What does nonsurgical periodontal therapy include?
Self-care measures, periodontal instrumentation, and use of chemical agents to prevent or control plaque-control-induced gingivitis or chronic periodontitis
What is the broad overall objective of nonsurgical periodontal therapy?
Eliminating inflammatory disease in the periodontium and returning the periodontium to a healthy state that can then be maintained by a combo of both professional care and patient self-care
What is another term for nonsurgical periodontal therapy?
Initial periodontal therapy, soft tissue management
What should treatment plan for nonsurgical periodontal therapy provide for?
Control, elimination, or minimization of primary etiologic factors for periodontal disease, local risk factors for periodontal disease, and systemic risk factors for periodontal disease identified in a patient during clinical assessment
Who should nonsurgical periodontal therapy be planned for?
Patients with plaque induced gingivitis and for all patients with chronic periodontitis
What can nonsurgical periodontal therapy help bring under control?
Plaque-induce gingivitis, slight to moderate chronic periodontitis, and more advanced perio disease but needs more advanced procedures such as perio surgery
What is indicated for patients with more advanced periodontitis?
Perio surgery
What should all patients with chronic periodontitis undergo prior to periodontal surgery intervention?
nonsurgical periodontal therapy
What can nonsurgical periodontal therapy successfully minimize?
Extent of any surgery subsequently needed and can improve outcomes of perio surgery
What is nonsurgical periodontal therapy not necessarily best therapy for?
Patients with other type of periodontitis such as aggressive periodontitis
Who should be referred to a periodontist?
People with other types of periodontitis other than chronic
What are specific goals of nonsurgical periodontal therapy?
To minimize bacterial challenge to patient, to eliminate or control local contributing factors for perio disease, to minimize impact of systemic factors for perio disease, and to stabilize the attachment level
What does control of bacterial challenge involve?
Intensive training of patient in appropriate techniques for self-care and professional removal of calculus deposits and bacterial products from tooth surfaces
What is an important step in achieving control of bacterial challenge?
Removal of calculus deposits and bacterial products contaminating tooth surfaces
What is calculus covered with if not removed?
Living bacterial biofilms that are associated with continuing inflammation
What can increase the risk of developing periodontitis in localized sites?
Local environmental factors such as defective restorations
What happens if there is plaque biofilm retention in a site over time?
Allows periodontal pathogens to live, multiply, and damage the periodontium
What will a thorough plan for nonsurgical periodontal therapy always include?
Minimizing impact of local environmental risk factors
What are two examples of systemic conditions that increase risk of periodontitis?
Diabetes mellitus and smoking
What is the ultimate goal of nonsurgical periodontal therapy in chronic periodontitis patients?
Stabilize level of attachment
What does stabilization of attachment level involve control of?
All factors listed in the other goals of nonsurgical periodontal therapy
What are examples of nonsurgical periodontal therapy procedures?
Customized self-care instructions including mechanical plaque biofilm control and chemical plaque biofilm control; perio debridement of tooth surfaces and pocket space; correction of systemic risk factors; correction of local contributing factors; modulat
What is an important aspect of nonsurgical periodontal therapy?
Patient self care
What might a typical plan for nonsurgical periodontal therapy for a patient with plaque induced gingivitis include?
Customized self care instructions including patient education and motivation; periodontal debridement; elimination of plaque biofilm retentive factors such as overhanging restoration, caries, or ill-fitting dental prostheses; correction of systemic factor
Why is response to nonsurgical periodontal therapy delayed?
Takes time for body defense mechanism to respond to individual treatment steps and for body to bring inflammation in periodontium under control
Why is dental team obligated to reevaluate results of nonsurgical periodontal therapy after period of healing?
To ensure all appropriate measures have been included and to identify any other measures that might be needed due to delay in healing
What is a typical plan for slight to moderate periodontitis?
Customized self care instructions, perio debridement, control of local risk factors, correction of systemic risk factors, reevaluation of patient's periodontal status
What complicating factors might patients with moderate/severe chronic periodontitis?
Deep probing depths, furcation involvement, or mucogingival problems
What should the dental team be aware of possible need for in a chronic periodontitis patient?
Perio surgery intervention
What is the objective of mechanical removal of calculus and bacterial plaque biofilm?
Physical removal of microorganisms and their products to prevent and treat periodontal infections
What is the most effective mechanism of control ?
Physical removal of bacterial plaque biofilm
Why is physical removal of bacterial plaque biofilm most effective mechanism of control?
Because of structure of biofilms
What is needed to remove/disrupt bacterial plaque biofilm subgingivally?
Frequent periodontal debridement of subgingival root surfaces
What remains the most imporant component of nonsurgical periodontal therapy?
Periodontal debridement
What is a critical step in any plan for nonsurgical periodontal therapy?
Removal of deposits from tooth surfaces
**What is rationale for periodontal instrumentation?
1. To arrest progress of perio disease
2. To induce positive changes in subgingival bacterial flora (Gram neg anaerobic bacteria)
3. to eliminate inflammation in periodontium
4. To increase effectiveness of patient self care
5. to prevent recurrence of di
*What has research indicate is as effective as hand instrumentation?
Electronically powered scalers and have some advantages over hand instrumentation when used for perio debridement
What are advantages for the use of powered scalers over hand instruments during periodontal debridement?
1. disruption and removal of plaque
2. slim diameter powered scaler tips more effective for furcation 3. Low-med power scalers do less damage to root surfaces
4. Slim tips penetrate perio pocket deeper
5. Water irrigation wash away toxic products and bact
What is scaling?
Instrumentation of crown and root to remove plaque and calculus and stain
What is root planing?
Removes cementum or surface dentin that is rough, impregnated with calculus, or contaminated with toxins/microorganisms
What is root planing a fundamental treatment procedure for?
Chronic perio patient
*What can be used with minimal amount of root planing to remove bacterial product from root surfaces?
Ultrasonic
What are riffle roots?
Root caries
What is used to replace term for scaling and root planing?
Perio debridement
What is perio debridement defined as?
Removal or disruption of bacterial plaque biofilm, its byproducts, and plaque biofilm retentive calculus from coronal tooth surfaces and tooth root surfaces to extent needed to reestablish perio health and restore balance between bacterial flora and host
What does perio debridement include?
Instrumentation of every square mm of root surface for removal of plaque biofilm and calculus, but does not include deliberate, aggressive removal of cementum
What is one goal of perio debridement ?
Conservation of cementum
What does conservation of cementum enhance?
Perio healing in the form of either repair or regeneration
What is an important function of cementum?
To attach PDL fibers to root surface; during healing process, cementum thought to contribute to repair of periodontium
What does research studies indicate that complete removal of cementum from root surface will do?
Expose ends of dentinal tubules and may allow bacteria to travel from pulp into perio pocket in some instances; infusion of bacteria from pulp may exacerbate alveolar bone loss
How far should root surfaces be instrumented?
To a level that results in resolution of tissue inflammation in perio tissue
What is deplaquing?
Disruption or removal of subgingival microbial plaque biofilm and its byproducts from cemental surfaces and pocket space
What is not currently recognized as an ADA procedure codes?
Periodontal debridement
What is the end point for nonsurgical perio instrumentation?
To return periodontium to state of soft tissue health
What does soft tissue health mean?
Periodontal tissues free of inflammation
What is the primary type of healing after perio debridement?
Through the formation of a long JE
What happens as inflammation in periodontium resolve?
Epithelial cells can readapt to the root surface
What is long JE?
Readaptation of epithelial cells to root surface
What is important to realize following perio debridement?
Normally no formation of new alveolar bone, new cementum, or new PDL
What does reduced probing depths result from?
Formation of a long JE combined in many instances with resolution of gingival edema that is usually a part of the inflammatory process
What is an important feature to monitor following periodontal debridement in addition to clinical attachment loss?
Probing depths
How long does it take to assess true tissue response?
At least one month
What does reevaluation refer to?
A formal step at the completion of nonsurgical therapy; dental team performs another perio assessment to gather info about patient's perio status
When should patient be scheduled for a reevaluation after completion of nonsurgical therapy?
4-6 weeks after
What are steps in a typical reevaluation appointment?
1. update medical status
2. Perform thorough perio clinical assessment
3. Compare initial perio assessment with reevaluation assessment
4. Make decisions related to the next step in therapy
What is the next step in therapy after reevaluation?
Additional nonsurgical therapy may be needed; need for periodontal maintenance may be identified; the need for periodontal surgery may be evident
What are nonresponsive disease sites?
Areas in periodontium that show deeper probing depths, continuing loss of attachment, or continuing clinical signs of inflammation in spite of thorough nonsurgical therapy
What should be done with nonresponsive disease sites?
Recheck for thoroughness of self-care ad recheck with explorer for presence of residual calculus
What should dental team consider if discover nonresponsive disease sites?
Other factors might be contributing to disease process
Why should reevaluation step indicate for additional nonsurgical periodontal therapy?
Self care efforts may improve but not adequate for control of inflammation; subgingival calculus deposits difficult to remove especially in presence of gingival edema; and systemic condition may contribute
What does perio maintenance include?
All measures used by dental team and patient to keep periodontitis under control
What is goal of perio maintenance?
Prevent recurrence of perio disease
When should patient be evaluated for periodontal surgery?
At initial perio assessment and at reevaluation
Who will need perio surgery?
Patients with more advanced periodontal conditions
Who might benefit from comanagement?
Patients with perio inflammation and diabetes, pregnancy, cardio disease, and chronic respiratory disease; patients who might be exposed to periodontal infection such as cancer therapy, cardio surgery, joint-replacement surgery, and organ transplantation
Who should be treated by periodontist?
Patients with severe chronic periodontitis, furcation involvement, vertical/angular bony defects, aggressive periodontitis, acute periodontal conditions, significant root surface exposure, progressive recession of gingival margin, and peri-implant disease