Nonsurgical Periodontal Therapy

Nonsurgical Periodontal Therapy, NSPT

1. Rationale of Non Surgical Periodontal Therapy

2. Sequence of Periodontal Therapy Emergency Phase Nonsurgical Phase Maintenance Phase Surgical Phase Restorative Phase Different names of NSPT: Cause related therapy, Initial therapy, Etiotropic phase of therapy, Phase I Therapy

3. Goals of NSPT: To alter or eliminate the microbial etiology and contributing factors for gingival & periodontal diseases. To halt the progression of disease and returning the dentition to a state of health and comfort. Control Or Elimination Of Local Factors

4. Rationale of NSPT: It may be the only treatment required for diseases like gingivitis or mild chronic periodontitis or it may be preparatory phase for surgical therapy Long term success of periodontal treatment depends predominantly on maintaining the results achieved with Phase I therapy Evaluation of tissue response Evaluation of patients attitude towards periodontal treatment

5. Kiser (1994) proposed three separate stages of treatment: Debridement : Instrumentation for disruption and removal of microbial biofilm Scaling : Instrumentation for removal of mineralised deposits Root planing : Instrumentation to remove contaminated cementum and dentin in order to restore biologic compatibility of periodontally diseased root surfaces

6. Studies suggested (Hatfield & Baumhammers 1971, Aleo et al 1974) , that aggressive scaling and root planing was required to remove bacterial products ( lipopolysaccharide ⁄ endotoxin ) bound to the contaminated root surface. It was established in-vitro studies ( Hughes & Smales 1986, Moore et al 1986) that bacterial endotoxins are weakly adherent to root surfaces and therefore excessive removal of cementum is not required to remove bacterial products ROOT PLANING or ROOT DEBRIDEMENT Removal of calculus is important because it is a major plaque-retentive factor, but intentional removal of root substance and contaminated cementum is not required for successful treatment. Mombelli A et al, 1995 in their split mouth study found, clinical and microbiological parameters showed similar improvements at test and control teeth with reductions in probing depths and in the proportions of periodontal pathogens ( Porphyromonas gingivalis, Fusobacterium sp. and Campylobacter rectus

7. It is defined as the removal of the inner surface of the soft-tissue wall of the pocket , , by means of a curette. It was performed in order to promote new attachment and tissue shrinkage, leading to pocket-depth reduction. “Curettage or Not to Curettage : That is the Question “ - Echeverria JJ et al 1983 SRP SRP + Curettage after 4 wk Gingival curettage After 5 wk, similar improvements in periodontal tissue health were observed, regardless of treatment, with a reduction in probing depth and gingival inflammation, and an increase in clinical attachment level

8. The full-mouth disinfection protocol: includes fullmouth scaling and root planing within 24 h, in addition to twice-daily chlorhexidine mouthrinsing , tongue scraping, chlorhexidine tonsil spraying and subgingival irrigation with chlorhexidine three times within 10 min and repeated after 8 days ( Quirynen et al, 1995) Conclusion : All three treatment approaches may be recommended for nonsurgical periodontal therapy. Therefore, operator and patient preference is important in determining the choice of instrumentation for nonsurgical therapy, including the choice between staged debridement, full-mouth disinfection and full-mouth scaling and root planing . Staged debridement with quadrant or sextant instrumentation or Full mouth instrumentation and Disinfection

9. Shift from a predominantly gram-negative to a gram-positive subgingival microbiota . Decrease in the number of microorganisms, including black-pigmented species and spirochetes. - Ultrasonic instrumentation can cause reduction in spirochete and motile rod counts with a concomitant increase in coccoid cells. Darby et al . investigated the effects of scaling and root planing on subgingival microflora . PCR was used to determine the presence of A. atinomycetemcomitans , P. gingivalis, T. forsythia, P. intermedia, and T. denticola in four sites from 28 patients before and after scaling and root planing . The treatment resulted in clinical improvement, and there were significant reductions in P. intermedia, T. forsythia , and T. denticola at a site level. Effect of scaling and root planing on subgingival microflora

10. Mechanical Therapy : Manual – Sonic - Ultrasonic Meticulous subgingival instrumentation is time consuming in all the three methods With manual instrumentation it takes 20-50% more time as compared to sonic or ultrasonic Deep pockets and furcation areas are difficult to reach by instrumentation. Dragoo et al . – Instrument limit to the depth of the pocket – 0.78 & 1.13 mm respectively for modified & unmodified ultrasonic tip and 1.25 mm for Manual curette. AAP 1996 world workshop consensus report – Similar clinical effects in all treatment modalities. For best result – combination of different modalities can be considered

11. Minnesota Study Pihlstrom et al 1981-1983-1984

12. This report concludes that SRP alone or in combination with MWF surgery results in sustained decreases in gingivitis, plaque, and calculus and neither procedure appears to be superior with respect to these parameter

13. Pihlstrom et al, 1984 – The 3 rd Report: The response of molar & non-molar teeth to SRP, alone or combined with MWF Molar tooth morphology accumulates plaque more- Thus Pocket reduction was harder to achieve

14. Michigan Study Hill et al (1981), Ramfjord et al (1982), Morrison et al (1982)

15. Conclusion: None of the surgical modalities had any better effect, which is directly related to reduction in pocket depth, than SRP in maintenance of periodontal support

16. Ramfjord et al. 1982. 78 Patients were treated by Occlusal adjustment Surgical therapy Recall prophylaxis every 3 months for 8 years 3 Groups 1- 3 mm 4 – 6 mm 7 – 12 mm Conclusion: Magnitude of reduction of pocket depth and changes in attachment level, following periodontal therapy, is positively related to the original pocket depth. All four surfaces of teeth responded similarly to treatment when pockets of initial equal depth were compared

17. Morrison et al. (1982) – Effect of Gingivitis on probing depth and attachment loss 1- 3 mm probing depth: No difference 4 – 6 mm pockets with lower gingivitis score – better gain in first 2 years, no difference thereafter 7 -12 mm pockets - better gain in first 3 years, no difference thereafter. The severity of gingivitis did not affect the maintenance of pocket depth reduction or CAL

18. Gothenberg / Swedish Studies: Lindhe et al (1982A, 1982B & 1984)

19. Conclusion

20. The critical probing depth represents a baseline probing-depth value above which the outcome of a therapy will result in attachment gain and below which the outcome of therapy will result in clinical attachment loss Lindhe et al (1982B) determined the CRITICAL PROBING DEPTH for SRP & MWF

21. - AARHUS/ DENMARK Studies ( Isidor et al – 1984 & 1985. Isidor and Karring 1986 - Tucson – Michigan - Houston Studies ( Becker et al – 1988 & 1990) : The research was done in private practice with aim to confirm the result from the universities studies Nebraska Studies ( Kaldahl et al – 1988, 1990 & 1992) Loma Linda studies Other Longitudinal Studies

22. Risk factors influencing NSPT outcomes Smoking : decreased immune response & compromised healing Persistent deep pockets and molars with furcation involvement: single rooted teeth and posterior teeth with intact furcation respond better Surgical periodontal therapy in pockets of > 5mm results in better outcome as reported By Kaldahl et al

23. Importance This studies were pioneer in providing the guideline to which the therapy will be most beneficial for the patient Selection of treatment and treatment protocol for the best short term and long term result for the patient Repeated instrumentation was of little benefit because calculus was often missed on the second attempt for the same reason it was missed the first time. The primary caveat with non-surgical therapy is that, there are sites and even patients where it may not be effective. This must be recognized at the reevaluation appointment and appropriate therapy, probably surgery, should be instituted.

24. Adjunct Therapies in NSPT

25. Local Drug Delivery Atridox – Gel Based system 10 % Doxycycline

26. LASER

27. But , In Meta-analyses ( Sgolastra F et al 2012) showed no statistically significant difference in clinical attachment gain, probing-depth reduction or change in gingival recession, indicating no evidence of a superior effectiveness of the Er:YAG laser compared with scaling and root planing

28. WHO has defined Probiotics as live organisms, which, when administered in adequate amounts, confer a health benefits to the host. Probiotics repopulate beneficial bacteria which can help to kill pathogens. Probiotics produce antioxidants. Antioxidants prevent calculus formation by neutralising the free electrons that are needed for the mineral formation. Probiotics prevents foul odour by fixating on the VSC Probiotics

29. Ozone Therapy

30. PhotodynamicTherapy

31. Perioprotect