Phase-I therapy

DISCUSSION TOPIC: PHASE I PERIODONTAL THERAPY
UNDER ESTEEMED GUIDANCE OF:
PROF(DR) SUHAIL MAJID JAN (HOD)
DR ROOBAL BEHAL (ASSOCIATE PROF)
PRESENTED BY:
ZUBAIR AHMAD JANBAZ
VINEE KACHROO
MUDASIR GANI
MOHD IMRAN BHATT
1ST YEAR PGs

CONTENTS
 INTRODUCTION
 TREATMENT PLAN
 PHASE I THERAPY
 RATIONALE
 SEQUENCE OF PROCEDURES
1. PLAQUE CONTROL INSTRUCTIONS
2. REMOVAL OF SUPRAGINGIVAL AND SUBGINGIVAL CALCULUS/ANTIINFECTIVE THERAPY
3. RE-CONTOURING RESTORATIONS/PROSTHESIS
4. MANAGEMENT OF CARIOUS LESIONS
5. MINOR ORTHODONTIC MOVEMENT/OCCLUSAL THERAPY
6. EXTRACTION OF HOPELESS TEETH.
 CONCLUSION
 REFERENCES

INTRODUCTION
 The ultimate goal of periodontal therapy is to restore the periodontium
to A state of health which includes comfort, function and esthetics.
 This is made possible by rational and meticulous treatment planning that
addresses the intricacies involved in pathogenesis and progression of
periodontal disease
 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.

TREATMENT PLAN
 In Every Patient Diagnosed With Periodontitis, A Treatment Strategy
Based On The Relevant Findings.
 Periodontal Treatment Plan Is Developed Using A Tetraphasic Model
(CARRANZA & TAKEI 2012)
 A Logical Treatment Plan Is Based On Eliminating The Cause Of Disease.

Periodontal therapy is an inseparable part of dental therapy, and all treatments must be
well coordinated.
Phase I, or the nonsurgical phase, is directed to the elimination of the etiologic factorsof
dental, gingival, and periodontal diseases.
Immediately after completion of phase I therapy, the patient should be placed on the
maintenance phase (phase IV) to preserve the results obtained and prevent any further
deterioration and recurrence of disease.
On periodic evaluation of the maintenance phase, the patient enters into the surgical
phase (phase II)and the restorative phase (phase III)of treatment.
Phase I, or the Nonsurgical phase.
Phase II, or the Surgical phase.
Phase III, or the Restorative phase.
Phase IV, or the Maintenance phase.
SEQUENCE OF THERAPY

Emergency phase
Non-Surgical phase
Maintenance Phase
Restorative phase
Surgical phase

PHASE I THERAPY
 First Step In The Chronological Sequences Of Procedures That Constitute
Periodontal Treatment.
 It Is Also Referred By Many Other Names : INITIAL THERAPY
NON SURGICAL THERAPY
CAUSE RELATED THERAPY
ETIOTROPIC PHASE OF THERAPY
 Cause-related Phase I Periodontal Therapy Has Been Succinctly Stated As
The Approach Aimed At Removal Of Pathogenic Biofilms, Toxins, And
Calculus And The Reestablishment Of A Biologically Acceptable Root
Surface

RATIONALE
• Phase I therapy is a critical aspect of periodontal treatment. Data
from clinical research indicate that the long-term success of plaque
or biofilm control results achieved with phase I therapy. In fact,
patients who do not have adequate plaque or biofilm control will
continue to lose attachment regardless of what surgical procedures
are performed.
• In addition, phase I therapy provides an opportunity for the dentist
to evaluate tissue response and provide reinforcement about home
care, both of which are crucial to the overall success of treatment.
• The cause and effect relationship between supragingival plaque and
gingivitis was demonstrated by Loe and his colleagues in 1965.

 Based On The Knowledge That Microbial Plaque Or Biofilm Is The Major
Etiologic Agent In Gingival Inflammation, One Specific Aim Of Phase I Therapy
For Every Patient Is Effective Daily Plaque Or Biofilm Removal At Home.
 The Removal Of Microbial Plaque Leads To Cessation Of Inflammation And
Stopping Plaque Control Measures Leads To Recurrence Of Inflammation.
 When plaque is allowed to accumulate , gingivitis developed within 21 days
when plaque control is initiated the gingivitis is reversed to clinical health
within a week.

 Plaque Control Is The Key Objective Of Every Therapeutic Periodontal
Procedure, But It Can Be Effectively Accomplished Only If The Tooth
Surfaces Are Free Of Rough Deposits And Irregular Contours So That
They Are Readily Accessible To Oral Hygiene Aids.

Phase I therapy achieves a reduction or elimination of etiologic factor
by increasing the cleansable area of the tooth surface

Goals of phase I therapy
 GOAL 1: TO MINIMIZE THE BACTERIAL CHALLENGE TO THE PATIENT.
1. Removal Of Calculus Deposits And Bacterial Products
2. Training Of Patients In Self Care Techniques
3. Antimicrobials
 GOAL 2: TO ELIMINATE OR CONTROL LOCAL CONTRIBUTING FACTORS FOR PERIODONTAL DISEASE
1. Hopeless Tooth
2. Habits
3. Unfavourable Tooth Alignment
4. Defective Restorations/Prosthesis

 GOAL 3: TO MINIMIZE THE IMPACT OF SYSTEMIC FACTORS
 GOAL 4: TO STABILIZE THE ATTACHMENT LEVEL.

SEQUENCE OF PROCEDURES
 1. PLAQUE CONTROL INSTRUCTIONS
 EDUCATION AND MOTIVATION
 MECHANICAL PLAQUE CONTROL
 CHEMICAL PLAQUE CONTROL
 DIET COUNSELING

 2. REMOVAL OF SUPRAGINGIVAL AND SUBGINGIVAL CALCULUS/ANTI INFECTIVE THERAPY
 PROFESSIONAL SCALING AND ROOT PLANNING
 LOCAL DRUG DELIVERY
 SYSTEMIC ANTIMICROBIALS

 3. RECONTOURING RESTORATIONS/PROSTHESIS
 4. MANAGEMENT OF CARIOUS LESIONS
 5. MINOR ORTHODONTIC MOVEMENT/OCCLUSAL THERAPY
 6. EXTRACTION OF HOPELESS TEETH

1. Education &
Plaque Control
2. Scaling & Root
planing
3. Remove local
factors
4. Treat/temporize
carious lesions
6. Re-evaluation
5. Adjunctive
aids
3. Remove local
factors

STEP
. 1 PATIENT EDUCATION &PLAQUE
CONTROL

PLAQUE/BIOFILM CONTROL INSTRUCTIONS
 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.
 The Explanation Of The Etiology Of The Disease Must Be Presented & 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. This Technique Is Sometimes Referred To As
Targeted Oral Hygiene (Takei H: Personal Communication, 2009) And Is Synonymous With The
Bass Technique.

 The process of periodontal treatment and maintenance requires:
1. Interest and Motivation on the part of patient.
2. Counseling, education and instructions from the dentist.
3. Encouragement and reinforcement of proper behaviors and skills.
MOTIVATIONAL INTERVIEWING:
“A client centered directive method of enhancing intrinsic motivation to change by exploring
and resolving ambivalence” (Miller & Rollnick 2002)
 The dentist invites the patient to describe his or her own view and then modulates them to
facilitate a particular behavioral outcome.

 Patient education:
 The Patient Should Be Educated Regarding The Development Of Periodontal Disease And Shown
How It Has Manifested In The:
a. Stained dental plaque
b. Bleeding of inflamed gums
c. Probing of pockets
 Plaque control record and Bleeding points index are simple indices often used for patient
education and motivation.

Oral hygiene instructions
 Importance Of Daily Disruption Dental Plaque.
 Share/Discuss With The Patient The Findings Of Periodontal Charting, I.E. BOP, Radiographs
(Bone Level).
 Illustrate The Locations Of Plaque In The Dentition (Disclosing Solution).
 Review/Modify Patient’s Tooth Brushing Technique. Introduce Additional Oral Hygiene Aids As
Needed, But In Step By Step Fashion.

Plaque Control methods
Mechanical Chemical

PLAQUE CONTROL METHODS
Mechanical
methods
Toothbrush
• Manual
• Powered
Dentifrices
Interdental Aids
• dental floss
•toothpick
•interproximal brush
Oral Irrigation
supragingival
subgingival

Mechanical plaque control instructions
TOOTH BRUSHING: (design)
 Several studies have investigated difference in plaque removal between brushes with different
handle design. In such studies brushes with long and contoured handles appeared to remove
more plaque than brushes with traditional handles. (Saxer & Yankell 1997)
 However comparison between brands and different available toothbrush designs are largely
inconclusive, and hence in the absence of this evidence the best toothbrush continues to be the
one that is used by the patient properly. (Cancro & Fischman 1995; Jepsen 1998)
 On average 60% of plaque is left after self performed brushing (De le Rosa et al 1979, Morris
2001)
 The morphology of the dentition (crowding, spacing, gingival phenotype etc) the type and
severity of periodontal tissue destruction as well as patient’s own manual dexterity determine
what kind of cleaning techniques are to be recommended.

TECHNIQUE:
 The ideal brushing technique is the one that allows complete plaque removal in the least possible
time , without causing damage to the tissues. (Hansen & Gjermo 1971)
 The method most often recommended is the BASS TECHNIQUE because it emphasizes sulcular
placement of bristles and access to subgingival plaque.
 In studies on teeth scheduled for extraction with use of this brushing technique the plaque removal
was found to reach a depth of approximately 1mm subgingivally.(Waerhaug 1981)
TOOTH BRUSHING TIME
 The best estimate of actual manual tooth brushing time seems to range between 30 to 60 secs.
(Van der Weijden et al 1993)
 If plaque is allowed to accumulate freely in dentogingival region subclinical signs of gingival
inflammation appear within 4 days. The minimum frequency of tooth cleaning to reverse
experimentally induced gingivitis is once everyday or every second day. (Egelberg 1964)

 Straube et al (1998) found that plaque must be completely removed at least once every 48 hrs to
prevent inflammation.
POWERED TOOTHBRUSHES:
 Two independent systematic reviews confirmed that oscillating rotating toothbrushes have
superior efficacy over manual toothbrushes in reducing plaque and gingivitis (Sicilia et al 2002;
Robinson et al 2005)
ELECTRIC AND ELECTROCHEMICAL TOOTHBRUSHES
 Brushes that convey imperceptible electronic current through brush head to enhance the efficacy
of plaque elimination have been developed. The electrons should reduce the H+ ions from the
organic acid in the plaque which may result in decomposition of the bacterial plaque.
 Some short term clinical studies with the use of these kinds of brushes documented a beneficial
effect in terms of plaque reduction and gingivitis resolution. (Hoover et al 1992; Weiger 1998)

RECOMMENDATIONS
Manual toothbrushes:
 Soft nylon bristles clean effectively when used properly. Hard bristles have more chances to cause
trauma , abrasion and gingival recession
 Brush twice a day
 Minimum of 2 mins brushing
 Toothbrush should be replaced every 3-4 months
POWERED TOOTHBRUSHES:
 Oscillating rotating brushes are better
 Patients who are poor brushers, childrens, and caregivers may particulary benefit for using
powered brushes.

Brushing technique
 Targeted hygiene which focuses on cervical and interproximal areas should be practiced. Usually
the bass method is recommended; for patients with gingival recession / after periodontal
surgery the charter’s method is used.
 Brushing should be practiced for minimum of 2 mins daily , twice a day.
 Patient may modify any technique to their needs as long as the goal of brushing until teeth are
free of plaque is achieved .

DENTRIFICES
“Substances used with a toothbrush for the purpose of cleaning accessible surfaces of teeth”- ADA
Council on Dental Therapeutics.
RECOMMENDATIONS:
 Dentrifices increases the effectiveness of brushing but should cause a minimum of abrasion to
root surfaces.
 Products containing flourides and antimicrobial agents provide additional benefits for controlling
caries and gingivitis.
Recommendations for Interdental aids:
 Often a toothbrush and dental floss are not sufficient to clean interdental space , so it is extremely
important to find a suitable interdental cleaning device that the patient likes and will use.
 Patient may need to try several devices before discovering the most acceptable one.

Gingival irrigation
 Useful adjuvant to supplement and enhance other homecare methods.
 The strongest and most consistent evidence for the benefit of daily use of dental water jet is the
ability of device to reduce gingivitis and bleeding. (Cutler et al 2000)
 Shown to disrupt and detoxify subgingival plaque and can be useful in delivering antimicrobial
agents. (AAP, 2005)
MECHANISM OF ACTION:
 Works through direct action of a pulsed stream of water solution
 Pulsation of 1200/min creates two zones of hydrokinetic activity
1. Impact zone- solution initially contacts gingiva
2. Flushing zone- solution reaches subgingival sulcus

INSTRUCTIONS FOR GINGIVAL IRRIGATION:
SUPRAGINGIVAL IRRIGATION:
 Aim the pulsating jet across the proximal papilla and hold it for 10 – 15 secs
 Trace along the gingival margin to next proximal surface
 Use from both buccal and lingual surfaces
SUBGINGIVAL IRRIGATION:
 Insert the tip gently below gingival margin . 3mm if possible
 Flush each pocket for few seconds
 Use from both buccal and lingual surfaces

RECOMMENDATIONS:
• Home irrigation is safe and effective for a wide variety of patients including those
in periodontal maintenance, calculus buildup, gingivitis, orthodontic appliances,
maxillary fixation and crown and bridge.
• Subgingival irrigation with specialized tips for deep pockets and furcation areas.
• Patients requiring Antibiotic prophylaxis for dental treatment should use
supragingival technique.

CHEMICAL PLAQUE CONTROL
Various clinical studies have shown:
 Additional benefit to control oral malador (Pitts et al.1983; Boever & Loesche 1995)
 Enhancement of the benefits of oral irrigation. (Flemming et al 1989)
 Improvement of gingival health around implants. (Ciancio et al 1995)
 Reduction in plaque and gingivitis in orthodontic patients. (Brightman et al 1991)
 Reduction in bacteria in saliva and dental aerosola when used preprocedurally. (Fine et al 1993)
 Acts as support of early healing after gingival flap surgery. (Zambon et al 1989; Sanz et al 1989)
 Prolongations of effects of mechanical therapy (Fine et al 1985)

RATIONALE:
 The rationale for the use of chemical antiplaque agents is based on two premises:
1. Plaque is a major etiological factor in gingivitis (Loesche 1987)
2. Studies have shown mechanical cleaning methods used are inadequate (Morris et al 2001)
 There appears to be a consensus that antiplaque agents cannot replace conventional
mechanical plaque removal methods but should be used as adjunts to mechanical cleaning
(Andy & Moron 2005)
GENERAL INDICATIONS :
1. Poor mechanical plaque control due to lack of dexterity
2. Post operatively
3. Orthodontic patients
4. Extensive fixed bridge work
5. Intraoral fixation
6. Mentally and physically challenged

RECOMMENDATIONS FOR CHEMICAL PLAQUE CONTROL
 Chemical plaque control can augment mechanical plaque control and reduce gingivitis
 CHX rinses can be used to augment plaque control during Phase I therapy, for patients with
recurrent disease, and for use after oral surgery.
 Essential oil rinses are effective to a lesser degree than CHX, have fewer side effects and are
available without prescription
 Oral irrigators with dilute solutions of effective antimicrobials agents can be used to reduce
gingivitis.

Diet counselling
 Periodontal screening and recording guidelines of AAP implicate nutritional counselling for control
of dental diseases as a step in the first hour of patient interaction, therefore the clinician should be
rightly equipped with the facts relating periodontal health to nutrition, So that proper diet
counselling can be provided and the patient’s doubt be clarified.
ROLE OF NUTRITION IN PERIODONTAL DISEASE:
 Peter 2014; when local factors are conducive to the production of periodontal disease in man it is
believed that the increase in destructive process is determined by constitutional factors of which
nutritional status may be an important factor.
 A periodontal lesion is essentially a wound & sufficient host resources must be available for optimal
healing
 The local nutrient requirement of periodontal tissues may be considerably increased compared with
other tissues. It is conceivable that inadequate nutrient levels in this tissue may result in “end organ”
deficiency, causing impairment of the repair process and facilitating the progression of periodontal
disease.
(Mealy et al.2004)

 Hence the main targets in nutritional deficiency may be:
 Epithelial barrier and Attachment
 Periodontal ligament
 Gingival connective tissue
 Alveolar bone
 Cellular and Humoral immunity
 Inflammatory response
 Composition of GCF/ Saliva

ANTI INFECTIVE THERAPY:
Professional periodontal care consists primarily of oral hygiene instruction and
non surgical anti infective therapy (Listgarten et al.1985; Wilson 1996). Anti
infective therapy includes both Mechanical and Chemotherapeutic approaches.

Mechanical approach
 The term mechanical therapy refers to both supragingival and subgingival scaling as well as root
planning. In theory, these procedures are different but clinically, the difference between scaling
and root planning is really a matter of degree (Cobb,1999)
 The term periodontal debridement was suggested by Smart et al (1990) to describe the light
overlapping strokes used for instrumenting the root with a sonic/ultrasonic scaler.
 The end point of all periodontal debridement is to produce a root that is biologically acceptable
for a healthy attachment (Drisko,2001)

• Scaling is the process by which plaque and calculus are
removed from both supragingival and subgingival tooth
surfaces . No attempt is made to remove tooth substance
along with calculus
(Pattison & Pattison,2015)
• Root planning :
the process by which residual embedded calculus and
portion of cementum are removed from the roots to
produce a smooth ,hard and clean surface.
(Pattison & Pattison,2015)
SCALING AND ROOT PLANNING

OBJECTIVE
 The primary objective of scaling and root planning is to restore gingival
health by completely removing elements that provoke gingival
inflammation (i.e. biofilm, calculus and endotoxin)
[Pattison & Pattison 2015]

 Factors that may influence calculus
Removal include :
I. The extent of disease,
II. Anatomic factors,
III. Skill of the operator,
IV. Instruments used.

a. Hand Instruments
c. Laser d. Photodynamic therapy
b. Powered Instruments

 Access to the root surface
The root surface are not easy to access because limitation of penetration of
instruments.
 In subgingival access.
Scaling and root planing skills is needed.
 In deep pockets .
Open procedure may be needed.

 Supra gingival scaling technique:
Sickles ,curettes ,and ultrasonic and sonic instrument are most commonly used for
removal of supragingival calculus .
 Sub gingival scaling and root planning technique:
The curette is preferred by most clinicians because of the advantages afforded by its
design.

Assesibility
Visibility, illumination and Retraction
Maintaining a clean field
Instrument stabilization ( instrument grasp & rests)
Modified pen grasp

Finger rest
• As close as possible to the site of instrumentation
• To facilitate controlled use of the instrument
• Provides:
(1) stable fulcrum,
(2) permit optimal angulation of the blade,
(3) enable the use of wrist–forearm motion .
 Instrument activation
(Adaptation, Angulation and lateral pressure)

Cutting position: The shank of the curette held parallel to the long axis of the tooth during
instrumentation of a posterior site.
Activation:
 The grasp of the instrument is tightened somewhat, the force between the cutting edge
and the root surface is increased, and the blade is moved in a coronal direction.
 Strokes must be made in different directions to cover all aspects of the root surface
(crosswise, back and forth) but, as stated above, strokes should always start from an apical
position and be guided in a coronal direction.

SUPRAGINGIVAL SCALING TECHNIQUE:
• Sickle or Curette is held with modified pen grasp
• Firm finger rest is established
• Blade is adapted with an angulation slightly less than 90 degrees.
• Cutting edge should engage the apical margin of the supragingival calculus
while Short , powerful , overlapping scaling strokes are activated coronally in
vertical or oblique direction.

SUBGINGIVAL SCALING TECHNIQUE:
• Subgingival instrumentation should preferably be performed under LA
• Curette is held with modified pen grasp and stable finger rest is established.
• Cutting edge is slightly adapted to the tooth with lower shank kept parallel to the tooth
surface.
• Working angulation is between 45 to 90 degrees.
• Calculus is removed by series of controlled overlapping , short powerful pull strokes
• Strokes should be confined to the portion of the tooth where calculus or altered cementum
is found “instrumentation zone”. Sweeping the instrument over the crown where it is not
needed wastes the operating time, dulls the instrument and causes loss of control.

The optimal angle between the cutting edge and the tooth is approximately 45-90
degrees
Too obtuse an angle, will result in cratering and consequent roughening of the root
surface.
Too acute an angle, will result in ineffective removal and burnishing of subgingival
calculus deposits.

Powered instruments
 Sonic scalers:
 Use air pressure
 The frequencies of vibration ranging from
2000–6000 Hz.

Ultrasonic scalers:
• Convert electrical current to mechanical energy in the form of high-frequency
vibrations at the instrument tip;
• The vibration frequencies ranging from 18 000–45 000 hz.
 Piezoelectric scalers
• Alternating electrical current
• Pattern of vibration is linear
 Magnetostrictive scalers
• Electrical current  magnetic field in the handpiece  the insert to vibrate.
• The pattern of vibration at the tip is elliptical.

Ultrasonic scaling:
Ultrasonic instrument have been used as a valuable adjunct to conventional hand
instrumentation .
Uses of Ultrasonic scaling devices :
1- Scaling and gingival curettage .
2-Removal of stains .
3- Remove overhangs and excess cement

Contraindications of ultrasonic scaling:
 Patient with cardiac pacemaker .
 Patients with Known communicable diseases .
 Chronic pulmonary problems.
 Porcelain bounded restoration .
 Patient with Titanium implant ( plastic-tipped ultrasonic and
sonic insert and Teflon-coated sonic scaler tips are available)

LIMITATIONS:
 Meticulous and requires more experienced operator .
 Time consuming(×2 the time needed for surgery)
 Less predictable in deep pockets ,furcations and interproximal groove.
 Ineffective as mono therapy in the treatment of aggressive
periodontitis .

Pain
Dentine hypersensitivity
The extent of the sensitivity can be diminished through good plaque
removal.
Higher in pre-existing sensitivity, intensity decrease with time
Gingival recession
Warning patients about these potential outcomes at the beginning of
the treatment sequence will avoid surprise if these changes occur.
Unexpected and possibly uncomfortable consequences to treatment
may result in distrust and loss of motivation to continue therapy.
POST TREATMENT COMPLICATIONS

• From a clinical standpoint, minimizing the total volume of dental calculus
present seems to be desirable. However, aggressive tooth substance
removal does not seem warranted.
• (Claffey et al. 2004)
• There was no difference between hand and powered instrumentation in
deposits removal and improved clinical parameters.
• (Badersten et al.1981,loos et al . 1987,Laurell et al . 1988)
• There was no difference between hand and powered instruments in the
treatment of class I furcation involved areas , while powered instruments
were more effective than hand instruments in class II and III furcation due
to smaller tip size
• (Matia et al .1986 ,Leon &Vogel 1987)

• Endotoxins are superficially attached to the root surface and can be removed by
brushing (Moore et al .1986),polishing (Nyman et al .1988) or light overlapping
strokes with ultrasonic scalers (smart et al .1990)
• The critical probing depth for scaling and root planing is 2.9 mm ± 0.4 and for
periodontal surgery is 4.2 mm ± 0.2 (Lindhe et al .1982 )
• Scaling and root planing did not result in total removal of subgingival calculus
particularly in deep pockets ( Rabbani et al .1981)

Ablative Laser therapy
 Carbon dioxide lasers
 Er:YAG lasers
 Nd:YAG lasers

Ablative laser therapy
Advantages:
 It has bacteriocidal and detoxification effects.
 Can remove the epithelium lining and granulation tissue within the periodontal pocket
which may potentially improve healing.
 Removing plaque and calculus with extremely low mechanical stress and no formation
of a smear layer on root surfaces.
 May allow access to sites that conventional mechanical instruments cannot reach.

Ablative Laser therapy
 Carbon dioxide lasers
o When used with relatively low energy output in a pulsed and/or
defocused mode
o Have root conditioning, detoxification, and bacteriocidal effects
on contaminated root surfaces.
o However, at low energy outputs they are unable to remove
calculus.
 Er:YAG lasers
o Are capable of effectively removing calculus from the root
surface.
o Energy is absorbed by water and organic components of the
biological tissues which causes their evaporation resulting in
heat generation, water vapour production, and thus an increase
in internal pressure within the calculus deposits. The resulting
expansion within the calculus causes its separation from the root
surface

Ablative laser therapy
 Use of lasers produces results comparable to scaling and root planing .
 Benefit of the use of lasers over scaling and root planing alone has been
demonstrated.
(Schwarz et al. 2003; ambrosini et al. 2005)
 Currently there is minimal evidence to support use of a laser for the purpose of
subgingival debridement either as monotherapy or adjunt to s/rp.

 Precautions:
 Inadvertent irradiation and reflection from shiny metal surfaces may cause damage to patient’s
eyes, throat, and oral tissues other than the targeted area.
 Risk of excessive tissue destruction by direct ablation and thermal side effects.
 Also the high cost of the laser apparatus is a drawback for many

PDT principle
Int Poster J Dent Oral Med 14 (2012), No. 1,
Poster 587

Photodynamic therapy (PDT)
 Advantages:
 Pdt is non-invasive local therapy,
 PDT offers thorough irrigation and elimination of pathogens in inaccessible areas
of periodontal pocket within short span of time, thus beneficial to both operator
and the patient.
 The risk of bacteraemia after periodontal debridement can be minimized.
 There is no need to prescribe antibiotics, therefore the possibility of side effects is
avoided.
 There is no need to anaesthetize the area and destruction of bacteria is achieved
in a very short period (<,60 seconds).

Photodynamic therapy (PDT)
 Antimicrobial photodynamic therapy acts as a beneficial adjunct to srp in non-
surgical treatment and management of chronic periodontitis in short-term.
 Further studies are required to assess the long-term effectiveness of a pdt.
(Sgolastra et al. 2013, Betsy et al. 2014)

Choice of method used
 In contrast to hand instrumentation, the use of
Sonic and ultrasonic scalers is less technique sensitive,
Requires less time to complete, and removes less
Root surface cementum. It has been shown to provide better access to deep pockets and furcation areas.
(Kocher et al. 1998; beuchat et al. 2001).
 In addition the flushing action of water used in sonic and ultrasonic scalers removes, to a certain extent,
debris and bacteria from the pocket area. However, tactile sensation is reduced, and there is production of
contaminated aerosols
(harrel et al. 1998; barnes et al. 1998; rivera-hidalgo et al. 1999; timmerman et al. 2004).
 Some patients may find the vibration, sound, and water spray uncomfortable.

 Corrections for restorative defects,
which are plaque traps, may be made
by smoothing surfaces and
overhangs with burs or hand
instruments or by replacing
restorations.
 These procedures can be completed
concurrently with other phase I
procedures.

EVA SYSTEM
 Most efficient and least traumatic instruments
for correcting overhangs or overcontoured
proximal alloy or resin
 These files are made of aluminum in the shape
of a wedge protruding from a shaft.
 Reciprocating handpiece.

 Removal of the carious tissue and placement with either temporary or permanent
restorations is indicated in phase i therapy because of the infectious nature of the
caries process.
 Healing of the periodontal tissues will be maximized by removing the reservoir
of bacteria in these lesions so that they cannot repopulate the microbial plaque.

Caries Control
 Dental caries, particularly root caries, is a problem for periodontal patients because of attachment loss associated
with the disease process and periodontal therapeutic procedures
 Fluoride works primarily by topical effects to prevent and reverse the caries process, whether in enamel,
cementum, or dentin.
 Low concentrations of topical fluoride inhibit demineralization, enhance remineralization, and inhibit the enzyme
activity in bacteria by acidifying the cells
 All periodontal patients should be encouraged to use a fluoride-containing toothpaste daily, 1000 to 1100 ppm, to
reduce demineralization and enhance remineralization of tooth surfaces.
 Patients at high risk for caries, including those with a history of root lesions or who have active lesions, should use
higher-concentration fluoride toothpaste or gels, 5000 ppm, daily until the risk for caries is controlled, then
maintain with the lower concentration toothpastes and mouthrinses.
 Other considerations in caries control, such as diet and reduced salivary flow, should be evaluated as with all
dental patients.

 Anti-infective therapy: systemic & local
 Host modulation therapy
 Orthodontic treatment

 An anti-infective agent is a chemotherapeutic agent that acts by reducing the
number of bacteria present
 Antibiotics, antimicrobials, antiseptics, disinfectants
 Locally, orally or systemically

Systemic Antibiotics
 An ideal antibiotic for use in prevention and treatment of periodontal diseases should be:
I. Specific for periodontal pathogens,
II. Allogenic and nontoxic,
III. Substantive,
IV. Not in general use for treatment of other diseases,
V. Inexpensive.
 Currently, an ideal antibiotic for the treatment of periodontal diseases does not exist.
 Although oral bacteria are susceptible to many antibiotics, no single antibiotic at concentrations
achieved in body fluids inhibits all putative periodontal pathogens.
 Indeed, a combination of antibiotics may be necessary to eliminate all putative pathogens from
some periodontal pockets

 The treatment of periodontal diseases is based on the infectious nature of these
diseases .
 Ideally, the causative microorganism(s) should be identified and the most effective
agent should be selected using antibiotic-sensitivity tests.
 Although this appears simple, the difficulty lies primarily in identifying specific
etiologic microorganism(s) rather than microorganisms simply associated with
various periodontal disorders.

Rationale
 Systemic antibiotics aims to reinforce mechanical treatment and to support host
defences in ovcercoming periodontal infections by killing subgingival pathogens
remaining after periodontal instrumentation
 Pathogens may escape the effect of mechanical debridement because of their
ability to invade periodontal tissue, to reside in anatomical tooth structure
inaccessable to instrumentation, or as a result of poor host defense
( position paper. J periodontol 2004; 75:1553-1565)

Systemic antibiotics
Regimen Dosage/Duration
Single Agent
Amoxicillin 500 mg Three times daily for 8 days
Azithromycin 500 mg Once daily for 4–7 days
Ciprofloxacin 500 mg Twice daily for 8 days
Clindamycin 300 mg Three times daily 10 days
Doxycycline or minocycline 100–200 mg Once daily for 21 days
Metronidazole 500 mg Three times daily for 8 days
Combination Therapy
Metronidazole + amoxicillin 250 mg of each Three times daily for 8 days
Metronidazole + ciprofloxacin 500 mg of each Twice daily for 8 days
TABLE 47-2 -- Common Antibiotic Regimens Used to Treat Periodontal Diseases*

A. Subgingival Chlorhexidine
B. Tetracycline-Containing Fibers
C. Subgingival Doxycycline
D. Subgingival Minocycline
E. Subgingival Metronidazole

Tetracyclin- containing fibers

Tetracyclin- containing fibers
 An ethylene/vinyl acetate copolymer fiber (diameter, 0.5 mm) containing tetracycline.
 When packed into a periodontal pocket, it was well tolerated by oral tissues, and for 10 days it sustained
tetracycline concentrations exceeding 1300 µg/ml, well beyond the 32 to 64 µg/ml required to inhibit the
growth of pathogens isolated from periodontal pockets.
 In contrast, gcf concentrations of only 4 to 8 µg/ml were reported after systemic tetracycline administration,
250 mg qid for 10 days.
 Tetracycline fibers applied with or without scaling and root planing reduced probing depth, bleeding on
probing, and periodontal pathogens and provided gains in clinical attachment level.
 Such effects were significantly better than those attained with scaling and root planing alone or with placebo
fibers.
 No change in antibiotic resistance to tetracycline was found after tetracycline fiber therapy among the tested
putative periodontal pathogens. However, these fibers are no longer commercially available.

Doxycyclin gel
 A gel system using a syringe with 10% doxycycline (atridox)
10% doxycycline (Atridox) gel.

Metronidazole (Elyzol 25%)
 It is applied in viscous consistency to the pocket,
where it is liquidized by the body heat and then
hardens again, forming crystals in contact with
water. As a precursor, the preparation contains
metronidazole-benzoate, which is converted
into the active substance by esterases in GCF.
 Two 25% gel applications at a 1-week interval
have been used.
 Metronidazole gel is equivalent to scaling and
root planing but have not shown adjunctive
benefits with scaling and root planing.

Minocycline microspheres
 The 2% minocycline is encapsulated into
bioresorbable microspheres in a gel carrier.
 Sustained release
 This product is available in the us and a
number of other countries.
 When compared to controls (scaling and root
planing with nonactive vehicle as subgingival
irrigant), there was a statistically significant
increase in clinical attachment levels in patients
who presented with pockets of 6 mm or
greater probing depth
minocycline microspheres (Arestin).

Chlorhexidine chip
 Periochip is a small chip (4.0 × 5.0 × 0.35 mm)
composed of a biodegradable hydrolyzed
gelatin matrix.
 2.5 mg CHX incorporated
 This delivery system releases chlorhexidine and
maintains drug concentrations in the gcf greater
than 100 µg/ml for at least 7 days,
concentrations well above the tolerance of most
oral bacteria.
 Because the chip biodegrades in 7 to 10 days, a
second appointment for removal is not needed chlorhexidine gluconate chip (PerioChip)

 Adjuncts to scaling and root planing
 A recent systematic review concluded “adjunctive local therapy generally reduced probing depth levels. Differences
between treatment and srp-only groups in the baseline to follow up period typically favored treatment groups but usually
only modestly (e.G., From about 0.1 mm to nearly 0.5 mm). Effects for clinical attachment level gains were smaller
(bonito 2005)
 American academy of periodontology stated:
 “the clinician's decision to use locally delivered agents (lda) should be based upon a consideration of clinical findings, the
patient's dental and medical history, scientific evidence, patient preferences and advantages and disadvantages of
alternative therapies.”
 The report also stated that use of ldas may be of value when probing depths greater than 5 mm with inflammation are still
present after conventional therapy. However if multiple sites are present in the same quadrant, therapy other than ldas
should be considered.

MINOR ORTHODONTIC TOOTH MOVEMENT
 The objective of phase I therapy is to create an environment that is more self cleaning and less
conducive to harbouring pathogenic bacteria. Hence with use of tooth movement further
elimination of plaque retentive areas can be accomplished and the clinician can dramatically
improve the local environment of periodontium.

Malocclusions predisposing to periodontal
disease

Periodontal maintenance during orthodontic
movement
1. Maintaining attached gingiva:
 Gingival recession can result from labial movement of teeth.
 Sufficient width of attached gingiva should be present.
 Soft tissue graft may be needed.
2. Oral hygiene:
 Fixed appliance makes hygiene difficult
 Periodic assessment and reinforcement
3. Occlusal relationships.

Periodontal problems during orthodontic
treatment
 Gingival hyperplasia
 Black triangles
 Root proximity and root resorption
 Periodontal pocket at extraction site
 Gingival recession
 Orthodontic bands that extent subgingivally
 Elastomeric rings

Orthodontic therapy can provide several benefits to the adult periodontal patient. The
following six factors should be considered:
1. Aligning crowded or malposed maxillary or mandibular anterior teeth permits the adult
patient better access to clean all surfaces of their teeth adequately. This could be a
tremendous advantage for patients who are susceptible to periodontal bone loss or do
not have the dexterity to maintain their oral hygiene.

2. Vertical orthodontic tooth repositioning can improve certain types of osseous defects in
periodontal patients. Often, the tooth movement eliminates the need for resective osseous
surgery.
3. Orthodontic treatment can improve the aesthetic relationship of the maxillary gingival
margin levels before restorative dentistry. Aligning the gingival margins orthodontically avoids
gingival recontouring, which could require bone removal and exposure of the roots of the
teeth.

4. Orthodontic therapy also benefits the patient with a severe fracture of a maxillary
anterior tooth that requires forced eruption to permit adequate restoration of the root.
Erupting the root allows the crown preparation to have sufficient resistance form and
retention for the final restoration.
5. Orthodontic treatment allows open gingival embrasures to be corrected to regain lost
papilla. If these open gingival embrasures are located in the maxillary anterior region, they
can be unesthetic. In most patients, these areas can be corrected with a combination of
orthodontic root movement, tooth reshaping, and restoration.
6. Orthodontic treatment could improve adjacent tooth position before implant
placement or tooth replacement. This is especially true for the patient who has been
missing teeth for several years and has drifting and tipping of the adjacent dentition.

OCCLUSAL THERAPY
 Occlusal therapy constitutes a delibrate interaction for the purpose of change of occlusal status.
 In person with healthy periodontium
EXCESSIVE OCCLUSAL FORCES
HEALTHY PERSON
ADAPTATION/REPAIR/RE
MODELLING WITH NO
LOSS OF ATTACHMENT
PERIODONTITIS
AMPLIFICATION OF
DISEASE AND DAMAGE
TO PERIODONTIUM

 GOALS OF OCCLUSAL THERAPY:
 To control the load that a tooth receives, so that periodontium is not overstressed.
 To improve occlusal stability and occlusal comfort
 To control the amount of loading that occurs at the TMJ.
 To produce an occlusal relationship with no pathologic symptoms for the muscles of
mastication.
 To improve aesthetics

INDICATIONS
 Trauma from occlusion
 Bruxism , muscular dysfunction
 Some forms of TMJ pathosis
 Need to improve functional relation , increase masticatory efficiency ,produce an
even disributon of occlusal stress
 Food impaction
 Increased/ Increasing tooth mobility
 Dental pain associated with occlusion
 Uneven marginal ridges
 Occlusal soft tissue injury

OCCLUSAL EQUILIBRATION
• According to World Workshop of the American Academy of Periodontology some
guidelines for situations when occlusal equilibration are indicated:
 When there are occlusal contact relationships that cause trauma to the periodontium,
joints, muscles or soft tissues
 When there are interferences that aggravate parafunction
 As an aid to splint therapy

FOUR PARTS OF OCCLUSAL EQUILIBRATION
 Reduction of all contacting tooth surfaces that interfere with the
completely seated condylar position
 Selective reduction of tooth structure that interferes with lateral excursion
 Elimination of all posterior tooth structure that interferes with protrusive
excursion
 Harmonization of the anterior guidance

CORONOPLASTY
 It is the selective reduction of occlusal areas with the primary purpose of
influencing the mechanical contact conditions and the neural pattern of sensory
input. KROGH,1968
 It is based on the premise that tissue damage and excessive tooth mobility caused
by occlusal forces are resolved when undesirable occlusal forces are corrected .
KARLSEN 1972

OBJECTIVES
 To direct the occlusal forces along the long axis of teeth
 To maintain simultaneous contact of all teeth in centric relation
 To eliminate any occlusal contact on inclined planes to enhance the positional
stability of the teeth
 To have centric relation coincide with the maximum intercuspation position
 To arrive at the occlusal scheme selected for the patient

OCCLUSAL ADJUSTMENT
 The clinical goal of Intercuspal position and Retruded contact position adjustment
are to reduce the supracontacts so as to create unobstructed closure of cusps into
fossae and marginal ridges
 The correction of occlusal supracontacts consists of grooving, spheroiding and
pointing

 • Grooving –
Restoring the depth of the developmental grooves
It is done with a tapered cutting tool until the desired depth is obtained

Spheroiding –
 reducing the supracontact while restoring the original tooth contour •
 Starting 2-3 mm mesial or distal to the prematurity, the tooth is recontoured
the occlusal margin to a distance of 2-3mm apical to the marking
 This is done with a paintbrush stroke gradually blending the area of the
prematurity with the adjacent tooth surface

Pointing
 – restoring cusp point contours •
 It is done by reshaping the tooth with rotating cutting tools

SEQUENCE OF CORONOPLASTY
 Remove retrusive prematurities and eliminate deflective shift from RCP to ICP
 Adjust ICP to achieve stable, simultaneous, multipointed, widely distributed
contacts
 Test for excessive contact(fremitus) on the incisor teeth
 Remove posterior protrusive supracontacts and establish contacts that are
bilaterally distributed on the anterior teeth
 Remove or lessen mediotrusive(balancing) interferences
 Reduce excessive cusp steepness on the laterotrusive (working) contacts

 Eliminate gross occlusal disharmonies
 Recheck tooth contact relationships
 Polish all rough tooth surfaces

REMOVE THE RETRUSIVE SUPRACONTACTS AND MINIMIZE THE
DEFLECTIVE SHIFTS FROM RCP TO ICP
 The retrusive prematurities can be marked with green wax or red marking tape
 Red tape should be placed in a ribbon forceps and inserted between the desired
teeth after they are properly dried.
 Occlusal registration wax is placed in the maxillary or mandibular posterior quadrant
 The occlusal surface of the wax is moistened with a wet finger to prevent adherence of
the opposing teeth.
 Significant supracontacts will cause perforation of the wax

 The supracontacts are marked on the teeth through wax with a pencil and the wax
strips are removed
 Typical sites of supracontacts are mesial inclines of maxillary lingual cusps and their
opposing tooth surfaces
 The mesial inner incline of the lingual cusp of the maxillary first premolars is the
most common initial supracontact at the Retruded contact position

Extraction of hopeless tooth
 Decision criteria:
 EXTRACT:
1. Tooth mobile for function
2. Can cause abscess
3. No use in treatment

 TEMPORARILY RETAIN
1. Maintain posterior stops; removed after prosthesis
2. Anterior esthetic zone; removed when permanent restoration is possible
3. Can be removed during periodontal surgery

 RETAIN:
1. Teeth with definite favourable prognosis

 Healing following non-surgical therapy is almost complete at 3 months.
 Patients also need the opportunity to improve their plaque control skills to both reduce inflammation and adopt new habits.
 At re-evaluation the effectiveness of treatment previously carried out is evaluated and the nature of further therapy, if
needed, is established.
 Measurements are made at baseline and again at 3 months as a method of evaluation of periodontal status, effectiveness of
therapy and to estimate prognosis.
 Measurements include:
 Plaque scores,
 Bleeding on probing,
 Suppuration on probing,
 Probing pocket depth,
 Recession,
 Clinical attachment level,
 assessment of mobility.

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.
 The attachment epithelium reappears 1 to 2 weeks after therapy. Gradual reductions in
inflammatory cell population, crevicular fluid flow, and repair of connective tissue
result in decreased clinical signs of inflammation, including less redness and swelling.
 One or two millimeters of recession is often apparent as the result of tissue shrinkage
 Transient root sensitivity frequently accompanies the healing process. Although
evidence suggests that relatively few teeth in a few patients become highly sensitive,
this development is common and can be disconcerting to patients.

Average changes after non-surgical
treatment
Mean changes generally observed in
studies
a) in improvements in plaque and
bleeding scores for sites of
different initial probing depths
b) in probing depth, probing
attachment levels, and gingival
recession after a single episode of
supra- and subgingival
instrumentation

Interpretation of probing
measurements at re-evaluation
 On average the change in pocket depth seen following treatment for
deeper pockets is a combination of recession at the gingival margin due
to resolution of inflammation and a tightening of the junctional
epithelium at the base of the pocket.
 Moreover the reduced bleeding on probing scores found after treatment
may reflect the increased resistance to probe penetration into the

Effects of non-surgical treatment on
microbiology
 A re-emergence of species of the red and orange complex 3–12 months post debridement
may be associated with ongoing attachment loss at these sites
(haffajee et al. 2006).
 In the absence of appropriate home care, the reestablishment of the pretreatment microflora
as well as the rebound of clinical improvements due to treatment will occur in a matter of
weeks
(magnusson et al. 1984; loos et al. 1988; sbordone et al. 1990).
 In the absence of professional maintenance an increase in the prevalence and counts of
periodontopathogens is to be expected
(renvert et al. 1990; shiloah & patters 1994).

Re-evaluation
 Many patients can have their periodontal disease controlled with phase i therapy and
not require further surgical intervention.
 In patients who do need surgical treatment, phase i therapy is advantageous in that it
also provides tissue with reduced inflammatory infiltration, thus improving the
surgical management of the tissue and improving the healing response.
 In the re-evaluation visit , consider surgery if:
 Patients with 5 mm or more of attachment loss and with pockets present after
phase i treatment.
 Those patients who do not demonstrate the ability to have 20% or less of tooth
surfaces free of plaque are poor candidates for successful surgical outcomes and
should be closely monitored on a recall maintenance program until plaque
control is established.

Re-evaluation
 If no response to conventional non-surgical therapy (scaling and root
planing/debridement) consider:
 Antibiotics/antimicrobials
 Repeat periodontal debridement
 Periodontal surgery

 Traditionally non-surgical treatment of periodontitis involves a series of appointments separated
by perhaps a week or more. Each appointment typically involves root debridement of a
quadrant depending on disease severity.
 In 1995 quirynen et al. Introduced the concept of total mouth disinfection as a new treatment
strategy. It involved:
 Full-mouth scaling and root debridement within a 24-hour treatment period,
 Subgingival irrigation (repeated three times within 10 minutes) with 1% chlorhexidine gel,
 Tongue brushing with 1% chlorhexidine gel,
 Mouth rinsing with 0.2% chlorhexidine.

 This full mouth disinfection protocol aimed to reduce the bacterial load in pockets and intraoral
niches to minimize the risk of reinfection of the treated pockets from areas harbouring
pathogenic bacteria.
 Recent studies suggested both the one appointment and staged or multiple appointment
treatment strategies work well, microbial parameters were not significantly different after 8
months, regardless of treatment modality and the risk of recurrence of periodontal pockets was
no greater for either modality.
 Staged therapy permits the advantage of evaluating and reinforcing oral hygiene care, and the
one or two appointment therapies can be more efficient in reducing the number of office visits
the patient is required to attend.

Response of Furcation sites to non-surgical treatment
 Patient-performed home care and professionally performed subgingival debridement become more difficult.
 Sheltered anatomic site for anaerobic and virulent microbes.
 Sites with furcation involvement consistently demonstrated higher microbial counts and greater proportions
of suspected periodontopathogens.
 Generally clinical improvement was found to be less pronounced in furcation sites than in other locations
(loos et al. 1989)
 Consequently, teeth with furcation involvement may be viewed with some caution with respect to long-term
prognosis.

When to refer?
 The rationale behind the 5-mm standard is
that the typical root length is about 13 mm
and the crest of the alveolar bone is at a
level approximately 2 mm apical to the
bottom of the pocket. When there is 5 mm
of clinical attachment loss the crest of
bone is about 7 mm apical to the
cementoenamel junction, therefore only
about half the bony support for the tooth
remains.

When to refer?
Specialist care can help preserve teeth in these cases by
eliminating deep pockets and regenerating support for
the tooth.
 The treatment of periodontal diseases is generally
successful in patients with 6- to 8-mm probe depths.
Success rates diminish when probing depths are 9 mm or
greater, so early referral of advanced cases is likely to
provide the best results.

Reasons for referral
 In addition to the 5-mm standard and evaluation of probe depths, the following factors must also be
considered in the decision to refer:
I. Extent of disease and generalized or localized deep involvement. Extensive bone loss, even in localized areas
suggest the need for specialized reconstructive techniques.
II. Root length. Short roots are more seriously jeopardized by 5 mm of clinical attachment loss than long roots.
III. Hypermobility. Excessive tooth mobility suggests contributing factors and a more guarded prognosis.
IV. Difficulty of scaling and root planing. The presence of deep pockets and furcations makes instrumentation
much more difficult and results can often be improved with surgical access.
V. Restorability and importance of particular teeth for reconstruction. Long-term prognosis of each tooth is
important when considering extensive restorative work
VI. Age of the patient. Younger patients with extensive attachment loss are more likely to have aggressive forms
of disease that require extensive therapy.
VII. Lack of resolution of inflammation after scaling and planing. If inflammation persists, further therapy is often
necessary to gain the most positive results.

 S/RP is an essential part of non-surgical periodontal therapy ,yet dose not
result in complete removal of calculus .
 Patient motivation and cooperation is important in success treatment outcomes
.
 Self performed OH should be applied regularly and modified if needed .
 Re-evaluation provides a check for treatment success and patient’s level of
cooperation .
CONCLUDING REMARKS

Phase-I therapy

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