Replacement restorations or orthodontic movement of the teeth can simplify plaque biofilm control and help the patient achieve periodontal health. 2013) resulting in periodontal attachment loss (Armitage 1999).Chronic periodontitis can be effectively treated by means of mechanical non-surgical and surgical therapy (Badersten et al. Notice the loss of gum and bone, which has exposed the tooth roots. The definitions of procedures must be clear and consistent. Periodontal disease is a common gum inflammation that affects 3 out of 4 adults, but it can be prevented or treated with regular periodontal exams. Cleaning agents are available for polishing the teeth and are preferable to those that contain abrasives. “Root planing” involves cleaning plaque from below the gum line that is most often the culprits in periodontal disease. A periodontal infection that can’t be fixed through ordinary periodontal therapy techniques may require surgery and will likely fall into 1 of 4 categories. The American Academy of Periodontology (AAP) defines scaling as “instrumentation of the crown and root surfaces of the teeth to remove plaque, calculus, and stains from these surfaces.”4 However, subgingival scaling is also referred to as simply the removal of subgingival calculus3 or the more general term, subgingival deposits.5 Scaling is most commonly thought of as the removal of identifiable deposits of calculus, but associated plaque biofilm deposits are also removed during the procedure. CLINICAL EVIDENCE • Describe the contributions of magnification with use of loupes, endoscopy, and microscopes to nonsurgical therapy. When the junctional epithelium has been injured or separated from the tooth surfaces, as it would be during periodontal debridement, healing can be expected to take approximately 1 week. When it does not achieve periodontal health, surgery may be indicated to restore periodontal health. Irvine, San Juan Capistrano, San Clemente, Mission Viejo, & Orange County CA. Gingival curettage, also called closed curettage or nonsurgical gingival curettage (truly a misnomer), was traditionally performed to remove inflamed pocket lining for reasons distinct from periodontal debridement. In the early stages it may not even be noticeable to you. For this reason, every patient must participate in treatment by adopting a regular and effective biofilm removal regimen. It commonly occurs during nonsurgical periodontal therapy. Material and methods: Fourteen CP cases received full-mouth non-surgical treatment and, after 6 months, at least two surgical sessions. It appears that variation in smoothness is acceptable as long as calculus that makes surfaces feel rough and irregular has been removed and plaque biofilm has been disrupted. Animal studies, the landmark study on human experimental gingivitis, and much additional evidence prove that plaque biofilm removal is a major part of nonsurgical periodontal therapy. The only study that attempted to measure root texture with quantifiable profilometer (Micrometrical Manufacturing, Ann Arbor, MI) readings found that the amount of root roughness did not affect plaque biofilm formation. Several other concerns about polishing exist. Some are under the patient’s control, and may, therefore, require lifestyle changes to achieve significant modification. Local anesthetics are also used to numb the area for greater comfort. Plaque biofilm must also be dislodged from all accessible surfaces. In the 1960s, this disease was recognized as different from typical periodontitis because the conventional therapy, which consisted of scaling and root planing in the localized affected areas of the anterior teeth and first molars, could only slow the loss of these teeth. These reasons are8 as follows: • Smooth surfaces retard plaque formation. are provided for commonly used terminology found in publications and other communications. The cycle may take as long as 6 months to complete.8 Repopulation can be expected to vary for many reasons, one of which is clinician differences in complete removal of plaque biofilm and calculus. This is why regular visits to your periodontist are important especially if other health problems are present, like heart problems or diabetes. A comprehensive explanation of periodontal maintenance is found in Chapter 17. Thus, the rationale for root planing to remove root roughness and achieve glassy, smooth root surfaces is no longer valid. Minimally-Invasive Non-Surgical Periodontal Therapy – Philip Ower, May 2013. 6. • Explain the limitations of calculus removal and the expectations for clinician proficiency. Connective tissue fibers are disrupted and lysed beneath the epithelium. • Explain the benefits and indications of antimicrobial adjuncts to nonsurgical therapy. The goal of root planing, leaving the roots clean, has not changed, but the extent to which root tissue is scraped away to create a glassy, hard texture has been under scrutiny. These terms include supragingival and subgingival scaling and root planing and disruption or removal of plaque biofilm, with a minimum of tooth structure removal.4 They also incorporate removal of plaque biofilm, plaque retentive features, and calculus, both above and below the gingival margin. Additional Services | Financial Policies | FAQs | Contact Our Office | Disclaimer | Sitemap. In some cases, it could be non-surgical or surgical. Can be single-ended or double-ended Many different types of periodontal probes available Both were effective in removing approximately 67% of the plaque in pockets deeper than 5 mm and the ultrasonic instruments performed as well as the hand instruments.16,17 The AAP consensus report on nonsurgical periodontal therapy suggested that 11% plaque remaining on root surfaces after thorough instrumentation was more likely an accurate figure.17. Dental hygiene procedures with hand instruments or powered scalers adequately accomplish subgingival plaque biofilm removal. Providing information about performing effective plaque biofilm control is more valuable than performing what is primarily a cosmetic procedure. Experience suggests that the roots in an individual patient’s mouth will feel equally smooth after thorough instrumentation. An excellent example of the application of the specific plaque hypothesis is the treatment of aggressive periodontitis in its juvenile form. Learning Outcomes • Define nonsurgical periodontal therapy. Removal of this tissue was assumed to enhance pocket reduction beyond the results achieved by scaling and root planing alone, providing faster healing and the formation of new connective tissue attachments to the root surfaces. Describe the process of healing after periodontal debridement procedures, scaling, and root planing. The appealing notion that rough surfaces would present more of a plaque control problem for patients is borne out by experience with obvious calculus or overhanging restorations. Describe how the. This end point is best evaluated by explorer detection of smooth surfaces. However, in periodontology, the term, In its broadest sense, nonsurgical therapy defines all of the procedures performed to treat gingival and periodontal diseases up to the time of reevaluation, which is when patients begin maintenance care and the need for periodontal surgery to enhance results is determined. Removal of endotoxins would require the planing away of diseased cementum. In 1976 Wilkins, in her fourth edition of. Dramatically thinned root surfaces are shown in, Conscientious removal of calculus and plaque biofilm with minimum destruction of cementum, termed. The repeated removal of tooth structure during nonsurgical therapy appointments and subsequent maintenance visits is not a goal of therapy, and it may result in thinned and sensitive root surfaces. Root planing, like scaling, may be successfully performed by hand instrumentation or powered scaling devices. Rationale for Nonsurgical Periodontal Therapy. Clearly, this requires clinical experience and judgment on the part of the dental hygienist. The numbers of organisms are reduced dramatically and grow back in different proportions. • Rough surfaces mechanically irritate gingival tissues. It is now known that the presence of plaque biofilms does not interfere with the uptake of fluoride by tooth structures. Bacteria live in the mouth and are present around diseased teeth. diagnosis and treatment of periodontal diseases. Appearance of the teeth is of great importance to patients, and the polishing procedure can be an excellent way to motivate them to remove plaque biofilm for health as well as appearance. The thoroughness of calculus removal by instrumentation has been studied and shows surprising results. It describes scaling procedures, both hand instrumentation and powered instrumentation, root planing, gingival curettage, and polishing. • Identify the techniques and applications for nonsurgical periodontal therapy procedures. All plaques are no longer considered intrinsically bad. No experimental evidence indicates that rough root surfaces are mechanical irritants and would therefore delay healing. Non-Surgical Treatments least invasive and cost effective manner. Calculus adheres to tooth surfaces through pellicular attachment, mechanical locking, and intercrystalline forces. Identify the techniques and applications for nonsurgical periodontal therapy procedures. • Describe the process of healing after periodontal debridement procedures, scaling, and root planing. Laser periodontal therapy is one of the latest and most exciting techniques being developed for the treatment of periodontal disease. Although some periodontal destruction has been observed in germ-free (gnotobiotic) animal experiments, it tends to be localized and related to the impaction of foreign objects, such as hairs. They receive up to three additional years of specialized training in periodontal disease treatment in both non-surgical treatments and periodontal plastic surgery procedures. The bacterial plaque shifts from predominantly gram-negative microbiota to one that is gram-positive, with many fewer motile forms, especially spirochetes. Nonsurgical therapy includes the procedures listed in. Phyllis L. Beemsterboer and Dorothy A. Perry. Eventually, they will be much better understood so that therapies directed toward the specific plaque bacteria in each individual can be used, including the use of more antimicrobial and antiseptic agents. Nyman and colleagues20 compared these treatment strategies by testing the healing of quadrants after periodontal surgery. Root roughness has been equated with incomplete instrumentation because of concerns that endotoxins (e.g., lipopolysaccharides) formed by gram-negative bacteria invade the root structure. Conscientious removal of calculus and plaque biofilm with minimum destruction of cementum, termed periodontal debridement, is justified. 3. Treatment frequently requires the use of pain control measures. Scaling and root planing are a basic approach to effectively treating the disease and allowing the gums and surrounding bone to heal properly. Plaque biofilm is the primary causative agent in gingival and periodontal diseases. Dental hygiene procedures with hand instruments or powered scalers adequately accomplish subgingival plaque biofilm removal. Afterwards, you return to your general dentist, who will place a crown or other restoration on the tooth to protect it … However, subgingival plaque is not effectively altered by supragingival oral hygiene procedures, especially in deeper pockets of 5 mm or more. The term selective polishing has been clarified to mean that the clinician selects the appropriate agent based on the presenting needs of the patient. Peri-implantitis: Nonsurgical therapeutic approach 6. If periodontal disease has progressed to the point where gum tissue no longer fits snugly against the teeth, minor gum surgery may be needed. Air powder polishing removes most extrinsic stains and soft deposits from the exposed surfaces of the teeth. The dental hygienist has many patient treatment options available for nonsurgical periodontal therapy, including the use of injected local anesthetics for pain control. A number of dental hygiene programs in the United States teach gingival curettage because it is a legally sanctioned duty in many states and may be performed by practitioners in the community. Cleaning agents are available for polishing the teeth and are preferable to those that contain abrasives. The cornerstone of management of chronic periodontitis is the non-surgical periodontal treatment. Capnocytophaga species and spirochetes are the last to grow back. The quality of the plaque is more important than the quantity, but plaque biofilm is still the causative agent in disease. Other concerns include the possibility of creating bacteremia in the patient and possibly damaging the tooth pulps by heat generated from the power-driven prophylaxis angle. Convincing experimental evidence that plaque microorganisms cause human gingival disease was presented by Löe and colleagues in 1965.14 The researchers initiated extensive plaque control in a small group of dental students and brought them to a level of excellent periodontal health; then the subjects refrained from oral hygiene procedures for 3 weeks. Periodontists are dentistry's e xperts in treating periodontal disease. Most importantly, no surfaces should feel rough, as if calculus is still present. Scaling and root planing is the standard of care for nonsurgical and nonpharmacologic treatment of chronic periodontal diseases. This uniform smoothness should be identified. Armitage reviewed the reasons dental hygienists and dentists attempt to smooth roots to a glassy, hard texture through root planing. The nonsurgical endodontic therapy or root canal removes the inflamed or infected pulp, carefully cleans and shapes the inside of the tooth, then fills and seals the space. Curettage had been defined by the AAP as scraping or cleaning the walls of a cavity or surface by means of a curette.12 It is a commonly misused term, often applied to a variety of procedures from removal of the pocket lining, termed closed curettage, to a surgical flap procedure called open curettage. The purpose of prophylaxis is to assist the patient in maintaining and preserving periodontal health. Polishing is the use of polishing agents to remove stains and supragingival plaque biofilm from the teeth. The alternatives to non-surgical periodontal therapy are: Surgical periodontal therapy; No treatment It is important to understand that periodontal disease is not curable. However, subtle signs such as red or swollen gums, gums that bleed when brushed or flossed, chronic bad breath or loose teeth can alert you to the presence of gum disease and the need to see a periodontist. A number of clinical trials have confirmed that gingival curettage provides no additional benefit to healing compared with scaling and root planing alone in terms of probing depth reduction, attachment gain, or inflammation reduction. Periodontists are also experts in replacing missing teeth with dental implants. This chapter defines the technical procedures applied by dental hygienists and the instruments used for treatment. These procedures are demanding technical activities that require a large share of each therapeutic treatment appointment. It works by mechanical abrasion using a slurry of sodium bicarbonate and water. This tactile sense is used to determine the amount of calculus present in the untreated patient, the existence of irritating factors such as overhangs, and the point at which thorough instrumentation (periodontal debridement) is finished at each appointment. During periodontal debridement procedures, the goal for the dental hygienist is to promote plaque biofilm control and instrument the tooth surfaces until they are clean and smooth, touching all portions of the roots to disrupt plaque biofilm and remove calculus. To effectively take care of periodontal disease, the initial treatment is typically scaling and root planing; this treatment exists to remove tartar at or below the gum line. 5. Glassy, smooth root surfaces are not end points in treatment. Because this system produces an extensive aerosol, it is contraindicated in patients with infectious diseases, respiratory illnesses, hypertension, or those who are on hemodialysis.10 The periodontal patient often has multiple exposed root surfaces and caution with the choice of polishing agent is advised. that smooth surfaces had less plaque biofilm formation; however, root texture was not measured. However, the roughness associated with calculus and poor restorations is far greater than the slightly granular texture of calculus-free root surfaces. To do so, the patient uses oral hygiene procedures and the dental hygienist performs coronal polishing. If the long-term goal of restoring periodontal health has not been achieved after conscientious nonsurgical therapy, the dental hygienist must first suspect residual calculus (and plaque biofilm) and re-treat nonresponding areas. However, in periodontology, the term surgery is reserved for more invasive cutting procedures. Inflamed pocket lining is composed of thin ulcerated strands of epithelium, with rete pegs extending into the underlying connective tissue and granulation tissue containing disorganized masses of cells. In particular, it shows the most promise for root surface treatment and is safe and efficient for use in periodontal bone surgery when used with concomitant water irrigation. If the non-surgical therapy effectively eliminates the gum disease, the only further requirement will be periodic maintenance every 3-4 months. The dental hygienist cannot focus solely on the technical aspects of calculus removal. 4. The quality of the plaque is more important than the quantity, but plaque biofilm is still the causative agent in disease. Specific definitions accepted in the dental hygiene community are provided for commonly used terminology found in publications and other communications. A thorough review of nonsurgical periodontal therapy by Cobb et al reported mean PPD reductions of 1.29 mm to 2.16 mm and CAL gains of 0.55 mm to 1.19 mm for initial probing depths of 4 mm to 6 mm or more than 6 mm before treatment in chronic periodontitis patients … This rationale has been questioned for many years and the procedure is no longer considered standard treatment. For periodontal patients, this goal often requires multiple appointments with the dental hygienist. It is defined as the removal of the inflamed soft tissue lateral to the pocket wall. Barnes recommended that the least abrasive paste necessary to remove stains was appropriate and if no stain was present a cleaning agent should be employed. The only study that attempted to measure root texture with quantifiable profilometer (Micrometrical Manufacturing, Ann Arbor, MI) readings found that the amount of root roughness did not affect plaque biofilm formation. Prophylaxis is a preventive procedure to remove local gingival irritants and includes complete calculus removal followed by root planing. Bacteria-specific tests and treatments have been developed and will be more widely used as the understanding of periodontal disease increases.7, It is possible to remove all supragingival plaque effectively. Both were effective in removing approximately 67% of the plaque in, Calculus is little more than calcified plaque biofilm. The term nonsurgical therapy is often considered a misnomer because the procedures performed require the application of sharp blades to cut tissues, which is a form of surgery. Repair after disruption of the junctional epithelium during scaling procedures (not removal, which occurs with surgical excision) is similar to the normal course of events in tissue turnover.25, Inflammatory activity occurs in the underlying connective tissue during the disease process and is also a result of treatment. Due to the contradicting findings in the literature, we wanted to evaluate the influence of nonsurgical periodontal therapy on the metabolic control in type 1 diabetes in Malaysian subjects. In a recent review, Ishikawa et al5 stated that the Er:YAG laser seems to provide the most suitable characteristics for various types of periodontal treatment. 2008;35(Suppl 8):29-44. 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