Review and Essay Material on Non Surgical Periodontal Therapy. Illustrative Contents for proper presentation on all aspects of NSPT. The Presentation helps in drafting A to Z of NSPT. Readers are encouraged to add newer studies and ideas under each aspect of NSPT.

1. NON SURGICAL
PERIODONTAL THERAPY
DR. SANTOSH MARTANDE
READER,
Dr. D Y Patil Dental College & Hospital,
Dr. D Y Patil Vidyapeeth, Pune
santosh.martande@dpu.edu.in

2. EXPECTED QUESTIONS
• ESSAY:
• Non surgical periodontal therapy 100 Marks
• LONG QUESTIONS: 20 Marks
• NSPT in Periodontitis and Periimplantitis
• Full mouth disinfection protocol in periodontal therapy
• Antibiotics in Periodontal therapy
• Mechanical plaque control
• Chemical plaque control

3. • SHORT QUESTIONS: 7 Marks
• Motivational therapy in periodontitis
• Habits Cessation in Periodontal disease
• Mechanical plaque control
• Chemical plaque control
• Full mouth disinfection protocol
• Local Drug Delivery
• Probiotics in periodontal therapy
• Antioxidants in periodontal therapy
• Coronoplasty and Splinting
• Lasers in NSPT
• PDT in NSPT

4. CONTENTS
Periodontal Disease
Plaque hypothesis
Models of periodontal pathogenesis
Phases of periodontal therapy
Non surgical periodontal therapy (NSPT)
• Rationale and Goals of NSPT
• Motivational therapy
• Behavioral Changes, Lifestyle modifications & Habit Cessation – Parafunctional habits
and Smoking
• Periodontal disinfection – Scaling, Root planning, Root surface debridement, full mouth
disinfection
• Root planning versus Root surface debridement
• Hand instrumentation versus Ultrasonic instrumentation
• Full mouth disinfection protocol versus Quadrant SRP protocol
• Subgingival Irrigation – Chlorhexidine versus Povidone Iodine

5. Oral Hygiene Home care maintenance –
Mechanical plaque control
• Toothbrushing (Manual versus Powered brushing)
• Interdental aids
• Gingival physiotherapy
• Tongue cleaning
Chemical Plaque control
• Chlorhexidine
• Essential oil mouthwashes
• Herbal mouthwashes

6. Adjunctive Chemotherapeutics in NSPT –
• Systemic antimicrobials
• Local Drug Delivery
• Host modulation therapy
• Probiotics therapy
• Antioxidant therapy
Adjunctive Biotherapeutics in NSPT –
• Lasers
• Photodynamic Therapy
• Ozone and hyperbaric oxygen therapy

7.  Removal of Predisposing factors –
• Carious lesions
• Faulty prosthesis
• Faulty restorations
• Malocclusion
• Open contacts
• Trauma from occlusion
 Control of Systemic conditions
• Role of NSPT in prevention and control of Systemic diseases

8. Host response following NSPT
Microbiological response following NSPT
Longitudinal studies of NSPT
Limitations of NSPT
Non surgical versus Surgical periodontal therapy
NSPT… Still the GOLD STANDARD..!!!

9. PERIODONTITIS…..
• Periodontitis is defined as an inflammatory disease of supporting tissues of teeth caused
by specific microorganisms or groups of specific microorganisms, resulting in
progressive destruction of the periodontal ligament and alveolar bone with periodontal
pocket formation, gingival recession or both.
• Host Microbial interaction influenced by various genetic and environmental
factors…(American Academy of Periodontology)

10. WHAT DO THE PLAQUE HYPOTHESIS SAY?

11. WHAT DO THE MODELS OF PERIODONTAL
PATHOGENESIS SAY?
Non Linear model Biologic Systems model

12. PHASES OF PERIODONTAL THERAPY

13. NON SURGICAL PERIODONTAL THERAPY
Phase I therapy, Etiotrophic phase, Cause related therapy, Initial phase, Hygienic phase, Preparatory phase

14. RATIONALE & GOALS OF NSPT
Gingivitis usually precedes periodontitis.
However, it is important to know that not all gingivitis progresses to periodontitis.
The main Goal of NSPT is to diagnose and treat disease at gingivitis stage and prevent it from
progressing to periodontitis

16. MOTIVATIONAL THERAPY

17. BEHAVIORAL FACTORS, LIFESTYLE
MODIFICATIONS & HABIT CESSATION
Oral-hygiene behaviour
Dietary modifications
Smoking
Parafunctional habits
Stress

18. PERIODONTAL DISINFECTION –
SCALING, ROOT PLANNING, ROOT SURFACE
DEBRIDEMENT
• Kieser and Corbet et al. proposed three stages of Professional periodontal disinfection: -
• 1) Periodontal debridement: Instrumentation for disruption and removal of microbial
biofilm
• 2) Scaling: Scaling has been defined as instrumentation to remove all supragingival
uncalcified and calcified accretions and all gross subgingival accretions
• 3) Root planning: Root planing has been defined as 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 dentine

19. ROOT PLANING VERSUS ROOT SURFACE
DEBRIDEMENT

20. ADVOCATES OF SRP
• The rationale for root planing was based on the notion that once the root surface became
exposed to the subgingival environment in periodontitis, it underwent both structural and
pathological changes.
• Pathological changes in cementum were implied, based on the assumption that bacterial
toxins or lipopolysaccharide (endotoxin) released by Gram-negative bacteria were adsorbed
into the root surface. This led to the concept of cementum becoming ‘infected’ and therefore
incompatible with attaching to healthy gingival/periodontal tissue.
• Advocates of SRP claimed that this layer of infected tooth structure had to be removed to
achieve a biocompatible root surface to allow healing to take place.

21. ADVOCATES OF RSD
• In the 1980s, several investigators started to question the extent of penetration of endotoxin
into cementum and therefore the actual clinical need to remove cementum as part of the
therapeutic process, as performed during SRP.
• Many in vitro studies showed that the endotoxin was located on the surface of the root and
was not adsorbed.
• Moreover the ease with which bacterial endotoxin can be removed from periodontally
involved root surfaces has profound clinical implications.
• A less invasive and gentler form of root surface instrumentation, which if used correctly does
not result in tooth structure removal, can be provided by ultrasonic instrumentation in form of
root surface debridement.

22. HAND INSTRUMENTATION VERSUS
ULTRASONIC INSTRUMENTATION

23. • The advantages of ultrasonic root debridement are multiple:
• 1) It is up to 10 times more conservative of root surface tissue. Other studies differ in this regard, possibly due
to use of different types of instruments/instrument settings.
• 2) Micro-ultrasonic tips allow better access to the base of deep (>6mm) periodontal pockets53,54 and within
furcations.
• 3) Being a non-invasive process, local anesthesia is usually not required.
• 4) Greater cost effectiveness; manual instrumentation takes 20–50% longer to achieve the same clinical result.
• 5) Greater comfort for the patient and, possibly, the operator.
• 6) The possibility of full-mouth treatments, particularly if local anaesthesia is not employed.

24. CONSENSUS
• Current nonsurgical treatment consists of root debridement with
sonic/ultrasonic devices and finishing instrumentation with curettes
(Graziani F 2017)

25. FULL MOUTH DISINFECTION PROTOCOL

26. ORIGINAL FMD PROTOCOL

27. MODIFICATIONS IN FMD PROTOCOL

28. FULL MOUTH FMD VERSUS QUADRANT SRP

29. SUBGINGIVAL IRRIGATION – CHLORHEXIDINE
VERSUS POVIDONE IODINE

30. EVIDENCE
POVIDONE IODINE PROVIDES BETTER MICROBIOLOGIC RESULTS AS
COMPARED TO CHLORHEXIDINE AND ESSENTIAL OILS

31. MECHANICAL PLAQUE CONTROL

32. MANUAL VERSUS POWERED TOOTHBRUSH

33. INTERDENTAL AIDS IN PERIODONTAL
THERAPY

34. GINGIVAL PHYSIOTHERAPY

35. BENEFICIAL EFFECTS OF GINGIVAL
MASSAGE AND TONGUE CLEANING
• Gingival massage:-
• 1) Increases gingival keratinization
• 2) Improves blood supply
• 3) Improves Oxygen supply
• Tongue Cleaning:-
• 1) Cleans bacterial deposits from tongue surface
• 2) Avoids bacterial translocation
• 3) Avoids halitosis

36. CHEMICAL PLAQUE CONTROL

38. ADJUNCTIVE CHEMOTHERAPEUTICS IN NSPT –
SYSTEMIC ANTIMICROBIALS
• The complex structure of the periodontal biofilm, consisting of multiple bacterial communities
residing in a glycocalyx matrix, has been well described by Marsh et al.
• It has been demonstrated that once bacteria attach to a tooth surface and reside within a
mature biofilm structure they have a reduced susceptibility to antimicrobials compared to
planktonic or free floating bacteria.
• Hence mechanical debridement is considered critical to disrupt the biofilm when using
systemic antibiotics to treat periodontitis.
• The rationale for use of adjunctive systemic antimicrobials is to further reduce the
bacterial load enabling resolution of the inflammation in the periodontal pocket.

40. INDICATIONS OF SYSTEMIC
ANTIMICROBIALS
• 1. In severe cases both of acute necrotizing ulcerative gingivitis and periodontitis, especially if there are signs of systemic
involvement, metronidazole can quickly alleviate the symptoms, which then permits through mechanical debridement to be
carried out.
• 2. Occasionally, the local infection of a periodontal abscess can spread within tissue planes to cause marked facial swelling
and systemic involvement. In these cases, broad-spectrum antibiotics should be prescribed to control the infection. Careful
clinical and radiographic examinations must be done to establish whether the lesion is wholly periodontal in origin or whether
there is pulpal involvement of the associated teeth.
• 3. Multiple abscess formation and gross periodontal infection would necessitate the administration of antibiotics (metronidazole
and tetracycline). A number of medical conditions (e.g. Diabetes mellitus) can predispose to advanced periodontal destruction
with abscess formation.
• 4. Antibiotic therapy is warranted in cases of periodontal disease, which, despite through non Surgical management and good
plaque control, continue to show breakdown and loss of attachment. These so called refractory cases can benefit from a short
course of antibiotic therapy. The drug of choice should be determined from sampling the cultivable pocket flora from which the
predominant populating organisms can be identified.
• 5. Antibiotic therapy is recommended in the management of cases of AP either in combination with flap surgery or a non-
surgical treatment program.

42. EUROPEAN FEDERATION OF PERIODONTOLOGY
CONSENSUS ON ADJUNCTIVE ANTIBIOTICS
Cons: ‘Broad-spectrum antibiotics should be a weapon of
last resort to be used in extreme cases only’
Pros: ‘There is increasing evidence that systemic
antibiotics in the non-surgical treatment phase reduce the
need and extent of surgery’
Cons: ‘We need to consider alternatives to antibiotics’
Pros: ‘Costs and benefits of alternative methods are not
clear’

43. LOCAL DRUG DELIVERY

44.  There are many local drug delivery devices available in market and many
more are under trials.
 Recent trials on Statins and Bisphosphonates has taken LDD from just
antimicrobial usage to regenerative purpose

45. HOST MODULATION THERAPY
• BACTERIA ------------ HOST MEDIATORS
45
1.Scaling Root planning
2. Mechanical plaque control
3. Chemical plaque control
4. Systemic Antibiotics
5. Local drug delivery
????
Cytokines, Prostaglandins and MMP’sRed, Orange and Green Complex

46. HOST MODULATION THERAPY-
PAST, PRESENT AND FUTURE

47. VARIOUS HOST MODULATORY THERAPIES (HMT)
HMT
1.Antiproteinase -
blocking of excessive
production of MMPs
2.Blocking
arachadonic acid
metabolites-
(NSAIDs)
3.Lipoxins and
Resolvins
4.Regulation of
bone metabolism
(Bisphosphonates)
5.Immune modulation
therapy
(Proinflammatory
cytokine inhibition)
47

48. FUTURE DIRECTIONS IN HMT
• To date, this is one approved, systemic therapy that is prescribed as a host response
modifier in the treatment of periodontal disease, and that is adjunctive subantimicrobial dose
doxycycline (SDD) (Periostat@, CollaGenex Pharmaceuticals Inc., Newtown, P A, USA),
which downregulates the activity of MMPs.
• Research is focussed on use of Anti-cytokine therapies, pro-resolving molecules as HMT in
periodontitis.
• Moreover the commercialisation of many HMT options like Bisphosphonates, NSAID’s and
Statins are currently pending due to risks and benefits associated with these drugs.

49. PROBIOTICS IN NSPT
Actions of Probiotics in Oral Cavity

50. RATIONALE FOR THE USE OF PROBIOTICS
• 1) Inability of the conventional antibiotic therapy to treat the disease completely
• 2) Developing antibiotic resistance and the severity of disease
• 3) Multidrug-resistant bacteria continue to emerge as the antibiotic pipeline dries up
• 4) To raise the profile of disease prevention rather than disease management
• 5) Short life of effectiveness of antibiotics.
• 6) The arrival of new variety of bacteria
• 7) Probiotics may prevent colonization resistance, colonization overgrowth, and
translocation of potential pathogens.

51. Commercially available Probiotics for Periodontal
disease prevention and management

52. PROBIOTICS AS GUIDED TISSUE
RECOLONIZATION
• The concept of replacing the pathogenic bacteria in the gingival sulcus with beneficial
bacteria is called guided periodontal pocket recolonization.
• Teughels et al. conducted a study on guiding periodontal pocket and hypothesized that
the application of selected beneficial bacteria, as an adjunct to scaling and root planing,
would inhibit the periodontopathogen recolonization of periodontal pockets.

53. ANTIOXIDANTS
Antioxidants for Periodontal health

54. • Oxidative stress is usually defined as a disbalance of the production of free radicals and
antioxidant mechanisms (Kopáni et al., 2006)
• The role of oxidative stress in periodontitis has been postulated (Shapira et al.,
1991; Chapple, 1997).
• Some studies showed that leukocytes from patients with periodontitis are exhausted and
have a low oxidation activity (Loesche et al., 1988), other studies pointed toward higher
production of free radicals by leukocytes from periodontitis patients (Kimura et al., 1993).
• Antioxidant therapy alone or as adjunct to NSPT could be the solution to treatment of
periodontal disease secondary to oxidative stress.

56. ANTIOXIDANTS IN PERIODONTAL &
SYSTEMIC HEALTH
• ™Periodontal disease has now been linked to oral cancer, heart disease, stroke, lung
infections, pre-term and low birth weight babies, osteoporosis, and other chronic
diseases. ™
• Patients with periodontitis tend to have lower antioxidant capacity – both locally and
systemically. ™
• Oral biologist from university at buffalo’s school of dental medicine have shown for the
first time that a diet low in antioxidant vitamins can increase the risk of developing
periodontal disease.

57. BIOTHERAPEUTICS AS ADJUNCT TO NSPT
LASERS
• Several types of lasers are used in the treatment of periodontal and peri-implant
diseases: diode lasers (DLs) (809 to 980 nm), Nd:YAG (1064 nm), Er:YAG and
Er,Cr:YSGG (2940 and 2780 nm, respectively) and the CO2 laser (10,600 nm).1
• In NSPT, laser therapy is advocated for sulcular debridement, also known as soft
tissue curettage, and for bactericidal effects within the periodontal pocket known
as laser pocket disinfection.

58. • LASER-MEDIATED SULCULAR AND/OR POCKET DEBRIDEMENT
• If one considers the clinical parameters of reductions in probing depth or gains in clinical
attachment level, the dental literature indicates that when used as an adjunct to SRP,
mechanical, chemical, or laser curettage has little to no benefit beyond SRP alone.
• The available evidence consistently shows that therapies intended to arrest and control
periodontitis depend primarily on effective debridement of the root surface and not removal
of the lining of the pocket soft tissue wall, i.e., curettage.
• Currently, there is minimal evidence to support use of a laser for the purpose of subgingival
debridement, either as a monotherapy or adjunctive to SRP.

59.  Er:YAG laser application in non-surgical periodontal therapy is valuable. In combination with mechanical
debridement, the results are similar or better with significant gains in clinical attachment level as
compared to other various lasers. It is an excellent alternative to control the proliferation of micro-
organisms.
 Nd:YAP, diode and other low power lasers can be used but with caution since they offer no additional
advantage over conventional treatment modalities.

60. PHOTODYNAMIC THERAPY
• PDT involves the use of 3 components:
• (1) Light, (2) Oxygen free radicals, and (3) Photosensitizer.
• When the photosensitizer is stimulated by an appropriate light wavelength (wavelengths
between 650-900 nm which are within the visible red light and near infrared), it provides free
radicals of oxygen that causes tissue damage).
• The cytotoxic products have a short half life (about 0.04 µs) and limited radius effect (0.20
µm). In other words, they are limited to the infected area, where the photosensitizer is
accumulated.
• Thus, PDT is a topical method that does not affect other host tissues.

61. Due to its safety, no side effects and more acceptability of non-surgical methods of treatment to
patients, PDT is important as an adjunctive therapeutic method with scaling and root planing
(SRP) in order to increase the efficiency of non-surgical treatments.
 Lasers and PDT hold an upper hand over systemic antimicrobials
because of lesser invasive nature and no antimicrobial resistance

62. Though both modalities show no statistical significant difference in clinical results when
used as an adjunct to SRP, Antimicrobial photodynamic therapy (aPDT) has the potential to
become a conventional therapy used in conjunction with SRP because of its less invasive
nature and no antimicrobial resistance

63. OZONE THERAPY
• Goals of Ozone therapy:
• 1. Elimination of pathogens.
• 2. Restoration of proper oxygen metabolism.
• 3. Induction of a friendly ecologic environment.
• 4. Increased circulation.
• 5. Immune activation.
• 6. Simulation of the humoral anti-oxidant system.

64. The beneficial biological effects of ozone, its anti-microbial activity, oxidation of bio-
molecules precursors and microbial toxins implicated in periodontal diseases and its healing
and tissue regeneration properties, make the use of ozone well indicated in all stages of
gingival and periodontal diseases.

65. ORTHODONTIC THERAPY AS AN ADJUNCT TO
PERIODONTAL THERAPY

66. Six factors are seen as benefits of orthodontic treatment of patients with periodontal
disease:
 1. Alignment of crowded anterior teeth, improving access to all tooth surfaces during hygiene,
which is a great advantage for patients that are prone to bone loss or that do not have the manual
dexterity necessary to maintain good oral hygiene.
 2. Tooth uprighting, which may correct certain bone defects and often rules out the need for
osteotomy.
 3. Teeth with fracture, perforations, subgingival or intraosseous caries may be treated with
adequate restorations or prostheses after forced eruption, which may even improve resistance
and retention.
 4. Elimination of open embrasures, which affect esthetics in the anterior region, and may be
corrected by tipping the roots of adjacent teeth or by reducing interproximal distance or distance
between roots.
 5. Esthetic improvement of coronal positioning before restoration, which may eliminate the need
for gingival recontouring, a procedure that may require bone excision and root exposure
 6. The position of adjacent teeth may be improved before implants, fixed or removable prostheses
are placed.

67. EFFECT OF NSPT ON MICROBIAL FLORA
• Several studies sought to determine the beneficial effects of scaling and root planing on both
clinical and microbiological parameters and have consistently reported shifts to a less pathogenic
subgingival microflora coupled with improvements in the periodontal status.
• SRP by and large decreased the population of gram- negative microbes, while at the same time
increased the populations of gram- positive rods and cocci; a change that is usually compatible
with periodontal health.
• It is unlikely that scaling and root planing can eradicate and permanently clear all microorganisms
from a site, signifying that the mere presence of a suspected pathogen in a site is not indicative of
disease presence.

68. EFFECT OF NSPT ON HOST RESPONSE
• NSPT has found to decrease Host derived inflammatory mediators like: -
• Cytokines (IL-1, IL-6, TNF-α)
• Matrix metalloproteinases (MMP-8, MMP-9)
• Prostaglandins (PGE2)
• Though NSPT has a positive effect of host – microbial interaction in periodontal disease,
• Optimal treatment outcome is guaranteed by thorough plaque control, which ensues from highly
motivated and skillful patients in oral hygiene practices for the long- term maintenance of plaque-
free periodontal tissues

69. LONGITUDINAL STUDIES OF NSPT
American Studies
Michigan Studies
Minnesota Studies
Nebraska Studies
Loma Linda Studies
European Studies
Sweden Studies
Denmark Studies

73. NON SURGICAL VERSUS SURGICAL
THERAPY

75. When sites with initial PPD 1–3 mm were involved in
treatment by open flap debridement, there was significantly
more CAL loss than with treatment by scaling and root
planing
When sites with initial PPD 4–6 mm were treated by open
flap debridement, there was significantly less CAL gain
than with the scaling and root planing procedure
When sites with initial PPD >6 mm were treated with open flap
debridement, there was significantly more CAL gain than with
scaling and root planing

77. LIMITATIONS OF NSPT
• Treatment of Choice in Gingivitis cases
• Treatment of Choice for mild to moderate chronic periodontitis.
• Severe Periodontitis cases (PPD > 6 mm, CAL > 5 mm)…???
• Gingival Enlargement cases (Drug Induced, Conditioned)…???
• Aggressive Periodontitis cases…???
• Refractory Periodontitis cases…???

78. NSPT…..STILL THE GOLD STANDARD..!!!
• Gingivitis usually precedes periodontitis. However, it is important
to know that not all gingivitis progresses to periodontitis.
• When gingivitis is left undiagnosed and untreated, it can advance
to periodontitis.

79. WHY CANT ALL CASES BE RESTRICTED TO
GINGIVITIS ???

80. GOLD STANDARD PERIODONTAL THERAPY
Motivation and
Awareness
about
periodontal
disease.
Well executed
Non surgical
periodontal
therapy
Properly
planned
supportive
periodontal
therapy
Highly motivated
patient
performing
plaque control of
the highest level.