This presentation evaluates phase I periodontal therapy.

1. PHASE –I PERIODONTAL
THERAPY

2. LEARNING OBJECTIVES –
1. Introduction
2. Rationale
3. Treatment Sessions
4. Sequence of Procedures
5. Results
6. Healing
7. Decision to Refer for Specialist Treatment

3. INTRODUCTION –
• Phase I therapy or cause-related therapy is the first in the
chronologic sequence of procedures that constitute periodontal
treatment.
• The objective of phase I therapy is to alter or eliminate the
microbial etiology and factors that contribute to gingival and
periodontal diseases to the greatest extent possible, thereby
halting the progression of disease and returning the dentition
to a state of health and comfort.

4. • Phase I therapy is referred to by a number of names,
including initial therapy, nonsurgical periodontal therapy, and
cause-related therapy.
• All terms refer to the procedures performed to treat gingival
and periodontal infections up to and including tissue
reevaluation, which is the point at which the course of
ongoing care is determined.

5. Rationale –
• Phase I therapy is deined by the evidence-based American
Association of Periodontology practice guidelines5 as the
initiation of a comprehensive daily plaque or biofilm control
regimen, management of periodontal-systemic
interrelationships as needed, and thorough removal of
supragingival and subgingival bacterial plaque or bioilm
and calculus.

6. Management of all contributing local factors is required in phase I
therapy. The following list of elements makes up phase I therapy:
1. Patient education and oral hygiene instruction
2. Complete removal of supragingival calculus
3. Correction or replacement of poorly itting restorations and other
prosthetic devices
4. Restoration or temporization of carious lesions

7. 5. Orthodontic tooth movement
6. Treatment of food impaction areas
7. Treatment of occlusal trauma
8. Extraction of hopeless teeth
9. Possible use of antimicrobial agents, including necessary plaque
or biofilm sampling and sensitivity testing

8. Conditions to be considered when determining the phase
I treatment plan:
• General health and tolerance of treatment
• Number of teeth present
• Amount of subgingival calculus
• Probing pocket depths
• Attachment loss
• Furcation involvement

9. • Alignment of teeth
• Margins of restorations
• Developmental anomalies
• Physical barriers to access the dentition (i.e., limited opening or
tendency to gag)
• Patient cooperation and sensitivity to therapy (requiring use of
anesthesia or analgesia)

10. Sequence of Procedures –
Step 1: Plaque or Biofilm Control Instruction
• Plaque or biofilm control is an essential component of successful
periodontal therapy, and instruction should begin at the first
treatment appointment.
• Before oral hygiene instruction, the patient must understand the
reason that he or she must actively participate in therapy.

11. • The explanation of the etiology of the disease must be presented
to the patient.
• Once the patient understands the nature of periodontal disease
and the etiology, it will be easier to teach the hygiene that he or
she must practice.
• The patient must be instructed on the correct technique to
remove the plaque or biofilm; this means focusing on applying
the bristles at the gingival third of the clinical crowns, where the
tooth meets the gingival margin.

12. • This technique is sometimes referred to as targeted oral hygiene
and is synonymous with the Bass technique.
• Instructions are also initiated for interdental cleaning with
dental loss and interdental brushes.
• The use of the multiple appointment approach to phase I
therapy is favored by many clinicians.

13. Step 2: Removal of Supragingival and Subgingival Plaque or
Biofilm and Calculus
• Removal of calculus is accomplished using scalers, curettes,
ultrasonic instrumentation, or combinations of these devices
during one or more appointments.
• Evidence suggests that the treatment results for chronic
periodontitis are similar for all instruments, which could be
hand instrumentation or other mechanical instruments, such
as ultrasonic scalers.

14. • Most clinicians advocate the combination of hand instruments
(scalers, curettes) and ultrasonic devices.
• In addition to calculus and plaque or biofilm removal, cementum
exposed to the pocket environment should be removed.
• At one time it was thought that the removal of all cementum was
necessary to attain a smooth, glassy, hard surface.

15. • The rationale was that cementum became necrotic from penetration of
endotoxins from the microbial biofilm and would interfere with healing.
• Laser treatment has also been advocated for periodontal therapy by some
clinicians.
• However, some reviews suggest that further well-designed studies are
needed to confirm the outcomes.
• In addition, gingival curettage, the systematic removal of the soft tissue
lining of the pockets, has not been shown to improve the results of
treatment.

16. • Another interesting approach to calculus removal and
debridement is full-mouth disinfection.
• In this technique, full-mouth treatment is performed during one
session or multiple sessions within a few days.
• Disinfectants are used after therapy, with the intention of
preventing reinfection of treated sites from untreated sites.
• This treatment approach is used during phase I therapy by some
clinicians, but then results have not been shown to be superior to
those of any other phase I therapy.

17. Step 3: Recontouring Defective Restorations
and Crowns
• Corrections of restorative defects, which are plaque or biofilm
retentive areas, may be accomplished by smoothing the rough
surfaces and removing overhangs from the faulty restorations
with burs or hand instruments, or complete replacement of the
failing restorations may be necessary.
• All these steps are important to remove the risk factors that
perpetuate the inflammatory process.
• These procedures can be completed concurrently with other
phase I procedures.

18. Step 4: Management of Carious Lesions
• Removal of the carious lesions and placement of either
temporary or permanent restorations are indicated in phase I
therapy because of the infectious nature of the carious process.
• Healing of the periodontal tissues is maximized by removing the
reservoir of bacteria in these lesions so that they cannot
repopulate the microbial plaque.

19. Step 5: Tissue Reevaluation
• After scaling, root planing, and other phase I procedures, the
periodontal tissues require approximately 4 weeks to heal.
• This time allows the connective tissues to heal, and accurate
probe depths can be measured.
• Patients will also have the opportunity to improve their home
care skills to reduce gingival inflammation and adopt new habits
that will ensure the success of treatment.

20. • At the re evaluation appointment, periodontal tissues are
probed, and all related anatomic conditions are carefully
evaluated to determine whether further treatment, including
periodontal surgery, is indicated.
• Additional improvement from periodontal surgical procedures
can be expected only if phase I therapy results in gingival tissues
that are free of overt inflammation and the patient has adopted
effective daily plaque or biofilm control procedures.

21. Results –
• Scaling and root planing therapy have been studied extensively
to evaluate their effects on periodontal disease.
• Many studies have indicated that this treatment is both
effective and reliable.
• Studies ranging from 1 month to 2 years in length
demonstrated up to 80% reduction in bleeding on probing and
mean probing depth reductions of 2 to 3 mm.

22. • In addition, deeper probing depths present the dentist with
greatly increased instrumentation challenges due to the
complexity of root anatomy and difficulty accessing the root
surfaces.
• Badersten and colleagues reported in the 1980s that
residual calculus remained on 44% of the surfaces in deeper
pockets.
• Other studies have confirmed these findings, including
studies comparing the use of hand instruments with that of
powered scaling instruments.

23. Healing –
• Healing of the gingival epithelium consists of the formation of a
long junctional epithelium rather than new connective tissue
attachment to the root surfaces.
• This long junctional epithelium occurs about 1 week after therapy.
• Gradual reductions in inflammatory cell population, crevicular fluid
low, and repair of connective tissue result in decreased clinical
signs of inflammation, including less redness and swelling.

24. • One or two millimeters of recession is often apparent as the
result of tissue shrinkage.
• Connective tissue fibers are disrupted and lysed by the disease
process and also by the inflammatory reaction to treatment.
• These tissues require 4 or more weeks to reorganize and heal,
and many cases may require several weeks for complete healing.

25. Decision to Refer for Specialist Treatment –
• It is fortunate that many periodontally involved cases do not require
any further therapy beyond phase I therapy.
• Therefore, these patients can be seen by general dentists for routine
maintenance therapy.
• However, advanced or complicated cases benefit from specialist care.
• Heitz-Mayield and Lang demonstrated that surgical treatment in
deep pockets, those >6 mm, gained 0.6 mm more probing depth
reduction and 0.2 mm more clinical attachment gain than did deep
pockets treated with scaling and root planing alone.

26. • This study also confirmed that in pockets of 4 to 6 mm probing
depth, scaling and root planing resulted in 0.4 mm more
attachment gain than surgical procedures, and shallow pockets
of 1 to 3 mm had 0.5 mm less attachment loss compared with
surgical results.

27. • The concept of the critical probing depth of 5.4 mm has been
advanced to assist in making the determination to proceed to
surgical intervention.
• This is the measurement above which therapy will result in
clinical attachment gain and below which it will result in
clinical attachment loss.

28. • When there is 5 mm of clinical attachment loss, the crest of
bone is about 7 mm apical to the cementoenamel junction, and
therefore only about half of the bony support for the tooth
remains.
• Periodontal surgery can help improve support for teeth in these
cases through pocket reduction, bone augmentation, and
regeneration procedures.

29. In addition to the 5-mm probing depth criterion, other factors
must be considered in the decision to refer to a periodontal
specialist:
1. Extent of the disease and generalized or localized periodontal
involvement. The amount of bone loss, even in localized areas,
suggests the need for specialized surgical techniques.
2. Root length. Short-rooted teeth are jeopardized to a greater
extent
by the 5-mm clinical attachment loss criterion than teeth with

30. 3. Hypermobility. Excessive tooth mobility suggests that
contributing
factors may be responsible for the mobility. The extent of mobility
could mean that the prognosis for the tooth may be guarded to
poor.
4. Dificulty of scaling and root planing. The presence of deep
pockets and furcations makes instrumentation dificult, but the
results
can often be improved with surgical access.

31. 5. Restorability and importance of particular teeth for reconstruction.
Long-term prognosis of each tooth is important when considering
extensive restorative work.
6. Age of the patient. Younger patients with extensive attachment loss
are more likely to have aggressive forms of disease that require
advanced therapy.

32. 7. Lack of resolution of inflammation after thorough plaque or
biofilm removal and excellent scaling and root planing. If
inflammation and progressive deepening of the pocket
continue, further therapy will be necessary. Such cases require
an understanding of the etiology to determine the best course
of treatment.

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