at 45deg to long axis, vibratory motion
Modified bass- same as above + sweep towards occlusal
Charters- brush at right angles to long axis, slight rotary movements
Stillmans- bristles partially on cervical aspect, partially on gingiva oblique to long axis, lateral pressure. Slight rotary motion, but not displacing bristles
Modified Stillman - same as above, except short back and forth strokes + coronal movement. Recommended in areas of progressive recession
Brushing Frequency
Plaque removal every 24 for health
Interdental brushes
wide interdental spaces better cleaned with interdental brushes vs floss, plaque can be removed 2-2/5cm subg.
