nonsurgical treatment of periodontal disease

Question 1

what is the sequence for treatment of periodontitis?

Answer 1

1. patient motivation, supragingival plaque control and risk factor control
2. cause related therapy, control subgingival biofilm and calculus
3. treatment of areas non-responding to the second step (surgery)
4. supportive periodontal case: maintain periodontal stability

Question 2

what are the goals of non-surgical management?

how does it aim to achieve this?

Answer 2

• reduce gingival inflammation
• reduce deepened pockets
• regain periodontal attachment of the tooth
• prevent tooth loss and loss of dental functions

by:

• controlling risk factors
• removal and disruption of the biodilm
• reduction of bacterial load

Question 3

what is the goal of polishing?

Answer 3

(prophylaxis)

• removal of soft deposits and unacceptable stain
• difficult to reach interproximal areas
• may motivate patient

Question 4

why should we remove calculus?

Answer 4

calculus does not induce inflammation but is a plaque retentive factor

if calculus is detected clinically the site is more likely to display ongoing inflammation

Question 5

which patients are periodontally susceptible?

Answer 5

• interproximal loss of attachment
• radiographic evidence of bone loss
• BPE scores of 3 & 4

Question 6

When is it ok to move on to the second step (non-surgical therapy) of periodontal treatment

Answer 6

after first step (initial therapy) has been successful

• improvement in habits and control of risk factors
• improvement in general appearance of the tissues
• plaque scores < 20%
• bleeding scores < 20%

Question 7

what are the outcomes of non surgical periodontal treatment on a histological level?

Answer 7

• microbial biofilm distruption
• removal of calcified biofilm microorganisms
• changes in microflora
  
  • reduced load
  • less pathogens
• smooth root surface - less likely to harbous residual bacteria
• reduction of inflammatory cascade

Question 8

describe histologically the healing after non surgical periodontal treatment

Answer 8

• inflammatory reaction in soft tissue pocket wall
• remnants of pocket epithelium will proliferate and pocket becomes fully epithelialised in 2 days
• in 5 days - epithelial reattachment at apical extremity of pocket
  
  • progress coronally
• rise to new long junctional epithelium

Question 9

what are the types of healing in periodontal wounds?

give definitions

Answer 9

• repair
  
  • restoration of a normal gingival sulcus at the same level as the base of the previous pathologic periodontal pocket
• reattachment
  
  • reattachment of the gingivae
• new attachment
  
  • newly generated fiberes are embedded in new cementum on a portion of tooth that was uncovered by disease
• resorption
  
  • loss or blunting of some proportion of a root
• ankylosis
  
  • fusion of the tooth to the alveolar bone
• regeneration
  
  • reproduction of reconstruction of a lost or injured part in such a way that the architecture and function are completely restored by growing precursor cells replacing lost tissue

Question 10

describe clinically the healing after non surgical periodontal treatment

Answer 10

• after RSD
  
  • bacterial remnants continue to be washed out of the pocket by blood and crevicular fluid
  • after 14 days - a new gingival sulcus will be formed near to the crest of the gingivae
  • some shrinkage of the gingiva will occur due to resolution of oedema
  • collagen repair ultimately takes about 12 weeks to mature fully

Question 11

what are the clinically outcomes of non surgical management?

Answer 11

• improvement of OH
• pocket depth reduction
• absence of bleeding on probing
• clinical attachment level gain (0.5-1mm)

Question 12

how much pocket reduction occurs?

how much clinical attachment loss?

how much recession?

Answer 12

• at 6/8 months
  
  • overall pocket depth reduction mean reduction of PPD of 1.7mm
• deeper pocket which are > 6mm
  
  • 2.6mm PPD reduction

Question 13

what are the patient outcomes of non surgical periodontal treatment?

Answer 13

• no bleeding on brushing
• accessible OH
• gingival recession
• more sensitivity to temperature
• improved oral health related quality of life

Question 14

when should evaluation after non surgical treatment occur?

Answer 14

usually 3 months after intervention - see if there has been improvement before RSP can be done

if no improvement - has to be reviewed again until theres improvement

Question 15

if a patient is stable, how should they present and what is the next step?

Answer 15

• BoP <19%
• PPD < 4mm
• no BoP at 4mm sites
• supportive periodontal therapy

Question 16

if a patient is in remission, how should they present and what is the next step?

Answer 16

• BoP > 10%
• PPD < 4mm
• No BoP at 4mm sites
• supportive periodontal therapy with emphasis on controlling BoP

Question 17

if a patient is unstable after non surgical treatment, how should they present and what is the next step?

Answer 17

• PPD > 5mm or PPD > 4mm and BoP
• engaging patient
  
  • further active periodontal therapy
• non engagin patient
  
  • palliative care

Question 18

A patient is on warfarin

Do you need an INR test to provide RSD?

Answer 18

Yes

it is more invasive than a scale and polish

Question 19

What if the plaque scores are low but there is still pocketing?

Answer 19

just means the pockets have not responded - common 35% of cases

pockets may be in difficult areas such as furcation areas

make patient aware that there may not be improvement