Root planing

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root planing/ root debridement, instrumentation,

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  • Distribution of lps in root surfaces.
  • was studied by implanting 70 autogenous fragments from periodontally involved roots into the mucosa of 56 patients.
  • designs allows the advantages of the area-specific shank to be combined with the versatility of the universal curette blade
  • Perio 2000vol 62 learned and unlearned surgical and non surgical…critical probing depth 2.9 and 5.4mm
  • Root planing

    1. 1. ROOT PLANING
    2. 2. • Marginal periodontitis is induced by bacterial plaque deposits and maintained by subgingival plaque and calculus present on root surfaces. • Therefore therapy of periodontally involved teeth is primarily directed towards removal of these accretions from root surfaces in order to allow for healing.
    3. 3. Non surgical therapy Non surgical therapy is defined as “plaque removal, plaque control, supra and sub gingival scaling, root planing and the adjunctive use of antibiotics.” (Ciancio 1989,1992)
    4. 4. Scaling is the process by which plaque and calculus are removed from both supragingval and subgingival tooth surfaces .
    5. 5. Root planing: instrumentation to remove the microbial flora on the root surface or lying free in the pocket, all flecks of calculus and all contaminated cementum and dentin.( O Leary, 1977)
    6. 6. • DCNA Meticulous instrumentation of the cemental surface of the root during periodontal treatment for the purpose of removing all the dental accretions(calcified and noncalcified) to render the surface biologically clean and clinically smooth
    7. 7. CLOSED DEEP SCALING ROOT SURFACE DEBRIDEMENT ROOT SURFACE INSTRUMENTATION ROOT DETOXIFICATION
    8. 8. ROOT SURFACE DEBRIDEMENT OR ROOT SURFACE INSTRUMENTATION Debridement of the root surface with only few strokes, and not to undertake aggressive instrumentation to remove the endotoxin and other root surface irregularities
    9. 9. • This term has appeared recently in the literature to better describe periodontal instrumentation associated with periodontal therapy. • “the treatment of gingival and periodontal inflammation through mechanical removal of tooth and root surface irritants to the extent the adjacent soft tissues maintain or return to a healthy , non inflamed state”
    10. 10. SCALING ROOT PLANING PERIODONTAL DEBRIDEMENT Removal of calculus from all tooth surfaces and removal of cementum from root surfaces Removal of plaque biofilms and calculus from tooth surface and within the pocket space Aggressive instrumentation removes significant amounts of cementum Conservation of cementum is a goal; bacterial products are removed with ultrasonic instruments or light instrumentation strokes Hand activated instrumentation A combination of hand activated and ultrasonic instrumentation preferred
    11. 11. CLARITY OR CONFUSION- BEST WAY TO DEBRIDE ROOT SURFACES • “Root planing implies removal of cementum (and possibly dentine) exposed within the pocket to maximise the chance of removing all components of the subgingival plaque.... • Subgingival scaling is the removal of deposits of subgingival calculus • “....in reality the procedures are similar and the term ‘root surface debridement’ is often used as a more generic term.” • Subgingival Plaque Control - The Clinician( BDJ)
    12. 12. RATIONALE OF ROOT PLANING REMOVAL OF DISEASED CEMENTUM GLASSY SMOOTH TOOTH SURFACE NEW ATTACHMENT
    13. 13. Stripped of periodontal attachment Contains remnants of embedded calculus, whole bacteria, and the products of microbial life. Exposed to septic contents of periodontal pocket DISEASED/ALTERED/NECROSED CEMENTUM
    14. 14. CHANGES IN DISEASED CEMENTUM STRUCTURAL CHANGES • Hypermineralization/ Demineralization • Presence of pathological granules CHEMICAL CHANGES • Changes in conc of Ca, Mg, Phosphate • Adsorption from saliva CYTOTOXIC CHANGES • Adsorption of endotoxins • Invasion of bacteria • Cell mediated resoption lacunae
    15. 15. • Polson and Caton( 1982) Role of reduced Periodontium and altered root surface Role of altered root surface on wound healing Experimental Periodontitis Rhesus monkey Block sections of periodontium evaluated after 40 days
    16. 16. • RESULTS No new CT attachment . pathologically altered root surface although placed in healthy periodontium • CONCLUSION pathologically altered root surface rather than reduced periodontium – prevented regeneration
    17. 17. ENDOTOXINS • THE MOST COMMONLY STUDIED SEPTIC COMPONENT IN DISEASED CEMENTUM IS ENDOTOXIN. • THEY ARE LIPOPOLYSACCHARIDE OF GRAM NEGATIVE BACTERIA.
    18. 18. ROLE OF ENDOTOXINS PYROGENICITY ATTRACTION OF INFLAMMATORY CELLS ACTIVATION OF COMPLEMEMT SYSTEM STIMULATION OF OSTEOCLASTIC ACTIVITY MITOGENIC ACTIVITY FIBROBLAST CYTOTOXICITY
    19. 19. • Aleo et al. (1974) LIMULUS LYSATE ASSAY Periodontally involved root surfaces contained an endotoxin-like material capable of depressing cell growth of tissue culture fibroblasts. Conclusion led to the long accepted concept that endotoxin lies within cementum, and that cementum removal during periodontal therapy might be appropriate.
    20. 20. HATFIELD AND BAUMHAMMERS( 1971) Periodontally involved roots which had been washed and scaled (not root planed) and placed these roots in sterile tissue cultures. Controls - uninvolved third molar roots. Results: After 24 to 96 hours, cell cultures over control roots showed irreversible morphologic changes. Conclusion: presence of some toxic factor, possibly endotoxin, which had penetrated the diseased root and was capable of upsetting cell attachment.
    21. 21. Jones and O’leary (1978) • Effect of vigorous root planing on quantity of endotoxin. • 50 root surfaces each of Diseased 146.8ng Healthy roots(0.05-0.45ng) • Meticulous instrumentation was performed.
    22. 22. • RESULT: Root planed roots contained only about 1 ng more endotoxin than healthy root surfaces. This small difference can be accounted for small flecks of calculus remaining after planing. • Conclusion: Root planing performed in the study was able to render diseased root as free of endotoxin as healthy root.
    23. 23. ENDOTOXIN PENETRATION • Endotoxin and whole bacteria may be found as deep as 12 microns beneath the cemental surface. • Zander (1953) Penetration of calculus bacteria Calculo-cementum Must be removed • Selvig (1969) Normal appearing areas Areas of decreased radio- opacity & cavitation Areas of partial decalcification (300µ) Highly mineralized areas
    24. 24. ENDOTOXIN DOES NOT PENETRATE BUT LOOSELY ATTACHED SUPERFICIAL LAYER Nakib et al (1982) • Weakly adherent • No penetration into cementum • Brushed away Nyman et al (1986) • Study on dogs • Endotoxins did not interfere with healing following flap surgery once soft deposits were removed • Endotoxin removed with bacteria during polishing within cementum. Neutralized by inflammatory response OPPOSING STUDIES
    25. 25. • Moore & coworkers (1986) Toxins(LPS) weakly bound to root surface Washing for 1 minute removes 40% Brushing for 1 minute removes 60% Remainder 1%
    26. 26. REMOVAL OF DISEASED CEMENTUM • The portion of root exposed to the disease process has little or no fibroblast cells attachment to the remainder of root surface. Following the mechanical removal of diseased cementum and the bacterial endotoxin, the cells attached normally on the planed root surfaces. The cementum bound endotoxin is capable of both cell death and decreased cell proliferation ( Simon, Goldman 1971)
    27. 27. LOPEZ et al,1980 • Inflammatory potential of diseased cementum • Histologic results showed – Implanted fragments from roots that had been scaled caused the most response with acute inflammation up to 14 days and chronic inflammation to 21 days. Autoclaved Fragments- the acute inflammation was not as severe.
    28. 28. • Autoclaved and planed roots- even less acute inflammation was seen in the 7-day specimens while some chronic inflammation persisted in the 21- day specimens. • Implants from healthy roots evoked no response. • The inflammation caused by the autoclaved diseased cementum: attributed to thermo-stable endotoxin. • Conclusion- Necessary to remove all of the cementum exposed to the pocket to eliminate its potential for inducing inflammation
    29. 29. CONTRADICTORY STUDIES • Nyman et al. (1986) demonstrated in beagle dogs that the removal of diseased cementum was not necessary for successful periodontal therapy. • In a later study in humans, Nyman et al. (1988) showed that the same degree of improvement of periodontal status was achieved regardless of whether cementum was removed or not. • Results : Intentional root cementum removal is not necessary for optimal postoperative healing.
    30. 30. ROOT SMOOTHNESS • EMPHASIS IN ROOT PLANING HAS ALWAYS BEEN ON THE ELIMINATION OF PLAQUE AND CALCULUS ALONG WITH SMOOTHENING THE ROOT SURFACE. • HOWEVER THE IMPORTANCE OF ROOT SMOOTHNESS NOT ESTABLISHED.
    31. 31. Jens Waerhaug(1956) Effect of rough surfaces upon gingival tissue, EXPERIMENT IN DOGS Described the irritating effect of calculus that is caused by bacteria or toxin.
    32. 32. • Emphasized - rough surface facilitates the retention of bacterial plaque and stressed the needs of well polished restoration below the gingival margin. • Supported by : Lindhe et al1984 Lekens KN 1996 Quiryen N 1995
    33. 33. Rosenberg & Ash(1974) Profilometer Sig diff b/w curretted & control teeth No significant diff in mean plaque scores/inflammatory indices Root roughness not significantly related to mean inflammatory index Khatiblou & Ghodssi (1983) Healing following surgical Rx Healing not affected by root roughness Hunter et al (1984) Gouges/ ripples ≤ 50µ smooth Biologically lack of evidence relating smooth surfaces to plaque formation Rough area favor plaque & calculus Smoothness only indicator of calculus removal OPPOSING STUDIES
    34. 34. PREPARATION FOR NEW ATTACHMENT • Removal of contaminated root surface Root surface demineralization with citric acid Pre requisite for new connective tissue attachment Accelerates new attachment in healing periodontal wounds
    35. 35. • Removal of hypermineralized surface- Prerequisite for effective demineralization. • ROOT PLANING –
    36. 36. • Garrett et al (1978) SEM & TEM Citric acid- no effect on unplaned roots Planed root surfaces- 4nm wide areas of demineralization Failure- hypermineralized areas on diseased roots • Polson et al (1984) Root planing (smear layer)2-15µm thick Citric acid (ph1 for 3 min) Removal of smear layer Fibrous mat like structure Not evident on unplaned roots
    37. 37. OBJECTIVES OF ROOT PLANING Restore health •Remove elements that provoke gingival inflammation Remove pathogenic microflora
    38. 38. • O’ LEARY Biologically acceptable root surface Probing depth Resolving inflammation Facilitating oral hygiene Improving & maintenance of attachment levels Preparing tissues for surgical procedures
    39. 39. INSTRUMENTATION
    40. 40. Hand instruments • HOE Blade, bowed -2 point contact instrument Single blade 99-100, bevelled at 45o Macalls type and Holst type
    41. 41. FILES Series of cutting edge lined up on a single base Series of hoes mounted on the base Mode of use- held parallel to calculus and crushed, Use of curette
    42. 42. • CHISEL Only instrument used with the push motion No more used for root planing
    43. 43. • CURETTES Instrument of choice for root planing Curved blade and rounded toe better adapted to the root surface
    44. 44. 2 TYPES –AREA SPECIFIC AND UNIVERSAL • Universal curettes have limited adaptability: Deep pockets Root convexities, and Developmental depressions Gracey curettes are the new modifications which are area specific and specially designed for subgingival scaling and root planing in periodontal patients.
    45. 45. • Gracey curettes are a set of area-specific instruments . • Designed by Dr. Clayton H. Gracey of Michigan in the mid-1930s
    46. 46. Four design features make the Gracey curettes unique: (1) They are area specific, (2) Only one cutting edge on each blade is used, (3) The blade is curved in two planes, and (4) The blade is “offset
    47. 47. Extended-Shank Gracey Curettes • 3 mm longer in the terminal shank • Deep pockets on maxillary and mandibular posterior teeth,
    48. 48. Mini-Bladed Gracey Curettes Mini-bladed Gracey curettes, such as the Mini Five curettes and the Gracey Curvettes, Terminal shank that is 3 mm longer than the standard Gracey curettes Blade that is 50% shorter. Micro Mini Five curette blades are 20% smaller than Mini Five curette blades
    49. 49. Standard Gracey curet vs a “Mini- Gracey curet”. GRACEY CURETTE MINI GRACEY CURETTE
    50. 50. • Micro Mini Five Gracey curettes (Hu-Friedy) • Blades that are 20% thinner and smaller than the Mini Five curettes • These are the smallest of all curettes,
    51. 51. • Provide exceptional access and adaptation • Deep, or narrow pockets; narrow furcations; Developmental depressions; line angles; and deep pockets on facial, lingual, or palatal surfaces.
    52. 52. Langer and Mini-Langer Curettes • Set of three curettes • Combining the shank design of the standard Gracey #5-6, 11-12, and 13-14 curettes with a universal blade honed at 90 Marriage of the Gracey and universal curette
    53. 53. QUENTIN FURCATION CURETTE • Shallow half moon radius that fits in to the roof or floor of the furcation • Shanks are slightly curved • Available in two width, BL1 & MD1 – small and fine 0.9 mm width • BL2 & MD2- larger 1.3 mm
    54. 54. Diamond coated files • Coated with fine grit diamond . Do not have cutting edge • Sharply abrasive – produce smooth, even clean surface • Particularly used along with the endoscope • Disadv : can cause over instrumentation
    55. 55. • Diamond-coated ultrasonic instruments will effectively plane roots, and that caution should be used during periodontal root planing procedures. Additionally, the diamond-coated instruments will produce a rougher surface than the plain inserts or the hand curettes. ( Vastardis 2005)
    56. 56. ULTRASONIC AND SONIC INSTRUMENTS • Magnetostricitve & Piezoelectric • Air or sonic • Operated by the air line usually connected to air turbine
    57. 57. COBB et al 2002 • “When one considers the demands of clinical skill, time and stamina, the instrument of choice for universal application would appear to be either a sonic or ultrasonic scaler.”
    58. 58. PERIOSCOPY SYSTEM • The Perioscopy system consists of a 0.99-mm-diameter, reusable fiberoptic endoscope over which is fitted a disposable, sterile sheath.
    59. 59. Allows clear visualization deeply into subgingival pockets and furcations Permits operators to detect the presence and location of subgingival deposits and guides them in the thorough removal of these deposits. Magnification ranges from 24X to 48X, enabling visualization of even minute deposits of plaque and calculus
    60. 60. PERIO TOR • Specially designed to optimize cleaning and planing of the rough root cementum and • Prevent further removal of root cementum once the surface is clean and smooth.
    61. 61. PERIOTOR CURETTE ULTRASONIC/HANS SCALER
    62. 62. Vector™ system • Specially devised to reduce the amount of tooth surface loss and treat the periodontal tissues less aggressively. • Uniqueness of this system lies in the oscillations produced by the ultrasonic tip.
    63. 63. • Ultrasonic tip of this system vibrates parallel to the tooth surface, which leads to less removal of the tooth structure. • Reduction in pain perception of the patient. This may be attributed to vertical vibrations of the ultrasonic tip.
    64. 64. AUTHOR STUDIES RESULTS SCULEAN et al 2004 (Vector-ultrasonic system) or scaling and root planing (SRP) using hand instruments. Non-surgical periodontal therapy with the tested ultrasonic device may lead to clinical improvements comparable to those obtained with conventional hand instruments. DAHIYA et al 2011,2012 Gracey curette, ultrasonic tip and rotary bur, compared for root debridement Favored the use of rotary instruments for root planing to achieve a smooth, clean root surface; however, the use of rotary instrument was more time consuming,
    65. 65. MARDA et al ,2012 Compare the remaining calculus, loss of tooth substance, and roughness of root surface after root planing with Gracey curette, ultrasonic instrument (Slimline® insert FSI-SLI-10S), and DesmoClean® rotary bur. Slimline™ insert was shown to be better than the other methods as assessed by the indices scores and the instrumentation time. Ana Chapper,2005 Compared the clinical effects of hand or ultrasonic scaling and root planing on the treatment of chronic periodontitis. ( BOP, PD,CAL) Methods of subgingival instrumentation were equally efficacious in the improvement of the studied clinical parameters.
    66. 66. LASERS • ABLATIVE LASER THERAPY Removes plaque and calculus with low mechanical stress No smear layer Can be reached to all the areas Photoablative and Photodynamic diode laser in adjunct to scaling -root planing (SRP) Diode laser treatment (photoablation followed by multiple photodynamic cycles) adjunctive to conventional SRP improves healing in chronic periodontitis patients.
    67. 67. AUTHOR STUDIES RESULTS Liu CM,1999 Nd:YAG laser treatment versus scaling/root planing (SRP) treatment on crevicular IL-1beta levels SRP was found to have a superior IL- 1beta response, Matthias Kreisler,2005 Clinical efficacy of semiconductor laser periodontal pocket irradiation as an adjunct to conventional scaling and root planing. Lasers can be recommended as an adjunct to conventional scaling and root planing. Schwarz F,2001 Effectiveness of an Er:YAG laser to that of scaling and root planing for non-surgical periodontal treatment. Er:YAG laser may represent a suitable alternative for non- surgical periodontal treatment
    68. 68. AIR POLISHING • The air-abrasive technology uses an abrasive powder introduced into a stream of compressed air to clean or polish a surface by removing deposits attached to it or smoothing its texture.
    69. 69. PERIOPLANER/ PERIOPOLISHER • The system involves two motor driven handpieces. One handpiece works with curettes and hoes (Perioplaner) and the other works with diamond-layered instruments (Periopolisher) • Study has shown that the use of the Perioplaner and Periopolisher results in about the same loss of root substance as the use of hand instruments. • Schweiz MZ, 1991
    70. 70. ROOT PLANING PROCEDURE SUBGINGIVAL CALCULUS TENACIOUS VISION OBSCUED BY BLEEDING MUST RELY ON TACTILE SENSITIVITY SRP COMPLEX THAN SUBGINGIVAL SCALING
    71. 71. INSTRUMENT SELECTION BEGIN WITH SMALL FILES/ HOES LOWER POWER SET ULTRASONIC/SONIC SCALER OR RIGID CURET FINISH WITH FINISHING CURET
    72. 72. STRATEGIES FOR INSTRUMENTATION • SELECTION OF CURET FINE SET: NON RETRACTABLE TISSUE HEAVY SET: RETRACTABLE TISSUE MEDIUM SET: RETRACTABLE TISSUE • FINGER REST/GRASP Grasp- modified pen and stable finger rest Identify the cutting edge of curette
    73. 73. • ACTIVATION OF INSTRUMENT Adaptation- lower shank parallel Angulation- 45- 90 degree established • STROKES Stroke length Stroke direction Stroke activation
    74. 74. Terminal shank parallel to tooth long axis.
    75. 75. • STROKE DIRECTION Vertical and oblique strokes are most effective strokes for root planing and exploring. VERTICAL OBLIQUE HORIZONTAL
    76. 76. • STROKE LENGTH Root planing strokes extend from the base of the pocket to the cemento enamel junction. • STROKE ACTIVATION Wrist forearm motion is the fundamental means of activation.
    77. 77. CHANNELS OF INSTRUMENTATION
    78. 78. • FORCE MAXIMIZED BY SCALING IN CHANNELS AND BY CONCENTRATING PRESSURE ONTO LOWER ONE THIRD OF THE BLADE. • Overlapping , short powerful stroke- Large calculus removal( Carranza,10th ed) • Root planing stroke- Long lighter overlapping with less lateral pressure( Carranza,10th ed)
    79. 79. TERMINAL FEW MILLIMETERS OF THE BLADE ENGAGES THE LATERAL EDGE OF THE DEPOSIT WITHOUT WITHDRAWING THE INSTRUMENT, LOWER THIRD OF THE BLADE ADVANCED LATERALLY AND REPOSITIONED TO ENGAGE THE NEXT PORTION CHANNELS ON TOOTH SURFACE
    80. 80. • HEAVY LATERAL PRESSURE WITH SHORT CHOPPY STROKES AFTER CALCULUS REMOVAL- ROOT SURFACE WITH NICKS AND GOUGES • HEAVY LATERAL PRESSURE WITH LONG STROKES- SMOOTH BUT DITCHED OR GOUGED ROOT SURFACE
    81. 81. NUMBER OF STROKES • Root modification using periodontal curette- 10 to 70 strokes • 20 strokes are sufficient for removing cementum • Aggressive root planing involves -10 or 20 strokes more
    82. 82. • Study used a piezo-electric receiver mounted into the upper shank of a curet in Gracey 1/2 design. • Results - 40 strokes at low force removed 148.7 μ and at high forces 343.3 μ . With an increasing number of strokes the amount of substance removed per stroke became less. (Zappa et al,1991)
    83. 83. • Oda (1992) Series of in vitro studies 2 scaling strokes with a sharp manual scaler – enough to remove endotoxin • Moore (1986) Gentle washing in water for 1 min or brushing with slowly rotating brush is enough to remove endotoxin Ultrasonic scalers with its cavitational effect considered effective for removal of Endotoxin
    84. 84. Manual scalers • Horning(1987) -57.8μ/40 strokes • Coldiron et al(1990) - 60μ/20 strokes • Ishizuker and co workers(1980) 3.9μ with 750g lateral pressure with 50 strokes Fine curettes- 9.1μ with clinically applied force/working stroke
    85. 85. CEMENTUM REMOVAL • U.S scaler-1 to 7.2 μ • Sonic-4.3 to 7.8 μ • Diamond file- 7.9 to 15.5μ • Fine curette- 5 –22μ/stroke ULTRASONIC SCALERS REMOVE LESS CEMENTUM BUT LEAVE A ROUGHER SURFACE.( KOCHER ET AL 2001)
    86. 86. Pain and discomfort during SRP • Tissue trauma due to inadvertent curettage Philstrom( 1999) • Pain of significant duration, peak in intensity between 2 and 8 hrs post SRP- almost 25 % self medicated • Small portions of patients noted root sensitivity , reduction occurred over 4 weeks . Tammaro et al ( 2006)
    87. 87. • Steenburgh et al ( 2004) 1/3 of patients taking analgesia 1/2 of the total patients revealed gingival soreness 2/3 complained problem while eating. • Ettin et al ( 2006) Pre-emptive analgesics (ibuprofen arginine)may have some beneficial effect.
    88. 88. LA DURING ROOT PLANING • Usually do not require. • Patients vary in their ability to tolerate pain. • LIDOCAINE 25mg/g can be an useful alternative to injections anesthesia in pain sensitive patients. (Magnusson 2003)
    89. 89. • Perry DA et al,2008 Transmucosal lidocaine patches provided sufficient anaesthesia for therapeutic quadrant scaling and root planing procedures.Lidocaine patch (46.1mg/2m) compared to placebo patch VA scale for pain Results greater pain relief with treatment patches after 15 min and at the end of treatment.
    90. 90. • Scotelberg JL(2007) Compared 20% topical benzocaine gel to 2% injected lidocaine 21 patients – divided 2 groups Results • The injected anaesthesia had less pain • 11 participants preferred topical – fear of injection
    91. 91. • Lidocaine plus prilocaine in a thermosetting agent also has been shown to be effective in controlling intra-operative pain during scaling and root planing (Jeffcoat et al. 2001, Donaldson et al. 2003, Magnusson et al. 2003). • Topical anaesthetics may be preferred over injected anaesthetics .
    92. 92. EVALUATION OF SRP • ROOT SMOOTHNESS • HEALING OF SOFT TISSUE FOLLOWING SRP
    93. 93. ROOT SMOOTHNESS • RELATIVE SMOOTHNESS OF THE ROOT SURFACE IS THE BEST IMMEDIATE CLINICAL INDICATION OF ADEQUATE INSTRUMENTATION. • Hu friedy 3-A • No 17 or orban • Pig tail (no 3ML) • generally thin and good tactile sensitivity, working end is curved, permits easy adaptation, enough to extend to deep pocket
    94. 94. ODU- 11-12, • Adapted from the gracey curette 11-12 by faculty of old Dominion university • Combines pigtail design with a long shank – deep pockets • Smoothness- does not guarantee the complete removal of calculus
    95. 95. HEALING SEQUENCE Histologic studies –humans and primates Long junctional epithelium – repair New dentogingival junction firms within 2 weeks • Sequence • 1-3 days • Hyperaemia, change in color& edema
    96. 96. PERIODONTAL DEBRIDEMENT
    97. 97. 1 -2 weeks • Resolution of edema • Shrinkage of the gingival margin • Color is about to normal • Little or no bleeding/suppuration
    98. 98. 2-3 weeks • Color is normal • Consistency firm ,no bleeding • Reduced tooth mobility • Histologically- connective tissue maturation-21 to 28 days, establishment of GM- 3-6 months
    99. 99. HEALING- CLINICAL END POINTS • CLINICAL EVALUATION OF SOFT TISSUE RESPONSE INCLUDING PROBING NOT CONDUCTED PRIOR TO 2 WEEKS FOLLOWING SRP.ASSESSMENT 4-6 WEEKS AFTER THERAPY.REPAIR CAN CONTINUE FOR ADDITIONAL 9 MONTHS. • RE EPITHELIAZATION OF THE WOUND CREATED DURING INSTRUMENTATION TAKES FROM 1 TO 2 WEEKS.
    100. 100. MOST COMMON END POINTS EVALUATED: • PROBING POCKET DEPTH • CLINICAL ATTACHMENT LEVEL • REDUCTION IN BLEEDING SITES AND EDEMA IS A SURROGATE INDIACTOR FOR THE RESOLUTION OF GINGIVAL INFLAMMATION.
    101. 101. Hajol(2004) • True end point- relief of pain, esthetics, and chewing comfort • Surrogate end point- No B.O.P. , pocket closure, attachment gain, and tooth loss
    102. 102. Probing depth and CAL A)Clinical attachment levels: • Loss of attachment low initial PD • Gain Deeper PD Proye et al (1982): • Recession after 1 wk (0.84mm) • Gain after 3 wks (0.52mm) • Probing depths reduced to1.36mm
    103. 103. COBB 1996 • 1-3 MM PD RED OF 0.03MM CAL 0.34MM • 4-6MM PD RED OF 1.3MM WITH GAIN OF 0.55MM • >7MM PD RED 2.6MM WITH GAIN OF 1.19MM • SIMILAR RESULTS REPORTED BY VENDER WEJDEN ET AL, 2002
    104. 104. • HALF OF THE DECREAE IN PROBING DEPTH ATTRIBUTED TO ATTACHMENT GAIN AND THE REMAINING DECREASE IS THE RESULT OF CHANGE IN GINGIVAL MARGIN POSITION.
    105. 105. Critical probing depth ( LINDHE et al,1982) BELOW- LOSS OF ATTACHMENT LEVEL ABOVE- GAIN IN ATTACHMENT LEVEL 2.92mm- Root planing 4.2mm- Flap debridement surgery
    106. 106. Creeping attachment • Goldman proposed the term mainly following FGG • Coronal shift in the position of the gingival margin
    107. 107. Aimetti et al (2005) • Coronal shift of 0.40 to 0.89 mm ( several other studies reported same) • This achieved complete root coverage 45.83% in 12 month
    108. 108. Reasons for root coverage in root planing • Initially thick gingiva will have better root coverage • Reduction in the convexity of the root and m-d distance between the periodontal space • Plaque free and flat root surface helps in easy regrowth of the marginal tissue
    109. 109. MICROBIOLOGICAL CHANGES • DECREASE IN GRAM NEGATIVE MICROBES ACCOMPANIED BY AN INCREASE IN GRAM POSITIVE COCCI AND RODS. • DOMINANCE BY BENEFICIAL SPECIES RESULTS IN: DECREASE IN GINGIVAL INFLAMMATION DECREASE IN PROBING DEPTH DECREASE IN BLEEDING ON PROBING COBB ET AL,2002
    110. 110. CUGNI ET AL 2000 DNA PROBE COUNT STUDY • DECREASE IN T.FORSYTHUS, P.GINGIVALIS, T.DENTICOLA AND INCREASE IN ACTINOMYCES SPS, STEPTOCOCCI, F.NUCLEATUM,VEILONELLA. • SIMILAR RESULTS REPORTED BY HAFFAJEE1997, MOMBELLI 2000.
    111. 111. Teles et al ( 2006) • Bacterial count decreased from 91+ 11x 105 to 23+6 x 105 Darby et al ( 2005) • Decreased T. forsythia and T.denticola several week following SRP
    112. 112. Bickler et al ( 2004) • if home care not followed, re-establishment of the pathogenic flora and rebound in the clinical parameters occur. Haffejee( 2006) • Increase in the Streptococci and Actinomyces species 3 months past SRP • Also noted re-emergence in the red complex and orange complex 3 to 12 months results in the increase loss of attachment
    113. 113. Re-emergence can occur from following locations; • Residual subgingival plaque deposit • Radicular dentin or cementum • Pocket epithelium or connective tissue • Supragingival plaque deposits • Subgingval deposits of adjacent teeth and from intraoral soft tissue sites
    114. 114. EFFECT ON DENTIN AND PULP • Minor structural alterations of both root surface and restoration margins.(Lee SY,1995,Eberhard ,2003) • Dentinal tubules are exposed, leading to direct avenues to the pulp for bacteria and bacterial elements present in the oral environment (Bergenholtz • & Lindhe 1978).
    115. 115. • Root sensitivity occurs in approximately half of the patients following subgingival scaling and root planing. The intensity of root sensitivity increases for a few weeks after therapy, after which it decreases.( Von Troil,2002- systematic review) • Unnecessary excessive root substance loss (hour-glass shaped roots), • Root fracture or Pulpitis
    116. 116. SRP IN COMBINATION WITH PHOTODYNAMIC THERAPY • SRP in combination with PDT seems to be effective and Is therefore suitable as an adjuvant therapy to the mechanical conditioning of the periodontal pockets in patients with chronic periodontal diseases. (Berakdar 2012)
    117. 117. SRP WITH AND WITHOUT PERIODONTAL FLAP • Mean accessible depth by curettes – 4.6 mm Supported by: • RABBANI et al,1981 concluding that curettes can not reach to a depth of more than 4 mm. • CLIFFORD,1999: Available depth for curettes has been re-ported to be 3.45 mm .The maximum accessible depth was found to be 6 mm in distal and buccal surfaces
    118. 118. • 1.Periodontal flaps for access provide a means for greater reduction of residual calculus. • 2. Periodontal flaps for access provide a means to achieve more tooth surfaces free of calculus in pockets >3 mm. • 3. The % of residual calculus is related to probing depth, despite the treatment approach. • 4. Anterior and posterior teeth respond similarly. CAFFESSE 1986
    119. 119. WYLAM ET AL 1993 • Sixty multi-rooted teeth were assigned to one of three groups: Untreated controls, Closed scaling/root planing, and Open flap scaling/root planing. • No significant difference in the percent stained residual plaque and calculus in shallow areas of the pocket • Furcation regions demonstrated heavy residual stainable deposits for both treatment methods, with no significant differences between techniques.
    120. 120. QUIRYNEN ET AL Full mouth disinfection vs PDS vs full mouth root planing Greater gain in clinical attachment and less bleeding upon probing with FRP and FDIS Reduced motile forms by 20% BOLLEN ET AL 1998 FDIS VD PDS Better gain in clinical attachment levels with fdis Fdis reduced motile rods and spirochetes reduced by 10% whereas pdis reduced by 20%
    121. 121. AUTHOR STUDIES RESULTS Eberhard et al (Cochrane SR 2008) Full-mouth disinfection for the treatment of adult chronic periodontitis The treatment effects of FMD compared with conventional SRP are modest and the implications for periodontal care are not profound.” Sanz & Teughels 6th (EWP 2008) FMD and chronic periodontitis Need to investigate the impact of different mechanical debridement protocols on patient centred outcomes and cost-effectiveness using appropriate methodology”
    122. 122. NON SURGICAL THERAPY VS SURGICAL THERAPY Meta analysis • Knowles( 1979) • Split mouth design • RP, RP+curettage, MWF, APF • 3 month maintenance, 6 yr follow up • Surgical technique better pocket depth reduction • All tech. yielded gain in attachment in deeper pocket
    123. 123. • Kaldahl (1988, 1996) • Split mouth • Root Planing Vs Modified widman flap • 6 yr follow up • Result favored non surgical treatment
    124. 124. Conclusion: • Shallow pocket- no significant difference of ---0.02 mm after 6 years • Medium pockets- no significant difference of –0.22 mm after 6 years • Deep pockets – the difference is 1.03 mm after 6 months to 0.22 mm after 6 years
    125. 125. SRP VERSUS CURETTAGE • Curettage Closed definitive surgical procedure aimed at pocket elimination, reattachment or new attachment. Removes pocket epithelium intentionally WORLD WORKSHOP IN CLINICAL PERIODONTICS,1989 Gingival curettage as a separate procedure has no justifiable application during active therapy during chronic preriodontitis. Without clean, hard roots results of curettage are limited.(Cohen,2007)
    126. 126. Limitations Anatomy of roots Depth of pockets Position of teeth Inadequate instruments for diagnosis Inadequate instruments for treatment Area of mouth being treated Size of mouth Elasticity of cheeks Range of opening Dexterity of operator
    127. 127. • Total substance removal by instrumentation includes calculus and root substance removal. • Calculus removal seems to require less than 20 working strokes to be complete, relative to a standard area of 1-mm width on the circumference of the root. The following strokes serve only to remove root substance, which seems to be unnecessary.
    128. 128. • Endotoxin removal is nearly completed after the same number of working strokes, reaching levels similar to periodontally healthy teeth. Clearly these levels are low enough to enable good clinical healing. • Aggressive scaling and root planing might be counterproductive for the future health of the periodontally diseased tooth.
    129. 129. SUMMARIZE Deep Endotoxin penetration Endotoxin as a superficial layer ROOT DEBRIDEMENT ROOT CONDITIONING
    130. 130. • Clinicians should choose the modality of debridement according to the needs and the preferences of the patient, their personal skills and experience, the logistic setting of the practice and the cost-effectiveness of the therapy rendered”
    131. 131. Thank you

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