11. • Penetration of microorganisms to the depth of the CDJ(Daly et
al 1982).
• Immuno histochemical technic -Endotoxins superficially bind
to the root surface(Hughes & Smales 1986 &Nakib et al1987).
• Endotoxin penetration into 57 teeth extracted for periodontal
involvement was examined by Oda et al(1988)
12. • 99% could be removed by gentle washing and/or brushing for
one minute.(Moore et al 1988)
• Extensive cementum removal?
• Not indicated.
• Conservative instrumentation of contaminated root surfaces
by manual or US could render them comparable to healthy
control teeth.
13. • Nyman et al.(1986) -Beagle dog study-Removal of diseased
cementum 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.
• In vitro studies-Detoxification of contaminated root shavings by
exposure to CA for 5 min(Olson et al 1988)
14. • Debride to an extent compatible with health. (Cobb et
al,1996,Sherman et al 1990 & Kepic et al 1990)
• Reduce calculus volume rather than presence or absence(Critical
mass concept).
16. MANUAL VS ULTRASONIC
TIME 20 VS 10
CALCULUS REMOVAL
WRT PPD.. 7 VS 10%
MICROFLORA-
EQUIVOCAL
Oosterwall et al
1989.US > REDUCTION
IN SPIROCHETES AND
MOTILE RODS
Caffese et al 1986,Rabbani et al 1981,Kapic et al 1990,Copulos et al 1993.
17. ANTIMICROBIAL
IRRIGANTS
• > REDUCTION IN PPD
• Taggart and Reynolds
1990,1992)
PLASTIC/TEFLON
COATED TIPS
• LESS REMOVAL OF TOOTH
STRUCTURE
• SMOOTHER ROOT
SURFACE
• Gantis 1992,Kocher et al
2001
18. POWER DRIVEN INSTRUMENTS IN NST
ADVANCES IN POWER DRIVEN POCKET/ ROOT
INSTRUMENTATION BY WALMSLEY ET AL 2008
QUALITATIVE REVIEW BY DRISKO ET AL 2000
SR BY TUNKEL ET AL 2002
HAZARDS OF US SCALERS BY TRENTER & WALMSLEY ET AL 2003
Tunkel et al,2002
No difference between manual & US inserts in
single rooted teeth although evidence was not
strong
In multi rooted teeth ?
Less time for US
19. HAZARDS OF US SCALERS BY TRENTER &
WALMSLEY ET AL 2003
20. Advances in Power Driven Instrumentation
A. D.Walmsley, S. C. Lea, G Landini., A. J. Moses(2008)
• Outcome similar.
• Variations in study designs
• The addition of antiseptic agents to coolants does not
provide any additional clinical benefits.
• No added benefit with newer designs of powered instruments
compared with other ultrasonic devices in NST.
• In vitro research shows that there is variation in the
performance of different tip designs and generators, but its
clinical relevance remains unknown.
21. • Mixed results
• Variety of instruments, study designs, and methods of
quantification.
1. Multirooted teeth most likely to exhibit residual calculus
after treatment.
22. 2. As probing depth increases, the power driven instruments
become less effective due to limitations of design.
3. The curette appears more efficient than US but requires
more effort, time, and expertise.
4. Sonic instruments seem to be more efficient compared to
US.
5. The best results are probably obtained by combining
sonic/ultrasonic instrumentation with manual scaling.( 1996
World Workshop in Periodontics)
24. BOP
A predictor of future CA loss.(Badersten et al &
Claffey et al 1990)
Correlation weak
Absence of bleeding - a criterion for stability Lang et
al 1990
Reduce level of inflammation- 57%
31. • Critical Probing Depth (Lindhe et al 1982)
• Based on regression analysis of published data
• It is that depth at which periodontal therapy resulted in gain or
loss of clinical attachment.
• The CPD for SRP was 2-9+_0.4mm
• CPD for MWF was 4.2+_0.2mm.
• They suggested that for patients with a large number of shallow
PD sites NST would be more beneficial while patients with sites
>4.2mm,surgical treatment may lead to more attachment gain
32.
33. MICROBIOLOGIC PARAMETERS
Residual pockets > 6 mm were found to harbor
greater than 20% spirochetes and motile
rods.(Lindhe & Nyman et al 1982)
Significant reductions in the percentage of
motile microbes and spirochetes &
Pg(Renevert 1993)
Concomitant increase in the percentage of
cocci and non-motile microbes.(Cobb 2002)
Persistance of Aa,while Tf removal was 27-43%
Haffajee et al 1997
35. RADIOGRAPHIC CHANGES
• No change in the bone height for sites with horizontal bone loss
(Isidor F 1982)
• Intra osseous defect showed increase in bone probing levels of
0.2 mm at 6 months, 0.3 mm at 12 months ,0.5 mm at 24 months
after NST, (Renvert ,1990).
• Decrease in density at 2months post SRP, Increase in density at 4
month post SRP, Not much change from 6-12 months(Dubrez B
1990).
36. SYSTEMIC EFFECTS OF SRP
• Acute Phase Response.
• Significant increase in pro inflammatory cytokines
immediately following SRP(Within 24 hours)
• Due due to massive bacterial innoculation in conjunction with
instrumentation.(Ide 2004, D’Aiuto 2005,2007)
38. PPD WMD IN REDUCTION
PPD
WMD IN CAL
1-3 MM -0.51 (CI—0.74 TO -0.29)
-
4-6 MM 0.35 (CI 0.23 TO 0.47) -0.37 MM (CI -0.49 TO -
0.26)
>6 MM 0.58 (0.38 TO 0.79) 0.19 MM (CI -0.04 TO
0.35)
CONCLUSION
39. 5 RCTS
MWF VS
SRP/CURETTAGE
OUTCOMES PPD & CAL
1 MO FOLLOW UP
SURGICAL TREATMENT
MORE EFFECT FOR ALL
LEVELS OF DISEASE
5 YEARS FOLLOW UP
SURGICAL TT MORE
EFFCTIVE IN PPD>7
MM
CAL BETTER WITH NST
FOR INITIAL TO MOD
PPD-NO DIFF AFTER 5
YEARS
Meta-analysis of surgical versus non-surgical methods of
treatment for periodontal disease Antczak-Boiickoms A,
Joshipura K, Burdick E, Tulloch JFC.1993
40. NST vs ST
Majority of the periodontal patients can be effectively managed
by NST
NST scores over surgical approach when the pockets are
shallow(<4mm)
In moderately deep pockets(4-6mm) the probing depth
reduction was superior with surgery but less clinical attachment
level gain was seen when compared with NST
In deep periodontal pockets >7mm surgery offers significantly
better results
41. No significant differences between molar & non molar
teeth were found
NST distinctly inferior to regenerative surgical procedures
in dealing with osseous defects
No significant differences b/w NST & surgery as far as
recurrence, retreatment, maintenance of attachment &
prevention of loss of teeth
No data exists to address the important issue of patient
centered evaluation of treatment outcomes or adverse
effects.(Suvans et al2005)
42. SRP AS A DEFINITIVE TREATMENT MODALITY
Inflammatory
status of the
tissues
Treatment
objectives of
the therapist
Skill of the
clinicianPatients needs
Severity of
disease
Minimal
inconvenience
& morbidity
44. EFFECTIVENESS OF SCALING AND ROOT
PLANING
Percentage of surfaces
exhibiting residual calculus
NST SURGICAL
Inexperienced operator 82% 55%
Experienced operator 17% to 69%. 14 to 24%
Furcations 68% 44%
45. SR-Hyuan et al 2009
NST is effective in
preventing disease
progression in G1
Furcations
Limited value in
advance furcations
5 year survival rate in
MR teeth
46. AMOUNT OF CEMENTUM REMOVAL
TYPE OF INSTRUMENT(After 12
strokes)
FORCE LEVELS & STROKE
Ultrasonic scaler -11.6µm Low pressure:32.4 µm at 5 strokes to
148.7 µm at 40 strokes
Sonic scaler -93.5µm Higher instrument pressures:103.2µm
at 5 strokes and 343.3 µm at 40 strokes
Manual curette-108.9µm
Rotating diamond bur-118.7µm
56. SRs & MA of the effects of full-mouth debridement with and
without antiseptics in patients with chronic periodontitis –Lang
et al 2008
57. SR & MA PPD BACTERIAL
LOAD
BOP CAL
LANG et al
(JCP 2008)
FMD vs CSD-
0.27mm
FMSRPvsCSD-
0.13mm
No difference
between FMD
& FMSRP
No difference FMDvsCSD-
8.75%
FMSRPvsCSD-
8.45%
FMD vsFMSRP-
5.72%
FMDvsCSD-
0.21mm
FMSRPvsCSD-
0.36mm
FMD vsFMSRP-
0.26mm in
favour of
FMSRP
58. SR & MA PPD BACTERIAL
LOAD
BOP CAL
Cochrane
Collaboration
Oral Health
Group by
Eberhard et al.
2008
No significant
differences
between
FMSRP and CSD
Slightly more
BOP%
reductions for
FMD than for
FMSRP, in
moderate
pockets of
single-rooted
teeth.
Minor
differences in
CAL gain for
FMD when
compared with
CSD in single-
rooted
moderately
deep pockets
(5–6 mm).
More CAL gain
was revealed
for FMSRP than
for FMD in
deep multi-
rooted teeth.
60. INDICATIONS(AAP 1996)
• In specific patient groups (AP & severe and progressing forms
of periodontitis or recurrent periodontitis)
• As adjuncts to mechanical NST.
• Not enough evidence to use as adjuncts to surgical
therapy.(Except in regenerative therapy)
• Acute infections
• Medically compromised patients
61.
62.
63.
64. ROLE OF SYSTEMIC ANTIBIOTICS IN
NONSURGICAL THERAPY
• Radiographic bone fill and periodontal regeneration has been
reported following periodontal debridement and systemic
antibiotics in some localized juvenile periodontitis cases.
• Case reports.
• Do not provide enough evidence to support predictable
regeneration of lost periodontium.
65. ANTIMICROBIAL EFFICACY
Nature &
virulence of
infection
Exponential vs
stationary
microbial growth
Local factors
Antibiotic
pharmacokinetics
Host resistance
Altered patient
physiology
66. Meta-analysis of the effect of SRP, surgical and antibiotic
therapies on periodontal PD and attachment loss (Hung &
Douglass, 2002)
Shallow initial PD-No significant improvement with SRP
Initial medium depth -1mm reduction in PPD &0.50mm attachment gain.
Deep initial PD-2mm reduction in PPD & 1mm gain in attachment
Antibiotics-similar result to SRP
Follow up of 3 years-Difference between ST & NST reduced to <0.4mm
Local antibiotics-enhanced outcome of SRP
67. SR-Herrera et al 2008
Systemic antimicrobials-as adjuncts to mechanical debridement.
No direct evidence to recommend a specific protocol
Evidence indirect
Antibiotic intake should start on the day of debridement
completion; it should be completed within a short time
(preferably 1 week) and with an adequate quality.
68. LIMITATIONS OF SYSTEMIC ANTIMICROBIAL THERAPY
Inability of systemic drugs to achieve high gingival crevice fluid
concentration (Goodson 1994).
An increased risk of adverse drug reactions (Walker 1996).
multiple antibiotic resistant microorganisms (Walker 1996)
Uncertain patient compliance (Loesche et al 1993).
77. LASERS IN PERIODONTAL THERAPY
• AAP-Commissioned Review: Lasers in periodontics:A Review of
the Literature;Charles M. Cobb.J Periodontol 2006;77:545-564.
• Laser application in non-surgical periodontal therapy: a
systematic review.F. Schwarz, A. Aoki, J. Becker, A. Sculean JCP
2008.
• The Effect of Laser Therapy as an Adjunct to Non-Surgical
Periodontal Treatment in Subjects With Chronic Periodontitis: A
Systematic Review Marcus R. Karlsson,Christina I. Diogo
Lofgren,and Henrik M. Jansson.J Periodontol 2008;79:2021-2028.
• AAP statement on efficacy of Lasers in NS treatment of
inflammatory PD-J.Periodontol;April2011
78. Evidence minimal for its use as adjunct to mechanical therapy
or even as monotherapy.
Reduction of subgingival bacterial loads Unpredictable &
evidence conflicting.
Laser of choice-Erbium.
More RCT required
79. ROOT MODIFIERS
• Efficacy of Chemical Root Surface Modifiers in the Treatment of
Periodontal Disease. A Systematic Review:Angelo Mariotti(2003)
• Most of the studies observational in nature.
• Evidence to date suggests that the use of citric acid, tetracycline,
or EDTA to modify the root surface provides no benefit of clinical
significance
80. GROWTH FACTORS
• GF in appropriate carriers .
• Two randomized, placebo-controlled clinical studies evaluated
the effect of EMD as an adjunct to nonsurgical periodontal
therapy in intrabony defects.
• Improvement in clinical parameters not significant unless used
in conjunction with antibiotics. (Mombelli et al and Gutierrez
MA,2003)
83. FUTURE CONSIDERATIONS
• Improvements in instrument design.
• Delivery of fiber optic illumination at the instrument tip to
facilitate visibility.
• Inserts that allow simultaneous delivery of liquid antimicrobial
irrigants with the scaling procedure.
84. • Antimicrobial Peptides (AMP).
• Probiotics.
• Pre-resolving mediators(Lipoxins & resolvins)
• Nutritional modulation of periodontal inflammation to reduce
oxidative stress or obesity.
85. CONCLUSIONS
• NST-the gold standard &the most routinely utilized NST
modality is SRP.
• It can result in reduction of inflammation,PPD & gain in CA .
• Effective in PD of varying severity.
• Root instrumentation is indicated only for disruption of
biofilm & not for removal of root surface.
86. • FMD,FMSRP,CSD all provide comparable clinical outcomes.
• Antimicrobials always used as adjuncts to SRP & not as
monotherapy.
• Risk modification-is of paramount importance in management
of periodontitis.
• Patient- a co therapist to achieve the best therapeutic outcome.
Editor's Notes
World workshop in periodontics1989:Immediate:Prevent,arrest,control or eliminate PD
Ideal: Promote healing through regeneration of lost form, function & esthetics & comfort
Pragmatic: Repair the damage resulting from PD
Ultimate: Sustain masticatory apparatus especially teeth or their analogues in a state of health
Elimination of the inflammatory lesions present in the periodontium,Reduction of probing pocket depth,Improvement of attachment level.(LINDHE & NYMAN1987).
The quantity, composition, and rate of subgingival plaque recolonization is, to some degree, dependent upon supragingival plaque accumulation. The microbes which repopulate the subgingival pocket following therapy have two possible origins: They may represent residual microorganisms following incomplete subgingival instrumentation or Extension of a growing and maturing supragingival plaque.
However, with poor supragingival plaque control, the microbiota may reestablish itself within 40–60 days following subgingival debridement. Deep pockets are particularly difficult to control, since repopulation of the subgingival plaques occurs by 120–240 days despite meticulous supragingival plaque control and multiple sessions of subgingival debridement. A frequency of once every 3 months appears to be sufficient to maintain the beneficial effects of therapy even in the presence of individual variations of personal oral hygiene. When objective is the reduction of PPD surgical therapy works well for all levels.(Initial,moderate & advanced) & when CAL gain is the objective nonsurgical therapy provides a greater benefit for initial disease severity ievels I (1-3 mm) and 2 (4-6 mm), and surgical therapy for level 3 (7 mm or more).
known as. ..Phase 1 therapy, Cause-related therapy, Initial therapy, Etiotrophic phase of therapy. Scaling and root planing are not separate procedures...differ is only a matter of degree
Debridement: Medical removal of dead,,damaged or infected tissue to improve healing potential of remaining healthy tissue.
Scaling: Instrumentation of the crown and root surfaces of the teeth to remove plaque, calculus, and stains from these surfaces."
Root planing:A definitive treatment procedure designed to remove cementum or surface dentin that is rough, impregnated with calculus, or contaminated with toxins or microorganisms." The definition further stated that, "When done in a thorough fashion, some unavoidable soft tissue removal occurs."
Root surface roughness increases surface free energyRoot surface roughness increases bacterial colonization.
Root surface chages:Cementum exposed to pocket shows structural ,chemical & cytotoxic changes.These changes are intimately involved in disease progression & outcomes of therapy.Literature remains inconsistent concerning both the possibility or need to remove all cementum, and whether it is more important to remove plaque & calculus rather than cementum? Robertson has raised other valid questions: Is the removal of all root surface accretions a valid clinical endpoint? And, if all such accretions are not removed, does failure of therapy necessarily follow?
Debridement may be accomplished by surgical,chemical, mechanical,autolytic means.
known as. ..Phase 1 therapy, Cause-related therapy, Initial therapy, Etiotrophic phase of therapy. Scaling and root planing are not separate procedures...differ is only a matter of degree
Debridement: Medical removal of dead,,damaged or infected tissue to improve healing potential of remaining healthy tissue.
Scaling: Instrumentation of the crown and root surfaces of the teeth to remove plaque, calculus, and stains from these surfaces."
Root planing:A definitive treatment procedure designed to remove cementum or surface dentin that is rough, impregnated with calculus, or contaminated with toxins or microorganisms." The definition further stated that, "When done in a thorough fashion, some unavoidable soft tissue removal occurs."
Root surface roughness increases surface free energyRoot surface roughness increases bacterial colonization.
Root surface chages:Cementum exposed to pocket shows structural ,chemical & cytotoxic changes.These changes are intimately involved in disease progression & outcomes of therapy.Literature remains inconsistent concerning both the possibility or need to remove all cementum, and whether it is more important to remove plaque & calculus rather than cementum? Robertson has raised other valid questions: Is the removal of all root surface accretions a valid clinical endpoint? And, if all such accretions are not removed, does failure of therapy necessarily follow?
Debridement may be accomplished by surgical,chemical, mechanical,autolytic means.
Rationale:Creation of a biologically acceptable root surface that is compatible with the health of adjacent periodontal tissuesA biologically acceptable root surface is defined as one that is smooth, hard, and completely divested of accrued substances and damaged tooth structure.
OBJECTIVES: Alteration in subgingival flora. Conversion of inflamed pathologic pockets to healthy gingival tissue, Shrinkage of the deepened pocket to a shallow, healthy sulcus Achievement of a root surface compatible with a healthy connective tissue and epithelial attachment:
