surgical versus non surgical

1. DR RAMYA GANESH
SENIOR LECTURER
MALABAR DENTAL COLLEGE AND RESEARCH CENTRE
Surgical versus Non Surgical therapy

2. Contents
• Introduction
• Manual debridement
• Machine driven debridement
• Supragingival Irrigation
• Subgingival Irrigation
• Local Drug Delivery
• Laser therapy
• Systemic Drug Delivery
• Host modulation Therapy
• Photodynamic therapy
• Ozonated therapy
• Surgical therapy
• Comparison between surgical and non
surgical periodontal therapy
• Systematic reviews
• Decision making
• Conclusion
• References

3. Introduction
Non surgical periodontal therapy
Surgical periodontal therapy

4. Reduction of
probing
pocket depth
Maintenance
or
improvement
of clinical
attachment
level
Reduction in
bleeding on
probing

6. Non surgical periodontal therapy
Gingival curettage
Machine
driven
debridement
LASERS
Manual debridement
PDT Pocket irrigation
Full mouth
disinfection

7. Manual debridement
1950s 1960s NSPT – hand instruments
with the aim of removing supragingival
and subgingival calculus and plaque, and
contaminated root cementum.
Listgarten et al 1973 - Periodontal healing
occurred, even in the presence of
calculus, provided that the subgingival
bacterial plaque had been removed.
Mombelli et al 1955 - reduction of
selected gram-negative anaerobic
organisms in the subgingival plaque is a
more important element for the success
of periodontal therapy than the removal
of contaminated root cementum and
mineralized deposits.

8. Baderson et al
1984
Copulos et al
in 1993
Busslinger
(2001)

9. Gingival curettage
1970s
SRP + gingival curettage = effective periodontal outcome
In 1983 Echeverria JJ et al performed a split mouth study where scaling and
root planing was performed in all quadrants and was followed, 4 weeks later,
by gingival curettage in two quadrants and concluded that gingival curettage
did not result in any additional improvement in periodontal tissue health.

10. Power driven devices
1990s – use of power driven devices became more popular with claims
of increased efficacy and efficiency.
Braun et al 2007 - Reduced time for scaling and root planing, improved
access, less damage to the root surface and less discomfort for the
patient using slimline tip designs.
Baderson and
coworkers in 1980s
Jepsen et al 2011
- Root sensitivity
- Patient
discomfort
- Root surface
damage

11. Pocket irrigation with antiseptics
Povidone iodine
Dilute sodium hypochlorite
Chlorhexidine gluconate

12. • Greenstein et al in 2000 indicated that supragingival irrigation enhanced the effects of tooth
brushing and reduced gingival inflammation in patients who did not perform good oral
hygiene. The additional reduction in gingival inflammation ranged from 6.5 to 54 %.

13. For Against

14. Full mouth disinfection
Full-mouth disinfection, a novel approach suggested for the
treatment of periodontal infections by Quirynen and
coworkers in 1995

16. Two systematic reviews, combining results of a number of randomized controlled trials,
concluded that all three treatment approaches (staged debridement, full-mouth
disinfection, full mouth SRP protocol) may be recommended for nonsurgical periodontal
therapy
( Eberhard et al, lang et al, 2008)
Quirynen and coworkers concluded that one-stage full-mouth disinfection
demonstrated significant clinical and microbiological advantages over SRP .

17. Systemic antibiotics
Can modulate the host’s immune
response to bacteria
Reduce host’s destructive
immunological response to bacterial
pathogens
Reduce bone loss

18. Systematic review including 22 studies evaluating if the antibiotics provided a consistent
benefit in mean CAL change for different patient populations, for different therapies, and for
different antibiotics concluded that SRP +systemic antibiotics improvement in clinical
attachment level . ( Haffajee et al 2003) .
SRP plus systemic antimicrobials resulted in a mean gain in CAL and also
Improvements in CAL was seen for tetracycline, metronidazole, and an effect of
borderline statistical significance for the combination of amoxicillin plus
metronidazole. ( Smiley et al 2015 )

19. The most well-documented systemic antimicrobial drug regimen is the combination of
amoxicillin and metronidazole, which is most commonly administered for 7–14 days at the
completion of scaling and root planing. ( Sgolastra, 2012 )
In a systematic review concluded that systemic antimicrobials are indicated in periodontal
therapy, they should be adjunctive to mechanical debridement. (Herrara 2008)

20. Local drug delivery

21. Periodontal pocket a
natural site for
treatment with local
release delivery
system.
GCF provides a
leaching medium for
the release of the
drug in its solid
dosage form.
Periodontal pocket-
bathed by GCF easily
accessible .
Rationale

23. Smiley et al (2015) in a meta analysis
compared SRP plus minocycline microspheres
with SRP alone. Results showed a significant
increase in mean CAL.
Goodson and coworkers (2007) found that
adjunctive minocycline microspheres
significantly reduced red-complex periodontal
pathogens as compared to SRP .
Lessem et al. (2004) a trial involving 2805
patients and 895 dentists to evaluate the use
of minocycline microspheres. Mean reduction
in probing pocket depth and CAL was seen

24. Host modulation therapy

25. Potential Targets For Host Modulation
Modulation of AA cascade
Lipoxins and Resolvins
Modulation of MMPS
Modulation of bone remodeling
Modulation of cytokine receptors
Modulation of NOS

26. Meta-analysis : To assess the efficacy of antiproteinase,
anti-inflammatory, and bone-sparing host-modulating
agents in the treatment of gingivitis, AP & CP and found
that changes in CAL and PD were maximum following
administration of SDD in conjunction with SRP in
patients with periodontitis ( Reddy 2003 )
SDD group showed greater reductions in PD than SRP
group ( Gapski R 2004)

27. Resolvin have potent anti-inflammatory & immunoregulatory
properties. ( Serhan 2004)
Found that intraperitoneal injection of Mercapto Ethyl Guanidine
exhibited less plasma extravasation & bone loss in ligature induced
periodontitis in mice Lohinai et al (1998).
To compare the efficacy of emdogain with placebo have demonstrated
that periodontal defects treated with local application of emdogain
during the regeneration therapy have shown a statistically significant
reduction in PPD, gain in CAL and bone fill. ( Heijl et al, Yukna and
Mellonig, Froum et al in 1998 )

28. Late 1990s …..LASER introduced in dentistry
LASERS
Laser type Wave length
Nd:YAG 1064nm
He:YAG 2100nm
Er,Cr:YSGG 2790nm
Er:YAG 2940nm
CO2 9300,9600,
10600 nm

29. Petrucci A et al in 2012 meta-analyses 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 .
Aoki et al in 2002 concluded Er:YAG laser would appear to be the instrument
of choice for effective removal of calculus, for root etching, and for creation of
a biocompatible surface for cell or tissue reattachment.
Cobb et al in 2006 concluded that Nd:yag or Er:yag in treatment of CP may
be equal to SRP with respect to reduction in probing depth and subgingival
bacterial populations.

30. Sgolastra et al in 2012 Meta analysis : 5 RCTs , found no difference in CAL,
PPD or change in gingival recession, indicating no evidence of a superior
effectiveness of the Er:Yag laser compared with SRP.

31. Photodynamic Therapy
Application of dye
Light is applied
Production of free oxygen radicals – cytotoxic and destroy
cell

32. Author/year of study Population (age, sex,
location)
Test group Control group Outcome
Qadri et al 2005
6 weeks
17 pts SRP+PDT SRP Difference in PD, GI, PI
but no diff in
subgingival microbiota
Moritz et al 1998,
6mths
50 pts SRP+PDT
37 pts
SRP + H2O2 Diff in PD, BOP overall
decrease in bacterial
count.
Yilmaz et al 2002 32
days
10 pts SRP+PDT SRP SRP+PDT group
showed improvement
in PD, CAL.

33. Ozonated water (4 mg/l) was found effective for killing gram-positive and gram-
negative oral microorganisms and oral Candida albicans in pure culture as well as
bacteria in plaque biofilm(Nagayoshi et al. 2004 )
Yilmaz et al in 2013 evaluated the clinical and microbiological results of treatment with
the Er:Yag laser and topical gaseous ozone application as adjuncts to initial periodontal
therapy in CP patients and it was found that ozone has an antimicrobial effect
equivalent to that of the er:yag laser.
Ozone therapy

34. Surgical periodontal therapy

35. 1978
• Nonsurgical periodontal therapy is
effective in eliminating inflammation in
deep pockets and in improving clinical
attachment levels.
1982
• Pocket elimination then became the
main objective of periodontal therapy,
flap procedures were commonly
performed to eliminate the periodontal
pocket.

36. Original Widman flap
1918
Neumann flap
1920
Kirkland flap
1931
Apically repositioned
flap
1962
Modified Widman
1974
Papilla preservation
flap
Enabled access to the root surfaces, root concavities and furcations for adequate
debridement.

37. Decision making
On the basis of clinical outcome data from a longitudinal randomized controlled clinical trial
in 15 patients with advanced periodontitis , a concept of ‘‘critical probing depth’’ was
developed for decision making following the completion of a hygienic phase [initial
periodontal therapy (non-surgical therapy + oral hygiene instruction)] [ Lindhe et al 1982] .
Critical probing depth
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 .
SRP = 2.9 mm & MW Flap surgery = 4.2 mm (Lindhe J , 1982)
Laser assisted attachment procedure = 4.8mm (Nevins M, 2014)
Surgical 5.4mm NSPT = 2.9 to 5.4 mm (Heitz-Mayfield LJ, 2013)

38. SYSTEMATIC REVIEWS: SURGICAL VS NON-SURGICAL
PERIODONTAL THERAPY
Both SRP alone and SRP + flap procedure are equally effective methods for the
treatment of CP, in terms of attachment gain and reduction in gingival
inflammation and preventing further loss of attachment Heitz-Mayfield (2002).
Systematic review concluded that efficacy of SRP as a bedrock treatment for
patients with chronic periodontitis is extensive and irrefutable. Conservative
surgical interventions added to scaling and root planing do not always offer
significant advantages in treating mild/moderate disease. David E. Deas (2016)

39. Surgical versus non surgical
Location Author Comparison Yrs Results
SWEDEN
Rosling et al. (1976) MWF w and w/o RP 2 More CAL gain: Associated with
better OH
Lindhe et al. (1982) Critical Probing
Depths
2 CPD: SRP=2.9±0.4 mm,
MWF = 4.2±0.2 mm
Lindhe et al. (1984) SRP, SRP+MWF 5 PD reduction and CAL gain: No ≠
b/w groups
More PD reduction and more CAL
gain: with better OH

40. Location Author Comparison Yrs Results
DENMARK
Isidor et al. (1984 and
1986)
SRP, MWF,APF 5 PD reduction and CAL gain: No ≠
b/w groups
CAL loss: <5% of sites
Location Author Comparison Yrs Results
MICHIGAN
Pihlstro¨m et
al(1983)
SRP , MWF 6.5 MWF: more PD reduction and higher CAL gain
Ramfjord et
al.(1987)
MWF, SRP 5 Gain in CAL and PD
reduction was seen.

42. Textbook of Hall 2nd edition Decision making

43. CONCLUSION
New techniques and technologies, new information has not
diminished our recognition of the importance of thorough mechanical
debridement and optimal plaque control for successful nonsurgical
and surgical periodontal therapy. While a thorough disruption and
removal of the periodontal biofilm is required for successful treatment
outcomes. Use of specific systemic antimicrobials, in patients with
advanced or aggressive periodontitis and deep probing depths, may
be beneficial as an adjunct to nonsurgical periodontal therapy, thereby
reducing the need for additional therapy. In patients with deep
pockets (>6 mm), access flap surgery may be beneficial, provided the
patient receives regular supportive periodontal therapy and has
adequate oral hygiene.

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