Nonsurgical Periodontal Therapy, NSPT

2. Sequence of Periodontal Therapy
Emergency Phase
Nonsurgical Phase
Maintenance Phase
Surgical Phase Restorative Phase
Different names of NSPT: Cause related therapy, Initial
therapy, Etiotropic phase of therapy, Phase I Therapy

3. -To alter or eliminate the microbial etiology and contributing factors for gingival &
periodontal diseases.
- To halt the progression of disease and returning the dentition to a state of health
and comfort.
Complete removal of
calculus
Correction of defective
restoration
Treatment of carious
lesion
Comprehensive daily
plaque control
Correction/
Replacement of
faulty prosthesis
Orthodontic
tooth movement
Treatment of
food impaction
areas
Treatment of
occlusal trauma
Extraction of
hopeless tooth
Control
Or
Elimination
Of
Local
Factors

4. - It may be the only treatment required for diseases like gingivitis or mild chronic
periodontitis or it may be preparatory phase for surgical therapy
- Long term success of periodontal treatment depends predominantly on
maintaining the results achieved with Phase I therapy
- Evaluation of tissue response
- Evaluation of patients attitude towards periodontal treatment

5. Kiser (1994) proposed three separate stages of treatment:
1. Debridement : Instrumentation for disruption and removal of microbial
biofilm
2. Scaling : Instrumentation for removal of mineralised deposits
3. Root planing : Instrumentation to remove contaminated cementum and
dentin in order to restore biologic compatibility of periodontally diseased root
surfaces

6. Studies suggested (Hatfield & Baumhammers 1971, Aleo et al 1974) , that aggressive
scaling and root planing was required to remove bacterial products (lipopolysaccharide
⁄ endotoxin) bound to the contaminated root surface.
It was established in-vitro studies ( Hughes & Smales 1986, Moore et al 1986) that
bacterial endotoxins are weakly adherent to root surfaces and therefore excessive
removal of cementum is not required to remove bacterial products
ROOT PLANING or ROOT DEBRIDEMENT
Removal of calculus is important because it is a major plaque-retentive factor,
but intentional removal of root substance and contaminated cementum is not
required for successful treatment.
Mombelli A et al, 1995 in their split mouth study found, clinical and microbiological
parameters showed similar improvements at test and control teeth with reductions in
probing depths and in the proportions of periodontal pathogens (Porphyromonas
gingivalis, Fusobacterium sp. and Campylobacter rectus

7. It is defined as the removal of the inner surface of the soft-tissue wall of the
pocket, , by means of a curette.
It was performed in order to promote new attachment and tissue shrinkage,
leading to pocket-depth reduction.
“Curettage or Not to Curettage : That is the Question “ - Echeverria JJ et al 1983
SRP SRP + Curettage after 4 wk
Gingival curettage
After 5 wk, similar improvements in periodontal tissue health were observed,
regardless of treatment, with a reduction in probing depth and gingival inflammation,
and an increase in clinical attachment level

8. The full-mouth disinfection protocol: includes fullmouth scaling and root planing
within 24 h, in addition to twice-daily chlorhexidine mouthrinsing, tongue scraping,
chlorhexidine tonsil spraying and subgingival irrigation with chlorhexidine three
times within 10 min and repeated after 8 days ( Quirynen et al, 1995)
Conclusion : All three treatment approaches may be recommended for
nonsurgical periodontal therapy. Therefore, operator and patient preference is
important in determining the choice of instrumentation for nonsurgical therapy,
including the choice between staged debridement, full-mouth disinfection and full-
mouth scaling and root planing.
Staged debridement with quadrant or sextant
instrumentation or Full mouth instrumentation and
Disinfection

9. - Shift from a predominantly gram-negative to a gram-positive subgingival
microbiota.
- Decrease in the number of microorganisms, including black-pigmented
species and spirochetes.
- Ultrasonic instrumentation can cause reduction in spirochete and motile rod
counts with a concomitant increase in coccoid cells.
Darby et al. investigated the effects of scaling and root planing on subgingival
microflora. PCR was used to determine the presence of A. atinomycetemcomitans, P.
gingivalis, T. forsythia, P. intermedia, and T. denticola in four sites from 28 patients
before and after scaling and root planing. The treatment resulted in clinical
improvement, and there were significant reductions in P. intermedia, T. forsythia, and
T. denticola at a site level.
Effect of scaling and root planing on subgingival
microflora

10. Mechanical Therapy : Manual – Sonic - Ultrasonic
-Meticulous subgingival instrumentation is time consuming in all the three methods
- With manual instrumentation it takes 20-50% more time as compared to sonic or
ultrasonic
- Deep pockets and furcation areas are difficult to reach by instrumentation.
- Dragoo et al . – Instrument limit to the depth of the pocket – 0.78 & 1.13 mm
respectively for modified & unmodified ultrasonic tip and 1.25 mm for Manual
curette.
- AAP 1996 world workshop consensus report – Similar clinical effects in all
treatment modalities. For best result – combination of different modalities can be
considered

11. Pihlstrom et al 1981-1983-1984

12. This report concludes that SRP alone or in combination with MWF surgery results in
sustained decreases in gingivitis, plaque, and calculus and neither procedure
appears to be superior with respect to these parameter

13. Pihlstrom et al, 1984 – The 3rd Report:
The response of molar & non-molar teeth to SRP, alone or combined with MWF
17 Patient – 453
Teeth
19 Extracted
Better
Response in
Non-Molar teeth
Molar tooth morphology accumulates
plaque more- Thus Pocket reduction
was harder to achieve

14. Michigan Study
Hill et al (1981), Ramfjord et al (1982), Morrison et al (1982)

15. Conclusion:
None of the surgical modalities had any better effect, which is directly related to
reduction in pocket depth, than SRP in maintenance of periodontal support

16. Ramfjord et al. 1982.
-78 Patients were treated by
- Occlusal adjustment
- Surgical therapy
- Recall prophylaxis every 3 months for 8 years
- 3 Groups
- 1- 3 mm
- 4 – 6 mm
- 7 – 12 mm
Conclusion:
1. Magnitude of reduction of pocket depth and changes in attachment level, following
periodontal therapy, is positively related to the original pocket depth.
2. All four surfaces of teeth responded similarly to treatment when pockets of initial
equal depth were compared

17. Morrison et al. (1982) – Effect of Gingivitis on probing
depth and attachment loss
1- 3 mm probing depth: No difference
 4 – 6 mm pockets with lower gingivitis score – better gain in first 2 years, no
difference thereafter
 7 -12 mm pockets - better gain in first 3 years, no difference thereafter.
-The severity of gingivitis did not affect the maintenance of pocket depth
reduction or CAL

18. Gothenberg/ Swedish Studies: Lindhe et al (1982A, 1982B & 1984)

21. 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
Lindhe et al (1982B) determined the CRITICAL
PROBING DEPTH for SRP & MWF

22. - AARHUS/ DENMARK Studies ( Isidor et al – 1984 & 1985. Isidor and Karring 1986
- Tucson – Michigan - Houston Studies ( Becker et al – 1988 & 1990) : The
research was done in private practice with aim to confirm the result from the
universities studies
- Nebraska Studies ( Kaldahl et al – 1988, 1990 & 1992)
- Loma Linda studies

23. -Smoking : decreased immune response & compromised healing
- Persistent deep pockets and molars with furcation involvement: single rooted teeth
and posterior teeth with intact furcation respond better
- Surgical periodontal therapy in pockets of > 5mm results in better
outcome as reported By Kaldahl et al

24. -This studies were pioneer in providing the guideline to which the therapy will be most
beneficial for the patient
- Selection of treatment and treatment protocol for the best short term and long term
result for the patient
- Repeated instrumentation was of little benefit because calculus was often missed on
the second attempt for the same reason it was missed the first time.
-The primary caveat with non-surgical therapy is that, there are sites and even patients
where it may not be effective. This must be recognized at the reevaluation
appointment and appropriate therapy, probably surgery, should be instituted.

26. Atridox – Gel Based system
10 % Doxycycline

30. But, In Meta-analyses (Sgolastra F et al 2012) 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

31.  WHO has defined Probiotics as live organisms, which, when administered in
adequate amounts, confer a health benefits to the host.
 Probiotics repopulate beneficial bacteria which can help to kill pathogens.
 Probiotics produce antioxidants. Antioxidants prevent calculus formation by
neutralising the free electrons that are needed for the mineral formation.
 Probiotics prevents foul odour by fixating on the VSC

34. Perioprotect