Describes all Surgical and Nonsurgical Periodontal Therapy, advantages, and indication- contraindication

1. 1
NON SURGICAL VERSUS
SURGICAL PERIODONTAL
THERAPY
SANGEETA ROY

2. Introduction
Goals Of Periodontal Therapy
Methods Of Non Surgical Therapy
Limitations Of Non Surgical Periodontal Therapy
Clinical Outcome Of Surgical Therapy In Comparison To
Non- Surgical Therapy
Periodontal Surgery
Critical probing depth
Supportive periodontal therapy
Conclusion
2

3. 3
• Periodontal treatment
•The aim of the effective treatment of periodontal diseases
The effectiveness of periodontal therapy is
made possible by remarkable healing capacity
of the periodontal tissues.
Periodontal therapy can restore chronically
inflamed gingiva to almost identical with
gingiva that has never been exposed to
excessive plaque accumulation.
Properly performed, periodontal treatment can eliminate pain,
exudate, gingival inflammation, and bleeding. It can also reduce
periodontal pockets, eliminate infection, arrest the destruction of
soft tissue and bone, reduce abnormal tooth mobility.
Also establish optimal occlusal function, restore tissue
destroyed by disease, reestablish physiologic gingival contour,
and prevent the recurrence of disease,

4. 4
GOALS OF
PERIODONTAL
THERAPY
IMMEDIATE
GOAL
IDEAL GOAL
ULTIMATE
GOAL
PRAGMATIC
GOAL

5. Mechanical therapy
Systemic antibiotics
Local drug delivery
Host modulatory agents
Lasers
Full mouth disinfection
Photodynamic therapy
Ozone therapy
Hyperbaric oxygen therapy
Connie Hastings Drisko. 2001
5

6. MECHANICAL THERAPY
Connie Hastings Drisko. Nonsurgical periodontal therapy. Periodontology 2000, Vol. 25, 2001, 77–88.
6
Self performed oral hygiene
professional removal of plaque and calculus
Manikandan.G.R 2016.

7. Sickle scalers Curettes
7

8. Ultrasonic and sonic instruments :
 Magnetostrictive
 Piezoelectric
 Alternating electrical current generates oscillations in the
materials in the hand piece that cause the scaler tip to vibrate.
8
vibration of tip is linear, or back
and forth , meaning that the two
sides of the tip are the most active.
 Do not generate heat but still
utilize water for cooling frictional
heat and flushing away debris.
the pattern of the vibration is
elliptic – all the sides of the tip
are active.
These tips generate heat and
require water for cooling.

9. Vector system :
 Specially designed
 Vibrates parallel to the tooth surface
 Use in conjunction with irrigation fluids containing hydroxyl-
apatite or silicon carbide.
 Braun A et al (2002) - Abrasive fluid forms a smear layer on
tooth surface, this layer is responsible for the reduction of the
post operative hyper sensitivity.
9

10.  Powdered air abrasive system – low abrasive amino acid
glycine powder.
10
Koshy G , 2004

11. Mechanical therapy alone may not effectively control
infection.
Medical conditions – poor glycemic control
Other factors – tooth / site dependent and include the presence
of plaque or anatomic features
Graziani F, , 2017 11

12. FULL MOUTH DISINFECTION:
 Periodontal treatment-1 week between appointments.
 Translocation of bacteria -reinfection of newly treated
periodontal site.
 FMD – involves scaling and root planing & chlorhexidine
application of entire dentition performed in one or two
appointments with in 24hrs.
12

13. Quirynen & coworkers in 1995 :
13

14. Advantages of full-mouth disinfection
1) Reduces the number of visits for patients and costly treatment
time.
2) With minimal side-effects.
3) Eliminate the need for surgical treatment
4) Advisable in patients with a low compliance.
5) It might be possible to increase the time
14
Disadvantages of full-mouth disinfection
1) Expertise of the operator
2) Duration of treatment
3) However, there is no way to rule out reinfection by
transmission from an extraoral source or person.

15. LASERS :
 A laser is a device that produces coherent electromagnetic
radiation.
 The first report of laser application for the treatment of dental
caries was published in 1964 by Goldman et al.
15
Isao Ishikawa et al. 2009

16.  The CO2 laser cannot be used for calculus removal
 The Nd:YAG laser is also basically ineffective for calculus removal
16
• Er:YAG laser is capable of easily removing
subgingival calculus without a major thermal
change of the root surface.
• With the Er:YAG laser, the use of water coolant
can effectively prevent thermal generation during
laser scaling while not compromising the
efficiency of laser scaling

17. Advantages
 Strong ablation and hemostasis
 Detoxification and bactericidal effects on the human body.
 These effects could be beneficial during periodontal
treatment, especially for the fine cutting of soft tissue as well
as in the debridement of diseased tissues.
17
Disadvantages
• High financial cost
• Improper irradiation of teeth and periodontal pockets by lasers
can damage the tooth and root surfaces as well as the attachment
apparatus at the bottom of the pocket.
• Possible damage to the underlying bone and dental pulp
should also be considered.

18. PHOTODYNAMIC THERAPY:
 Oscar Raab
18
Soukos NK, 2011

19.  TYPE I- radical ions interact with oxygen to create
cytotoxic specise i.e. lipid derived radicals, hydroxyl
radicals, superoxidase
 TYPE II- singlet oxygen oxidize lipid , nucleic acid
proteins
 Finally free radicals-> irreversible damage to
cytoplasmic membrane of bacteria ( by inactivation of
transport system and enzymatic function), breakdown of
nucleic acid and cell death.
19

20. Photosensitizer :
 The photo sensitizers are based on the Tetrapyrrole Nucleus
20
Soukos NK, 2011

21. New frontiers in oral antimicrobial photodynamic therapy
21
Soukos NK, 2011
Phototherapy
Antibody-targeted
Nanoparticle( liposome,
polymeric micells)

22. Connie Hastings Drisko. 2001,
22
 Systemic antimicrobial therapy aims at reducing or
eradicating specific periodontal pathogens that are not
reached by subgingival.
Drug regimen Dosage/duration
Amoxicillin 500mg 3 times daily for 8 days
Azithromycin 500mg Once daily for 4-7 days
Ciprofloxacin 500mg Twice daily 8days
Clindamycin 300 mg 3 times daily 10 days
Doxycycline or
Minocycline
100-200mg Once daily 21 days
Metronidazole 400 mg 3 times daily 8 days
Metronidazole+
Amoxicillin
200 mg each 3 times daily 8 days
Metronidazole+
Ciprofloxacin
500 mg of each Twice daily 8days

23. Combination antibiotic therapy may help:
 To broaden the antimicrobial range
 Bacterial resistance
 To lower the dose
23
Winkelhoff A, 1996

24. 24
Rams and slots (1996)
• Depending on usage
1.Personally applied
A. Non-sustained subgingival drug delivery
Home oral irrigation
Devices with traditional jet tips
Oral irrigator (water pik , fort collins)
Soft cone – rubber tips
Blunt tipped metal canula connected to syringe or oral irrigator.
B. Sustained subgingival drug delivery
Akhilesh Shewale1 , 2016

25. 25
II. Professionally applied
A. Non sustained subgingival drug delivery
professional pocket irrigation
 Syringe with blunt end needle.
 Blunt tipped cannula attached oral irrigator.
 Ultrasonic scaling devices.
 Thin ultrasonic scaler inserts.
B. Sustained subgingival drug delivery
 Reservoirs without a rate controlling system
hollow fibers,gel,dialysis tubing
 Reservoirs with a rate controlling system
Akhilesh Shewale1 , 2016

26. 26
LDD AGENT DRUG
Periochip 2.5mg chlorhexidine gluconate
Actisite 25% tetracycline hydrochloride
Atridox 10% doxycycline
Metronidazole dental
gel (Elyzol)
25% Metronidazole benzoate
Arestin 1mg of minocycline
Dentamycine 2% minocycline (10mg in 0.5 g
ointment)

27. Patient applied home irrigation
DENTAL WATER JET
 The body of evidence on the dental water jet (also called oral
irrigator and water flosser) consistently has been shown to
significantly reduce gingivitis, bleeding on probing, and
periodontal pathogens.
27
Jolkovsky DL. 2009

28.  A pulsation rate of 1200 per minute
28
Jolkovsky DL. 2009.

29. HOST MODULATORY AGENTS
 Aims to reduce tissue destruction and stabilize or even
regenerate the periodontium by modifying or down regulating
destructive aspects of the host response & up regulating
protective or regenerative response .
29
Ryan M E, 2009

30. 30
Ryan M E :2009
• Nonsteriodal Anti-
inflammatory Drugs
• Bisphosphonates
• Subantimicrobial-dose
Doxycycline
Systemically
Administered
Agents
• Nonsteriodal Anti-
inflammatory Drugs
• Enamel Matrix Proteins,
• Growth Factors,and
• Bone Morphogenic Proteins
Locally
Administered
Agents

31.  Various Host modulation therapies have been developed to
block or modify the pathways of periodontal breakdown.
 More specifically 3 types of Host modulatory agents have
been investigated for the management of periodontitis include
 Anti-proteinases(MMP-inhibitors)
 Anti-inflammatory agents
 Anti-resorptive agents
Driwal G,, 2012
31

32. 32
Modulation of
arachadonic acid
metabolites
- NSAIDS
- Lipoxins
- Omega-3 fatty acids
- Triclosan
Modulation of matrix
metalloproteinases
- Tetracyclines
- Subantimicrobial
dose doxycycline
- Chemically modified
tetracycline
Ryan M E, 2009

33.  Modulation of bone remodelling
- Bisphosphonates
 Disruption of cell signalling pathways
- Mitogen Activated Protein Kinase Inhibitors
- Anti-nuclear factor kappa-beta strategy
- JAK/STAT pathway
-Anti-cytokine therapy
- Vaso-active intestinal polypeptide
- Modulation of nitric oxide synthase
- RANK-RANKL-inhibitors
33
Ryan M E, 2009

34. OZONE THERAPY
 German chemist Christian Friedrich Schonbein - ozone in
1840.It is an unstable gas and quickly gives up nascent O
molecule to form oxygen gas.
 Ozone is a gas-O3, and is the third most powerful oxidant.
Medical ozone is produced by oxygen and its passage through
a voltage gradient, using ozone generators that react to
dioxygen molecules, forming ozone.
Ozone generators :
 UV system: Produces a low concentration of ozone
 Cold plasma system: used in air and water purification.
 Corona discharge system: produces high concentration of
ozone. It is the most common system used in medical/dental
fields.
Kaul R.Silpa PS. 2014
34

35. Routes of ozone administration
 Ozone can be administered via three different routes–gaseous
ozone, ozonated water, and ozonized oil.
 Gaseous ozone:
 Ozonated water:
 Ozonized oil:
35
Kaul R.Silpa, 2014

36. Ozone therapy in periodontics
 ozonated water flushed below the gum line and/or ozone gas
infiltrated into the gum tissue and supporting tissues.
 Ozonated water (4ml/l) strongly inhibited the formation of
dental plaque and reduced the number of subgingival
pathogens both gram positive and gram negative organisms.
 Gram negative bacteria, such as P.endodontalis and P.
gingivalis were substantially more sensitive to ozonated water
than gram positive oral streptococci.
Gupta C and Mansi B.2012.
36

37. HYPERBARIC OXYGEN THERAPY:
 The Committee on Hyperbaric Medicine defines HBO
therapy as “A mode of medical treatment in which the patient
is entirely enclosed in a pressure chamber and breathes 100%
oxygen at a pressure >1 atmosphere absolute (ATA).”
 1 ATA = 760 mm of mercury or pressure at sea level.
Jain N, 2014.
37

38. Cellular and biochemical benefits of hyperbaric oxygen
• Promotes angiogenesis and wound healing
• Kills certain anaerobes
• Prevents growth of species such as Pseudomonas
• Prevents production of clostridial alpha-toxin
• Restores neutrophil mediated bacterial killing in previously
hypoxic tissues
• Reduces leucocyte adhesion in reperfusion injury preventing
the release of proteases and free radicals which cause
vasoconstriction and cellular damage.
38
.

39. Effects of hyperbaric oxygen therapy on
periodontal disease
 Inhibits the growth of anaerobic microorganisms, effectively
supporting antibiotic and surgical therapy.
 In addition, an oxygen-rich milieu enhances the function of
leukocytes, activating or supporting the body’s local defense
mechanisms in areas that are already frequently poorly
perfused, which in turn speeds up the healing process.
 In addition, the healing process in damaged bone can be
accelerated by oxygen therapy or even made possible in the
first place.
39
.

40. PROBIOTICS
 Lilly & Stillwell (1965)
 Lactobacillus acidophilus by Hull et al. in 1984
 Bifidobacterium bifidum by Holcombh et al. in 1991.
Stamatova I & Meurman JH. 2009, 40
Others
Bacillus cereus
Clostridium butyricum
Escherichia coli
Propionibacterium freudenreichii
Saccharomyces boulardii
Enterococcus fecalis
Enterococcus faecalis
Streptococcus thermophilus
Lactobacillus
species
L.acidophilus
L.rhamnosus
L.gasseri
L.casei
L.reuteri
L.bulgaricus
L.plantarum
L.johnsonii
L.lactis
Bifidobacterium
species
B.bifidum
B.longum
B.breve
B.infantis
B.lactis
B.adolescentis

41. 41

42. Some periodontal pathogens are tissue invasive tend to spread
along tissue planes.
Some of the pathogens also have been recovered from oral
tissues such as tongue,…
Adriaens et al have shown that inspite of SRP and personal
oral hygiene bacteria remained in radicular cementum and
dentinal tubules.
Graziani F,,2017
42

43. Periodontal pathogens reside in the deep pockets.
It is difficult to access a periodontal pocket deeper than 5 mm
adequately while scaling and root planing.
The anatomy of the periodontal pocket also affects the
effectiveness of debridement.
Noiri and Ebisu suggested that C. rectus and T. denticola may
invade the most apical border plaque area by use of their
motility.
43

44. 44

45. Longitudinal Studies
Michigan studies - Ramjford & Co
Minnesota studies - Pihlstrom & Co
Arizona studies – Tucson-Michigan - houston
Nebraska studies – Kaldahl & Co
Loma Linda studies – Egelberg & Co
Swedish studies - Lindhe & Co
Denmark studies - Isidor & Co
Khalaf . F.,2002
45

46. Michigan Studies
Khalaf . F. Al Shammari, , Rodrigo F. Neiva et al Surgical and non- surgical treatment of chronic periodontal disease.. INT CHIN
J DENT,2002;2:15-32. 46
AUTHOR COMPARISON YEARS RESULTS
Ramfjord et al
(1968)
CR, PE
(curettage),
(pocket
Eliminatiion
surgery)
2 CAL : similar results for CR
and PE
Knowles et al
(1979)
CR, PE ,MWF 8 PD and CAL : Improved for all
4-6 and 7-12 mm pockets.
Hill et al (1981) CR, PE, MWF, SRP
(modified
widman flap)
2 1-3mm :minimal PD
reduction and CAL loss. No
difference b/t groups.
4-6mm: more PD reduction
PE>MWF, but more CAL loss.
>7mm:more PD reduction for
PE, but no sig.diff in CAL gain
b/t groups.

47. 47
AUTHOR COMPARISON YEAR
S
RESULTS
Ramjford et al
(1982)
effects of OH
after therapy
.(oral hygiene).
8 higher OH more PD reduction
and higher CAL gain.
Morrison et al
(1982)
effects GV
(gingivitis) after
therapy
8 no correlation with PD and CAL
change.
Ramjford et al
in 1987
CR, PE, MWF, SRP 5

48. 48
CAL PD reduction
1-3mm:PE=MFW=SRP=CR No changes
4-6mm: PE>MFW>SRP>CR Sig. reduction. No difference b/t
groups
>7mm: PE>MWF>SRP>CR PE> MFW>SRP>CR

49. Minnesota Studies
Pihlstrom et al
(1981)
SRP, SRP+MFW 4yrs MWF:increased PD reduction and
CAL gain for deeper pockets.
Pihlstrom et al
(1983)
SRP, SRP+MWF 6.5 yr 1-3mm :MWF led to more CAL loss.
4-6mm: similar PD reduction. SRP
causes less CAL loss.
7mm : MWF – resulted in
sustained PD reduction for 6.5yrs.
PD reduction in SRP group was
only sustained for 3yrs.
Effective sustain gain of CAL in
both groups.
Pihlstrom et al
(1984)
SRP, MFW
Molar , non molar
6.5 yrs 4 -6mm: less PD reduction and less
gain on molars thannon molars.
7mm : No sig.diff in PD reduction
b/t M and NM teeth Following SRP
alone
49

50. Nebraska Studies
Kaldahl et al (1988) CS(coronal
scaling), SRP,
MWF, APF+ OS
2 PD reduction:
APF+OS>MWF>SRP>CS
Kaldahl et al (1996-
I)
CS(coronal
scaling), SRP,
MWF, APF+ OS
7 APF+OS: sustained more PD
reduction on >5mm sites.
CAL- gain in CAL - >7mm
loss in CAL – 1-4mm
Kaldahl et al (1996
II)
CS(coronal
scaling), SRP,
MWF, APF+ OS
(osseous surgery)
7 CS: higher incidence of
breakdown.
breakdown / yr: SRP=MWF> APS
+OS in 1-6 mm sites.
50

51. Loma linda studies
Badersten et al (1981) SRP: HI vs. USI 2 Comparable results obtained by both
methods.
Cerceck et al .(1983) OHI (hygiene instructions),
SRP
2 OHI minimal effect, SRP: Greater PD reduction
and CAL gain
Badersten et al (1984-II) OHI, SRP, severe
periodontitis
2 Deep residual PD: higher incidence of BOP.
Badersten et al (1984 III) SRP, single , repeated 2 No additional benefits of repeated SRP
Badersten et al (1985- IV) SRP, operator variability 2 Operator variability b/t clinicians is minimal
Badersten et al (1985- V) SRP, recurrence of CAL loss 2 73% of the non responding sites showed a
linear pattern of CAL loss
Badersten et al (1985 VI) Effects of SRP 4 Initial shallow PD more CAL loss
Badersten et al (1987) Effects of SRP 4 Maintenance of CAL :no diff. bt shollow and
deep PD
Nordland et al (1987) SRP;M, NM, M w /FI 2 ≥4.0mm :Mw/FI responded less favourably to
therapy
≥7mm :MwFI showed higher recurrence of CAL
loss
Loss et al (1989) SRP; M, NM,Mw/FI 2 The greater the FI the lesser the response to
SRP.
51

52. Tuscon michigan houston
BECKER ET AL
(1988)
SRP, MWF, APF+OS 1 PD:reduction:
AP+OS=MWF>SRP
CAL gain: All
treatments
produced similar
CAL gain
BECKER ET AL
(1990)
SRP, MWF, APF+OS 5 PD reduction:
significant and
similar in 4-6and ≥
7mm
KERRY ET AL (1990) SRP, MWF, APF+OS 5 1-3mm: significant
CAL loss, 4-6 and
≥7mm:
insignificant CAL
gain
52

53. Sweden Studies
AUTHOR COMPARISON YEARS RESULTS
Rosling et al(1976) APF, MWF w/wo
OR(osseous
recontouring)
2 More CAL gain: associated with
better OH
Lindhe et al (1982-I) SRP, SRP+MWF 2 MWF: more PD reduction and
higher CAL gain
Lindhe et al (1982-
II)
Critical probing
depths
2 CPD:SRP=2.9±0.4mm, MWF
=4.2±0.2mm
Rosling et al(1983) APF, MWF w/wo OR 4 Good OH:No≠ b/t groups
Lindhe et al (1984) SRP, SRP+MWF 5 PD reduction and more CAL
gain : with better OH
Lindhe et al (1985) SRP, SRP+KF 1 PD reduction and CAL gain:No
≠b/t groups.
53

54. Denmark Studies
AUTHOR COMPARISON YEARS RESULTS
Isidor et al (1984) SRP, MWF, APF 1 CAL gain: similar for all groups,
slightly increase for SRP
Isidor et al (1984) SRP, MWF, APF 5 PD reduction and CAL gain: no≠
b/t groups.
CAL loss: < 5% of the sites.
54

55. Comparison American Studies European Studies
Measurement sites 4 points at line
angles
6 sites/tooth(deepest
part)
Study teeth Molars and single
rooted teeth
Single- rooted teeth
Maintenance 3- month
SPT(professional
maintenance more
important than
patient OH)
2 Wks at first (OH
and maintenance
equally important)
Unit of analysis patient site
Occlusal adjustment Some studies No
Probe type Not uniform Not uniform
55

56. PERIODONTAL SURGERY
5 basic categories of surgical procedures are used in periodontal
therapy.
 Surgical procedure for pocket elimination
 Treatment of osseous defects and
 Procedures for new attachment
 Procedures for access to the root surface
 Procedures for mucogingival problems
56
Indications
Accessibility
Establishment of a morphology
Pocket depth reduction.
Correction of gross gingival
aberrations.
Shift of the gingival margin
Restorative therapy.
Contraindications
Patient cooperation
Cardiovascular disease
Organ transplantation
Blood disorders
Hormonal disorders
Neurological disorders

57. Noel Claffey, 2004
57
Schematic
representation of
typical treatment
modalities and their
sequence of use in
periodontal pocket
management

58. Robiscek in 1884.
Grant et al.(1979).
reducing deep gingival pockets formed by enlarged fibrotic
tissue and suprabony periodontal pockets.
Not indicated in the reduction of infrabony pockets
58
Where the initial depths were < 3 mm,
When initial depths were 3 mm or over, (Ian M.Waite)

59. In 1954, Nabers described the technique of repositioning of
attached gingiva.
Friedman later introduced the term apically repositioned flap.
59
Kaldahl et al.in 1996 , surgical treatment of pockets 5 mm by flap and
osseous surgery

60. Morris (1965)
Ramfjord & Nissle (1974)
During healing some crestal bone resorption and osseous
repair can be expected with the establishment of a long
junctional epithelium between the bone and the root surface.
60

61. In response to concerns about aesthetics and root sensitivity
consequences of pocket elimination procedures, pocket
reduction procedures were advocated as a more conservative
and constructive surgical approach.
61
Gothenburg studies.Lindhe et al. (1982) reported results of a 2-
year study comparing SRP to modified Widman surgery.
Both treatments resulted in a decrease in probing depth. Initial
values were 4.2 and 4.1 mm and decreased to 2.4 and 2.5
(surgery) and 2.9 and 2.8 mm (no surgery).

62. Treatment of osseous defect:
 Conservative , resective or regenerative surgery.
 Osteoectomy or osteoplasty
 Indication for this type of surgery is based on need for
anatomic changes and is an ideal surgical technique for root
lengthening and pre prosthetic management of soft tissue.
62
Graziani F, 2017

63. NEW ATTACHMENT - Union of connective tissue or
epithelium with a root surface that has been deprived of its
original attachment apparatus.
63
Reconstructive
surgery
Non bone
graft
associated
Bone Graft
associated
Combined
technique
In:Newmann M.G, ;2009.

64. Non bone graft associated procedures
64
Biomodification
of root surface
Enamel matrix
proteins
Removal of JE
Bone
morphogenic
proteins
Guided tissue
regeneration
Growth factors

65. ROOT BIOMODIFICATION
Changes that takes place on the surface of root in case of
periodontal disease is –
 Loss of collagen fiber insertion
 Contamination of root surface by bacteria and endotoxins
Alterations in mineral density and composition
 Lack chemotactic stimuli
65
Mechanical root biomodification
Scaling and root planing
Smear layer – Physical barrier ,
inhibiting new attachment and
acting as a substrate for bacterial
growth
Chemical root biomodification
Acid Etching – Citric Acid
Detergents- Cetylpyridinium
chloride , sodium N- Lauroyl
sarcosine
Chelating agents- EDTA
Enzymes
Attachment proteins- Fibronectin

66. Procedures for mucogingival problem
 “Surgical procedures performed to prevent or correct anatomical,
developmental, traumatic or disease induced defects of gingiva,
alveolar mucosa or bone ” - Wennstorm 1996 / WWS
 Perioplastic surgery adopted by AAP proposed by Miller in 1998
 Techniques to increase the width of the attached gingiva
66
Gingival
augmentation apical
to the area of the
recession
Gingival augmentation
coronal to the
recession.

67. SURGICAL VS NON-SURGICAL DEBRIDEMENT
 In 2002, Heitz- Mayfield et al –
Surgical therapy resulted in 0.6mm more probing
depth reduction and in 0.2mm more clinical attachment gain
than nonsurgical therapy in deep pockets.
In pockets of 4-6mm, scaling and rootplaning
resulted in 0.4mm more clinical attachment gain and 0.4mm
less probing depth reduction than surgical therapy.
67
He concluded that both scaling and rootplaning alone and combined with a
flap procedure are effective methods for the treatment of chronic periodontitis,
in terms of attached gain and reduction in gingival inflammation.
In the treatment of deep pockets open flap debridement results in greater probing
depth reduction and clinical attachment gain.

68. Critical probing depth for decision making :
 For nonsurgical therapy- 2.9mm.
 For the access flap therapy - 4.2mm (lindhe et al)
68
Lisa J,Lang, 2013

69. SUPPORTIVE PERIODONTAL THERAPY :
 AIMS:
(i) To prevent the recurrence and progression of periodontal
diseases.
(ii) To prevent or reduce the incidence of tooth loss by monitoring
the dentition and any prosthetic replacements of natural teeth.
(iii) To increase the probability of locating and treating the disease.
69

70. Optimal interval between supportive periodontal
visits.
 2weeks , 2-3 months , 3months, 3-4months, 3-6 months.
 Frequency of supportive periodontal therapy has to be
individually tailored by assessing risk factors, initial disease
severity, treatment outcomes , age in relation to disease
severity , plaque control or presence of restoration.
70
Graziani F, 2017

71. CONCLUSION
The choice of the therapy may depend not only on the
outcome measures of probing pocket depth reduction and
CAL gain, but also on the influence of other variables,
including the evaluation of adverse effects and patient
centered outcomes, such as patient discomfort and
apprehension, root sensitivity and aesthetic considerations.
71

72. THANK YOU
72