Surgical v/s Non surgical periodontal therapy

Dr. ACHI JOSHI
SAIMS, INDORE
1


CONTENTS
 INTRODUCTION
 LONGITUDINAL STUDIES
1. MINNEOSTA STUDY
2. MICHIGAN STUDY
3. GOTHENBERG STUDIES
4. AARHUS STUDIES
5. TUCSON-MICHIGAN-
HOUSTON STUDIES.
6. NEBRASKA STUDIES
7. LOMA LINDA STUDIES
 META- ANALYSIS
 Factors effecting therapy
 AGGRESSIVE PERIODONTITIS
 Kornmann and Robertson
(1985)
 Christersson, Slots and Genco
(1985)
 Lindhe et al 1986
 Gunsolly JC 1995
 Adjunct therapies in non-
surgical therapy
2


PERIODONTAL
THERAPY
NON-
SURGICAL
SURGICAL
INTRODUCTION
3


 Both surgical and nonsurgical therapy produced improvement in the
periodontal health.
 Treatment approach was based on the comfort level of the practitioner.
 In the late 60’s and continuing into the 70’s and 80’s, many series of
longitudinal studies were conducted, aimed to document the immediate
and most importantly long term clinical results following several types
of periodontal therapy.
4


The purpose of these studies can be best summarized as followed:
1. Therapeutic result changed over time were documented by comparing the
short and long term data in the long term data study.
2. Determine the therapeutic approach in treatment of patient with periodontal
disease by evaluating the benefit of nonsurgical and surgical therapy, the
effects of plaque control and potential resolution of inflammatory response.
LONGITUDINAL STUDIES
5
DR. DIHN X- longitudinal studies in periodontics part I

4. Evaluated various surgical periodontal treatment modalities.
5. Determine the adequate supportive maintenance protocol.
6. Exploring the expected and unexpected response following periodontal therapy.
7. Exploring the short term and long term effects on the specified clinical parameters
8. Evaluating the inflammatory indices based on different modalities of treatment and
maintenance.
6


1. MINNEOSTA STUDY
Pihlstrom et al 1981
Pihlstrom et al. 1983
Pihlstrom et al. 1984
8

17 PATIENTS
OHI
SRP (RP)
SRP (RP)
OHI
MWF (RP + Sx)
Data were separated into 3 groups
by initial pocket depth;
PATIENTS WERE RECALLED 3-4
TIMES PER YEAR FOR 4 YEARS
Both procedures resulted in reduction in probing depth and maintenance of
attachment levels with the RP resulting in slightly more gain in attachment.
The > 7 mm group showed the greatest reduction in probing depth and gain
in attachment with better results in the RP+Sx procedures
Increased probing depth and loss of attachment1 to 3 mm,
4 to 6
mm
> 7 mm.
9


 This report concludes that SRP alone or in combination with MWF
surgery resulted in sustained decreases in gingivitis, plaque, and
calculus and neither procedure appears to be superior with respect to
these parameters.
10

 Pihlstrom et al. (1983) in a second report analyzed the 6.5 year results of the
previous study.
 For shallow pocket, the attachment loss and recession is more prominent with
the MWF (RP + Sx) probing depth did not change for both modalities.
 For moderate group, RP resulted in a slight gain of attachment compared to the
flap; however, both therapy resulted in a stable attachment level over 6.5 years.
 For advance group, there was no difference in CAL between both therapies.
Probing depth reduction were obtained in both moderate and advance group
regardless of whichever therapy was utilized. Flap resulted in better reduction
initially but approaching the same result as nonsurgical therapy after 6.5 years.
11


After 2 years, No consistent difference between treatment methods
was found in degree of pocket reduction. For pockets initially 4 to 6
mm in depth, attachment level was maintained by both procedures.
Pockets > 7 mm in depth treated by either procedure resulted in a
sustained gain in attachment.
12

Pihlstrom in 1984 in his third report-
The response of molar and non-molar
teeth to SRP alone or combined with
MWF.
 This report is different from the
previous reports in that they related the
result to the location or type of tooth
involved.
3-4 months
13

For attachment level, the flap surgery resulted in the higher attachment level in the
moderate group. However, for the advance group, there is no difference for both
therapy.
Thus, the molar tooth morphology probably accumulate plaque more and thus the
pocket reduction was harder to achieve.
14


2. MICHIGAN STUDY
Hill et al. (1981)
Ramfjord et al. (1982)
Morrison et al. (1982)
15

 Hill et al. (1981) published a 2-year study of scaling and root planing compared
to modified Widman surgery.
 Study – 90 patients, multi rooted teeth
 A hygienic phase which included SRP and OHI,
 Each quadrant was treated by 1 of 4 treatments-
 Pocket elimination,
 Modified widman flap (MWF),
 Subgingival curettage, and
 Scaling and root planing
MICHIGAN STUDY
16


 Pocket depth and attachment levels were taken at the
 initial examination,
 after the hygienic phase and
 1 and 2 years after treatment.
 RESULT
 1 to 3 mm crevices- slight loss of attachment after all types of treatments.
 4 to 6 mm pockets- significant reduction in probing depth in all four,
 greatest reductions after pocket elimination and MWF,
 a loss of attachment for pocket elimination and a gain for curettage and scaling.
 > 7 mm pockets -significant reduction after all modalities with the
 greatest reduction after pocket elimination,
 no significant differences in attachment results among the 4 methods.
17


CONCLUSION
None of the surgical modalities had any better effect than scaling and root
planing alone in maintenance of periodontal support which was not
directly related to reduction in pocket depth.
18

Ramfjord et al. (1982)
 78 patients
 treated with occlusal adjustment
 followed by surgical therapy, and
 recall prophylaxis every 3 months for 8 years.
 They were grouped into 3 classes:
 1 to 3 mm,
 4 to 6 mm, and
 7 to 12 mm.
19

 This study concluded that-
 The magnitude of pocket reduction following periodontal therapy is positively
related to the magnitude of the original pocket depth;
 Changes in attachment levels also have a positive relationship to the original
pocket depth;
 All four probed surfaces of the teeth responded similarly to the treatment when
pockets of initial equal depth were compared;
20

 Moderate and deep periodontal pockets can be reduced in depth and stayed
reduced over 8 years following subgingival curettage, MWF, and pocket
elimination surgery
 Attachment levels can be improved clinically both for moderate and deep pocket
 The pocket reduction for moderately deep pocket is greater following modified
Widman procedures and pocket elimination surgery than following curettage
but the total reduction is significant for all three methods; the long term gain is
significant only after curettage and MWF in the case of moderately deep pocket.
21

Plaque was scored according to the periodontal disease index (PDI).
The scores were used to test the hypothesis of equal effect of plaque scores
above and below the median for the 3 severity groups of the initial disease
based on probing depth.
•25% of patients having the lowest plaque scores
•25% having the highest score showed.
After 1 year, there was no indication that poorer oral hygiene leads to a
greater loss of attachment than better oral hygiene.
Similar results were seen in the 4 to 6 and the > 7 mm group after 4 years of
study.
no significant differences in
pocket depth responses over
the 8 years
22

Morrison et al. (1982)
In previously mentioned 8-year longitudinal study analyzed the effect of
gingivitis scores on probing depth and attachment loss.
 For pockets- 1-3 and 4-6 mm -no difference in pocket reduction maintenance.
 For attachment there was no difference in 1 to 3 mm probing depths and in 4 to
6 mm pockets and lower gingivitis scores had better gain the first 2 years but
thereafter no difference was recorded.
 For 7 to 12 mm pockets, the lower gingivitis scores seemed to result in better
probing levels and attachment gain for the first 3 years but this was not
maintained throughout the experiment.
 The severity of gingivitis did not affect the maintenance of pocket depth reduction or
clinical attachment levels. 25


3. GOTHENBERG/SWEDISH
STUDIES
Lindhe et al. (1982A)
Lindhe et al. (1982B)
Lindhe et al. (1984)
26


 Lindhe et al. (1982A) reported results of a 2-year study comparing SRP to
modified Widman surgery.
 15 Patients with advanced periodontal disease (mutilated teeth) Split
mouth design
 The initial examination and baseline record include the plaque index, the
gingival index, the probing depth, and the attachment level.
SRP
SRP
MWF
27


GINGIVAL CONDITION:
 Both the nonsurgical and surgical results in a low GI score and improved or
unaltered clinical attachment level.
PROBING DEPTH:
 The probing depth reduction was more pronounced in initially deep than in
initially shallow pockets.
 The probing depth reduction for the initially deep pockets was more marked in
sites subjected to surgery than in sites exposed to scaling and root planing alone.
CAL:
 The initial probing depth of 6mm or more showed gain of clinical attachment,
while the initial probing depth of less than 4mm showed loss of attachment.
28


 The results demonstrated that in patients maintained on a properly
controlled oral hygiene regimen, careful scaling and root planing was a
measure in the treatment of periodontal disease which was equally
effective used alone as in combination with the modified Widman flap
procedure in establishing clinically healthy gingiva and preventing
further loss of attachment.
29

Lindhe et al. (1982B) in another report from the previous study determined the
critical probing depth for SRP and MWF.
Probing depths shallower than the critical probing depth tend to lose
attachment following the procedure.
The results showed that the critical probing depth for the SRP group was 2.9
mm ± 0.4 mm and for the MWF group was 4.2 mm ± 0.2 mm
30

 This indicates that in patients with a large number of shallow probing
depths, a non-surgical approach is preferable, while in patients with a
large number of pockets > 4.2 mm, surgical treatment may result in
more gain of attachment.
 The results also showed that the level of oral hygiene established during
healing and maintenance is more critical for the resulting probing
depths and attachment levels than the mode of treatment used.
31


 Lindhe et al. (1984) reported 5-year results of a continuation of the previous study.
 The results showed that patients who maintained good oral hygiene had more
reduction in probing and a greater gain in attachment than patients who failed to
perform good plaque control, indicating that the patients' self-performed plaque
control had a decisive influence on the long-term effect of treatment.
32


 All the Sweden series stress the significant of maintenance care in the
treatment of periodontal disease. In patient who suffer from periodontitis,
a treatment program that involved oral hygiene instruction, scaling and
root planing and modified Widman flap procedures resulted in the
establishment of clinically healthy gingiva and shallow pockets.
33


4. AARHUS /DENMARK
STUDIES
Isidor et al. (1984)
Isidor et al. (1985)
Isidor and Karring (1986)
34

 Isidor et al. (1984), in a 6-month study on single-rooted teeth, compared 3
treatments utilizing a split-mouth design: S/RP versus MWS versus reverse bevel
flap.
 17 patients were treated for advanced periodontitis.
MWS
S/RP
Reverse bevel flap
surgery without
osseous recontouring
35


 Patients were recalled every 2 weeks and data was recollected at 3 and 6
months after the completion of treatment.
 At 6 months S/RP resulted in considerable reduction in pocket depth,
but surgical treatment give more reductions in PPD.
 Clinical gain of attachment was obtained following all 3 modalities but
S/RP resulted in slightly more gain of attachment than the 2 surgical
procedures.
36

 Isidor et al. (1985) reported 1-year results of the previous study, emphasizing
on the bone regeneration in the angular bony defects.
 Patients were recalled every second week for professional tooth-cleaning.
 The plaque index and bleeding on probing baseline, 3, 6, and 12 months after
treatment.
 Probing depths and CAL baseline and 1 year after treatment.
 Radiographs -bisecting angle technique baseline and 1 year after treatment.
RESULT
 On comparing MWS , reverse bevel flap surgery, and S/RP , for regeneration
of alveolar bone,
only the modified Widman flap surgery resulted in significant coronal regrowth of bone
in angular bony defects.
37

 Isidor and Karring (1986) reported 5-year results of the previous studies.
 Patients were then recalled regularly for the next 5 years.
 All methods were effective in halting the progression of periodontitis.
 No correlation was found between oral hygiene and recurrence of
periodontitis, suggesting sub-gingival scaling at frequent recalls is an
important factor in halting the progression of disease.
38


5. Tucson-Michigan-Houston Studies.
The research was done in private practice with aim to confirm the result from the
universities’ studies.
Becker et al. (1988)
Becker et al. (1990)
39


 Becker et al. (1988) reported 1-year results of a study comparing S/RP,
modified Widman surgery, and osseous surgery utilizing a split mouth
design.
 The response variables included
 plaque index,
 gingival index,
 probing depth,
 clinical attachment levels,
 mobility,
 furcation status.
 The probing depth was subgrouped into
 Incipient (1-3mm),
 Moderate (4-6mm), and
 Advance (>6mm).
40


 The clinical attachment level was also subgrouped into
 Incipient (2mm or less),
 Moderate (3-5mm), and
 Advance (>5mm).
 All patients were given the three month maintenance recall.
41


RESULT
 The result indicates that at 1year, scaling and root planing, osseous
surgery, and modified Widman flap were equally effective in treatment
of moderate to advance periodontitis.
 The advance pocket result in more effective pocket reduction.
 Shallower pocket, when treated surgically, result in loss of attachment.
42


Becker et al. (1990) reported 5-year attachment level and gingival recession
results of the previous studies.
 Shallow pocket demonstrated significant loss of attachment, moderate and
advance pocket demonstrated insignificant gain of CAL and all three
modalities of treatment yielded comparable results.
 All procedures yielded significant recession.
It was concluded that all techniques behave similarly regarding clinical attachment levels
and gingival recession.
43


6. NEBRASKA STUDIES
Kaldahl et al. (1988)
Kaldahl et al. (1990)
Kalkwarf et al. (1992)
44


 Kaldahl et al. (1988) reported 2-year results of a split mouth design study of
multi-rooted teeth that compared supragingival scaling to subgingival
scaling to modified Widman surgery to osseous surgery.
 82 patients with moderate to advanced periodontitis had each of 4
quadrants randomly assigned to receive
 coronal scaling (CS),
 subgingival scaling and root planing (RP),
 root planing plus modified Widman flap (MW),
 flap with osseous resection (FO).
45


 The FO group showed the greatest reduction in probing depth followed by MW, RP,
and CS. In deep sites MW, RP, and FO demonstrated the largest gain in attachment
while CS was the least.
 There is a direct relationship between the amount of probing depth reduction and the
initial probing depth.
 Root planing and modified widman resulted in a greatest gain of mean attachment
level in the moderate pocket. For the advance pocket, root plaing, modified widman,
and osseous flap surgery resulted in similar pocket reduction and CAL.
 In term in gingival recession,
 osseous flap surgery >modified Widman> root planing>coronal scaling.
46


 Kaldahl et al. (1990) reported 2-year results of the previous study that
compared the site response.
1. The inter-proximal sites of single rooted teeth,
2. The facial and lingual sites of single rooted teeth,
3. The non furcation site of molar teeth, and
4. The furcation sites of molar teeth.
 Similar to the Becker studies, the non-molar or single root teeth
demonstrated better probing depth reduction and attachment level gain
in the advance pocket areas.
 Furcation sites showed increase of pocket depth and attachment loss over
the two years of maintenance phase.
47


 The results showed that single-rooted sites > 5 mm had a greater mean
probing depth reduction and greater probing attachment gain than did
the molar sites. Furcation sites showed a greater increase in probing
depth and loss of attachment during the 2 years of maintenance.
48


 Kalkwarf et al. (1992) reported 2-year results of the 2 previous studies that analyzed
patient preference of treatment method.
 At the conclusion of 3 years of maintenance care, a 7 question interview was
conducted with each patient to obtain perceptions regarding the results of therapy
in each region of their mouth.
 The results of this study indicate that the ability of the patient to cope with post-
therapy sequelae following either coronal scaling, root planing, modified Widman
surgery, or flap with osseous resectional surgery is not significantly different.
49


7. LOMA LINDA STUDIES
The only studies in the periodontal literature that evaluates the separate effects of
oral hygiene and S/RP
50

 Cercek et al. (1983) reported results of a 2-year study that compared supragingival
plaque control to subgingival plaque control to scaling and root planing.
 Seven patients with chronic periodontitis were monitored during 3 phases of
treatment:
 Tooth brushing and flossing;
 Perio-Aid used subgingivally; and
 Subgingival debridement.
 An increasing gingival recession was noted during the study. Minimal effect was
derived from patient-performed plaque control, whether supra- or subgingival.
 The bulk of the effect was derived from professional subgingival instrumentation
(S/RP).
51


 Badersten et al. (1981) in a 13-month study of patients with moderate
periodontitis compared the effect of hand versus ultrasonic instrumentation on
attachment levels of single-rooted teeth.
 Improvements in plaque scores, bleeding on probing, decreased probing and
attachment levels were similar for both treatment methods.
 Badersten et al. (1984A) Comparable results were obtained by both methods.
It was shown that the deep probing depths could be successfully treated non-
surgically based on probing depth, probing attachment levels, bleeding on
probing, plaque, and gingival recession.
52


 All research groups found non-surgical therapy to be effective in molar
and non-molar teeth, in shallow and deep sites and whether the study
was conducted in a university or private practice setting. When proper
results are not achieved, surgical treatment should follow.
Summary
54


 Prior to these studies, there was not any guideline to which therapy is
more beneficial for the periodontal patient.
 The results of these longitudinal studies have provided the practitioner
invaluable information in selecting the method of treatment and
treatment protocol which ensured the best short and long term result for
the patient.
55


 Conclusion :
1. When the objective is reduction of probing depth, surgical therapy
provides a greater beneﬁt than nonsurgical therapy for all levels of initial
disease severity.
2. When the objective is to increase attachment level, nonsurgical therapy
provides a greater beneﬁt for initial disease severity levels 1–3 mm and 4–6
mm, and surgical therapy for > 6 mm.
Antczak- Bouckoms et al. 1993
57


 When sites with an initial probing pocket depth of 1–3 mm were treated
by open flap debridement, there was more clinical attachment level loss
than after S/RP.
 When sites with an initial probing pocket depth of 4–6 mm were treated
by open flap debridement, there was less clinical CAL gain than after
scaling and root planing. There was a greater reduction in probing
pocket depth reduction after the open flap debridement procedure
Heitz-Mayfield 2002
58


 When sites with an initial probing pocket depth of >6 mm were treated
by open ﬂap debridement, there was a greater increase in the clinical
attachment level than after scaling and root planing.
59


 Concluded:
1. Surgical treatment is better for reduction of periodontal probing depth and these
beneﬁts become greater with the increase of initial probing depth.
2. The gain of attachment level differences indicates an advantage for nonsurgical
treatment in shallow and medium initial periodontal probing depths.
3. For deep initial periodontal probing depths, surgical therapy showed similar
attachment gains when compared with scaling and root planing.
Hung & Douglass 2002
60


FACTORS AFFECTING OUTCOME OF
SURGERY
61


 Aging has been proposed to result in a variety of periodontal changes,
such as increased periodontal breakdown, accompanied by a slower rate
of wound healing.
 The effect of age on the periodontium was overlooked in the various
longitudinal clinical trials since subjects with wide age ranges were
recruited.
1. Age
62

 Lindhe et al( 1985). compared the healing capacity of subjects with different ages and failed to
demonstrate a difference between the different age groups.
 SAMPLE A- 62 patients were examined and treated between 1980 and 1982.
 13 of these subjects were less than 40 years of age,
 26 subjects were 40-49 years of age and
 23 subjects were greater than 49 years old.
 SAMPLE B- 21 subjects treated for advanced periodontal disease in 1969.
 6 patients were between 26 and 29 years of age at the start of treatment and
 15 were at least 60 years old.
 The findings from this retrospective analyses failed to demonstrate that the age of patients with
moderately advanced or advanced forms of periodontal tissue breakdown had an influence on
the results of periodontal therapy.
63


 An inconsistency regarding the effect of personal OH on the results of
treatment appears to exist when comparing different studies.
 The Minnesota, Michigan, and Denmark studies reported patients with
imperfect OH responded equally, as well as patients with high OH
scores. However, Swedish studies reported that plaque-free sites did
not lose attachment while plaque-associated sites tended to lose
attachment.
2. Oral Hygiene
64


 The discrepancy may be related to the differences in the maintenance
protocol implemented in these studies.
 The Swedish studies performed only supra-gingival tooth cleaning at
maintenance visits, while the Minnesota, Michigan, and Denmark studies
performed subgingival debridement during SPT.
 The subgingival scaling may aid in disrupting the subgingival ecosystem
and reducing the pathogenicity of the microflora, thereby minimizing CAL
loss even in the presence of imperfect patient’s performed OH.
65


 Periodontal disease seems to be more prevalent in smokers than in
nonsmokers.
 Studies have reported-
 decreases in gingival blood flow due to smoking
 chemotaxis and the phagocytic capacity of the polymorphonuclear
leukocytes (PMNs) is reduced
 smokers have lower IgA, IgG, IgM and suppressor CD8 lymphocytes levels
than nonsmokers.
3. Smoking
66


 Since the success of periodontal therapy is dependent on thorough
debridement, the ability of different clinicians with different skill levels
and training backgrounds to predictably achieve successful results can't
be expected to be the same.
 Badersten et al.(1985) found only small differences in clinical results
with various experience levels.
 Studies by Brayer et al. (1989) and Fleischer et al.( 1989) found that
experienced operators were more proficient in removing calculus in
furcation and deep pockets than those with less experience.
4. Skill Level of the Therapist
69


70
5. Psychosocial factors


 Coping mechanisms and enhanced perceptions of positive outcomes
can better a patient’s level of wound healing and future research should
focus on developing targeted interventions that periodontists could use
to improve the quality of life of their patients during treatment and the
treatment outcomes.
72


AGGRESSIVE PERIODONTITIS
75


Lindhe et al (1984)
 16 patients - Juvenile Periodontitis, 12 control ( adult periodontitis)
 These were treated with flap debridement coupled with systemic
tetracycline administration.
 Recall – 6,12,18,24, 36 and 60 months.
 Both groups responded well with reduction in probing depths, gain in
attachment and fill of angular bone defect.
76

Kornmann and Robertson (1985)
 Staged protocol for 8 JP patients-
 Stage 1: Root planing alone
 Stage 2: more RP and systemic tetracycline
 Stage 3: Flap debridement with concurrent systemic therapy
RESULT
 NO CASES were SUCCESSFULLY treated with STAGE 1
 3 patients had Signs of disease elimination after Stage 2
 4 patients showed clinical arrest of disease following Stage 3
CONCLUSION
 They concluded patients initially positive for Aa and Bacteroids sp.
Required Stage 3 to achieve clinical success. 77


Christersson, Slots and Genco (1985)
 Found that RP was not sufficient
 Gingival curettage or flap debridement suppressed levels of Aa.,
reduced probing depth and increased gain in attachment.
78

79
 Lindhe et al 1986
 16 patients with JP; split mouth design utilized RP with flap debridement
and RP alone.
 Active therapy was followed by professional tooth cleaning every 4 weeks
for 6 months
 Maintenance recall at 3 month interval for an additional 1 ½ year and was
terminated at 2 years.
 Examination was done at baseline, 6 months, 2 and 5 years.
Conclusion:
 No difference was found in both treatment modalities

80
 GUNSOLLY JC 1995
 23 patients with severe EOP
 SRP and OHI were given to patients
 Microbial samples were taken at Baseline, 3,6, 9and 12 months.
 Severe EOP- flap surgery.
 Following surgery, there was reduction in probing depth and gain in
attachment in moderate (1.62mm) severe (3.6mm) pockets.


Microbiologic results-
 Porphyromonas gingivalis were significantly reduced following SRP but Aa
was not reduced. After flap surgery the levels of Aa were significantly
reduced.
 This study indicated that the nature of sub-gingival infection is
important in determining appropriate periodontal therapy.
81


ADJUNCT THERAPIES IN
NON-SURGICAL THERAPY
Newer Advancements
83


1. SUB ANTIMICROBIAL DOSE
DOXYCYCLINE (SDD)
• SDD remains at present, the only systemic host response modulators specifically
indicated as adjunctive treatment for periodontitis.
• It has been approved by U.S. Food and drug administration, UK medicine and
health care products regulatory agency and by similar agencies in other
countries through out the world.
84


SEQUENCING PRESCRIPTION
WITH PERIODONTAL TREATMENT
 Not used as monotherapy, Used as an adjunct to SRP
 Taken as 20mg twice daily for 3 months and up to a
maximum of 9 months
 Three month prescription fits well with the typical
maintenance recall of 3 months.
85

 Local antimicrobial therapy in periodontitis involves direct placement of
an antimicrobial agents into sub-gingival sites, minimizing the impact of
the agents on non-oral body sites.
86
2. LOCAL DRUG DELIVERY


 A conventional pulsed oral irrigator (Water Pik@) at a
high-pressure setting may deliver an aqueous solution
to approximately 50% of the distance between the free
gingival margin and the most coronal connective
tissue attachment.
 Clinical and ultrastructural studies have reported
pulsed oral irrigation at high pressure to disrupt sub-
gingival plaques to at least 6 mm into periodontal
pockets without inducing soft tissue injury or forced
penetration of microorganisms into gingival tissues
(Cobb et al 1988, White 1988, Wikesjo 1989) 87
SUB-GINGIVAL IRRIGATIONS


88
Actisite ®
• Tetracycline preloaded in hollow
ethyelene, vinyl acetate fibers.
• 23 cm long 0.5mm in diameter
contains 12.7 mg of tetracycline.


89
Atridox ®
• Gel based system
• 10% doxycycline


90
Arestine ®
• 2% minocycline
• Each sphere contain 1 mg of minocycline


 25% metronidazole gel
91
Elyzol ®


92
Perio-chip ®
• Biodegradble chip made of 2.5 mg
CHX
• 4 X 5 X 0.35mm


PERIODONTAL PLUS AB®
 Unique system based on the
collagen fibril delivery system,
fibrillar collagen which it not cross
linked and has been impregnated
with tetracycline HCL which is
leached out as the fibrils
themselves degrade .


 LASER is proved as an effective adjunct to mechanical debridement.
 The soft tissue lasers—argon (488nm, 514 nm), diode (800–830 nm, 980 nm)
and Nd:YAG (1064 nm)—are well absorbed by melanin hemoglobin and other
chormophores present in periodontally diseased tissues. The laser energy is
transmitted through water and poorly absorbed in hydroxyapitite. These
properties of the soft tissue lasers make them an excellent choice to use in a
periodontally involved sulcus that has dark inflamed tissue and pigmented
bacteria.
94
3. LASER


 In 1998, Moritz et al compared the use of a diode laser after scaling and root
planing with scaling and root planing alone. Gingival index and bacterial
populations were the parameters used for the study. At 3 and 6 months, the
laser group showed significant less bacterial populations and greater
improvement in gingival index compared with the scaling only group.
 Similar results were given by Neil amd Mallonig( 1997) Liu (1999), Finkbeiner
(2000)
95


 The World Health Organization (WHO) has defined Probiotics as live
organisms, which, when administered in adequate amounts, confer a
health benefit on the host. Probiotics repopulate beneficial bacteria
which can help to kill the pathogenic bacteria and fight against
infection.
 Also called as "friendly bacteria" or "good bacteria"
96
4. PROBIOTICS


 Probiotics lower the pH in the oral cavity so that Pathogenic bacteria
cannot form dental plaque and calculus that causes the periodontal
disease.
 They produce antioxidants. Antioxidants prevent calculus formation by
neutralizing the free electrons that are needed for the mineral formation.
 Probiotics are able to breakdown putrescence odours by fixating on the
toxic gases (volatile sulphur compounds)
97
Probiotics and Periodontal Health


 A majority of the strains including L. salivarius were shown to suppress
the growth of A actinomycetemcomitans, P. gingivalis and Prevotella
intermedia.
 Probiotic strains included in periodontal dressings at optimal
concentration of 108 CFU/ml were shown to diminish the number of
most frequently isolated periodontal pathogens.
98


 Ozone is a powerful oxidizer - it effectively kills bacteria, fungi, viruses,
and parasites at a dramatically lower concentration than chlorine, with
none of the toxic side effects.
99
5. Ozone therapy


•Damage to cell membrane
•Oxidation of cellular contents
•Effective in antimicrobial resistant cells
Antimicrobial
•Activates cellular and humoral immune system
•Activation of biologic antioxidants
Immuno-
stimulating
•Anti hypoxic and detoxicating
•Activation of aerobic processesAnti-hypoxic
•Activate protein synthesis
•Enhance cell metabolism
•Synthesis of interlukins, leukotrienes and prostaglandin
Biosynthetic
5/12/2017 100


 Photodynamic therapy is based on the principle that a photoactivatable
substance (the photosensitizer) binds to the target cell and can be activated by
light of a suitable wavelength. During this process, free radicals are formed
(among them singlet oxygen), which then produce an effect that is toxic to the
cell.
 PDT is beneficial during the maintenance of periodontal therapy also serves as
an adjunct to mechanical therapy in sites with difficult access.
101
6. Photodynamic Therapy


 PerioProtect is a comprehensive method that is customized for
individual patients to help manage biofilms, growing in the
periodontal pockets.
 The Method is a combination of treatments, including a non-invasive
chemical debriding therapy used in conjunction with traditional
mechanical debriding procedures.
 1.7% hydrogen peroxide gel is typically the medication of choice. This
medication and delivery system creates a hyperbaric chamber-like
state.
102
7. Perioprotect®

PATIENT RELATED FACTORS OPERATOR RELATED FACTORS
NEWER DEVLOPMENT IN NON SURGICAL
THERAPY
RISK: BENEFIT OF SURGERY
TREATMENT PLAN
104
Conclusion


1. Literature reviews of periodontology.
2. Khalaf F. Al-Shammari. Surgical and non-surgical treatment of chronic
periodontal disease. Int Chin J Dent 2002; 2: 15-32.
3. Perio 2000, 2005
4. RArpita, JL Swetha, MR Babu, R Sudhir. Recent Trends in Non-Surgical
Periodontal Care for the General Dentist -A Review. Bangladesh
Journal of Dental Research & Education
105
References

Surgical v/s Non surgical periodontal therapy

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