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NON-SURGICAL APPROACH OF PERIODONTAL THERAPY

Comprehensive Postgraduate Theory Examination Notes

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SECTION 1: NOMENCLATURE AND DEFINITION

"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." — Newman & Carranza's Clinical Periodontology and Implantology, 14th Ed., Chapter 43

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SECTION 2: OBJECTIVES AND RATIONALE

2.1 Overall Objective

2.2 Aims of Non-Surgical Treatment (Heasman, Preshaw & Robertson — Successful Periodontal Therapy: A Non-Surgical Approach)

• decontamination by removing LPS/endotoxins from the root surface
• disrupting and eliminating the biofilm from the root surface
• removing the bulk of subgingival calculus from the root surface."

2.3 The Periodontal Pocket — A Pathological Environment

• A periodontal pocket is a pathologically deepened gingival crevice
• The diseased root surface is contaminated with subgingival calculus deposits and a layer of dental plaque
• Dental plaque is now regarded as a biofilm: "an organised community of bacteria that forms on a non-shedding surface such as a tooth"
• The majority of bacteria in an established biofilm are recognized anaerobic organisms with cell walls containing powerful lipopolysaccharide (LPS) based endotoxins
• Studies have shown that the vast majority of LPS is only loosely bound to, or associated with, the root surfaces although a small percentage may cause subsurface contamination at root surface irregularities, root grooves or resorption lacunae

"Laboratory studies have shown that a gentle stream of water can remove about 39% of the LPS whilst brushing the root surface eliminates a further 60%. This suggests that the hygiene phase of non-surgical treatment may be instrumental in disrupting the biofilm and eliminating up to 99% of endotoxins in the pocket." — Heasman et al., Successful Periodontal Therapy: A Non-Surgical Approach

2.4 Important Rationale Points (Newman & Carranza 14th Ed.)

• "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."
• "Phase I therapy is a critical aspect of periodontal treatment. Data from clinical research indicate that the long-term success of periodontal surgical treatment is dependent on maintaining the plaque or biofilm control results achieved with phase I therapy."
• "Patients who do not have adequate plaque or biofilm control will continue to lose attachment regardless of what surgical procedures are performed and therefore are not good candidates for phase II or surgical therapy."

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SECTION 3: PHASES OF PERIODONTAL THERAPY — OVERVIEW

FLOWCHART: Sequence of Periodontal Treatment

PRELIMINARY PHASE
[Treatment of dental/periodontal emergencies; extraction of hopeless teeth]
            |
            v
PHASE I THERAPY (NONSURGICAL / CAUSE-RELATED THERAPY)
[Plaque control + patient education; Supragingival & subgingival scaling;
Root planing/debridement; Correction of local factors; Caries management;
Antimicrobials as needed; Occlusal adjustment]
            |
            v
PHASE IV — MAINTENANCE BEGINS IMMEDIATELY after Phase I completion
[Placed on maintenance to preserve results; periodic checkups]
            |
            v
REEVALUATION (4-8 weeks after Phase I)
[Reassess tissues; probing; determine need for further intervention]
            |
       _____|______
      |             |
      v             v
ADEQUATE       INADEQUATE
RESPONSE       RESPONSE
(Maintain       |
 Phase IV)      v
           PHASE II THERAPY
           [Periodontal Surgery]
                |
                v
           PHASE III THERAPY
           [Restorative/Prosthetic Phase]
                |
                v
           PHASE IV — MAINTENANCE (Lifelong)

"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." — Carranza's Clinical Periodontology, 10th Ed.

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SECTION 4: EFP S3-LEVEL CLINICAL PRACTICE GUIDELINE — FOUR STEPS IN TREATMENT

FLOWCHART: Algorithm for Treatment of Periodontitis (Stage I–III)

STEP 1 (FIRST STEP):
Behavior and Risk Factor Modification
• Oral hygiene instruction
• Professional mechanical plaque removal (PMPR)
• Supragingival instrumentation
• Correction of plaque-retentive restorations
• Smoking cessation
• Glycemic control
            |
            v
STEP 2 (SECOND STEP):
Cause-Related Therapy
• Subgingival instrumentation
• Adjunctive use of antiseptics
• Adjunctive use of antibiotics (local or systemic)
• Adjunctive use of host-modulating agents
• Periodontal reevaluation
            |
            v
REEVALUATION ENDPOINTS:
• PD ≤ 4mm with no BOP → STEP 4 (Supportive Periodontal Care)
• PD ≥ 6mm → STEP 3 (Surgical therapy)
• PD ≥ 4mm with BOP → Repeated subgingival instrumentation OR STEP 3
            |
            v
STEP 3 (THIRD STEP):
Surgical Therapy
• Access flap periodontal surgery
• Resective periodontal surgery
• Regenerative periodontal surgery
            |
            v
STEP 4 (FOURTH STEP):
Supportive Periodontal Care (SPC)
• Reevaluation of supragingival biofilm and risk factor control
• Regular interval professional mechanical plaque removal
• Periodontal reevaluation to assess periodontal condition

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SECTION 5: COMPONENTS/STEPS OF PHASE I (NONSURGICAL) THERAPY

5.1 Comprehensive List — Phase I Procedures

5.2 Phase I Components as Described by Levi et al.

1. Patient plaque control technique instructions
2. Identify and remove calculus deposits
3. Remove diseased altered cementum
4. Reduce periodontal pathogens
5. Eliminate etiologic factors (local and systemic risk factors)
6. Educate and motivate patients to take personal responsibility

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SECTION 6: STEP 1 — PLAQUE/BIOFILM CONTROL (HYGIENE PHASE)

6.1 Rationale

6.2 Mechanical Plaque Control

6.2.1 Manual Toothbrushes

• Bristles are generally made of nylon, which is relatively flexible, resistant to fracture and does not become saturated with water
• Round-ended bristles cause fewer scratches on the gingiva than flat-ended bristles
• Softer bristles have greater flexibility and have been shown to reach further interproximally and subgingivally
• Hard bristles are more likely to result in gingival trauma
• However, "the technique and the force applied when brushing are more important determinants of plaque removal capability and gingival trauma than the hardness of the bristles themselves"
• Should be replaced approximately every three months
• Typical manual toothbrush: brush head dimensions 1.5–2.5 cm long and 0.15–0.75 cm wide; four rows of bristles of medium texture; nylon polymer filaments of 10–12 mm length

• Children's toothbrushes — reduced head size, bulky handle
• Single tufted toothbrushes (interspace brushes) — inaccessible areas, recession sites, furcations, large interdental spaces
• Orthodontic toothbrushes — V-shaped indentation for fixed appliances
• Denture brushes — dual-purpose head with tapered firmer bristles

6.2.2 Powered Toothbrushes

• "It is now more generally accepted that powered brushes may be advantageous for a much wider group of patients"
• "Numerous studies have confirmed that, for most patients, powered brushes are more effective than manual toothbrushes"
• May be because of better mechanical cleaning, or novelty improving compliance
• Compact brush heads facilitate interproximal brushing
• Special features: timing mechanisms, pressure indicators
• Brush head designs: side-to-side/back-and-forth motion; circular heads with oscillating motion
• Sonicare® oscillates about 31,000 strokes per second; Oral-B® rotates between 7600 and 8800 rotations/oscillations per minute and pulses 20,000–40,000 pulses per minute (Non-Surgical Control of Periodontal Diseases — Levi et al.)

6.2.3 Toothbrushing Techniques

6.2.4 Interdental Cleaning Aids

6.3 Chemical Plaque Control (Mouth Rinses and Other Agents)

• "At low concentrations, chlorhexidine is bacteriostatic, but at high concentrations, it is bactericidal"
• Important property: substantivity — retention in the mouth and subsequent release from oral structures
• "Chlorhexidine should, therefore, only be used for short periods (two to three weeks)"
• "Toothpaste components called anionic surfactants interact with chlorhexidine activity and lower its effective delivery"

• After periodontal surgery
• Management of periodontal problems in palliative care
• Prevention of drug-induced gingival overgrowth
• Necrotizing ulcerative gingivitis (NUG/NUP)
• Fixed orthodontic appliances or intermaxillary fixation
• Gingival ulcerative conditions (viral infections, erosive lichen planus)

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SECTION 7: STEP 2 — SUPRAGINGIVAL AND SUBGINGIVAL SCALING AND ROOT INSTRUMENTATION

7.1 Terminology Change — IMPORTANT EXAMINERS' KEYWORD

"Root surface instrumentation, a term which is used in preference to root planing. Root surface instrumentation describes the procedure that is necessary to eliminate endotoxins, disrupt the biofilm and, when present, remove subgingival calculus from the root surface (also called root surface debridement)." — Heasman et al., Successful Periodontal Therapy: A Non-Surgical Approach, Chapter 1

• "Current studies have indicated that endotoxins do not penetrate into the cementum as deeply as once believed, and complete removal of the cementum may not always be necessary, but removal of the plaque or biofilm and calculus is absolutely necessary." — Newman & Carranza 14th Ed., Chapter 43 (KEY FACT box)

7.2 Periodontal Hand Instruments

7.2.1 Periodontal Scalers (Sickle Scalers)

7.2.2 Periodontal Files (Hirschfeld 3/7, 5/11, 9/10)

• Multiple straight cutting edges at working end
• Two main indications: (1) removal of burnished calculus deposits; (2) "crushing" calculus to make it easier to remove with a curette
• Each file designed for use on a single tooth surface: mesial, distal, lingual, palatal
• Diamond tipped files make furcation instrumentation much easier — Heasman et al.

7.2.3 Curettes

• Rounded back and rounded toe
• Two parallel cutting edges at the working end
• Applied to all tooth surfaces in both anterior and posterior parts of the mouth
• Used for removal of both supragingival and subgingival calculus
• Adaptation: "placing the distal 2 to 3 mm of the blade in the appropriate working relationship next to the tooth surface"

• Designed by Dr. Clayton Gracey in the 1930s
• "Area-specific" — each curette can be applied only to certain surfaces
• A complete set is needed to instrument the entire dentition
• Designed for access to root surfaces with deep pockets (>5mm) without causing trauma to the pocket epithelium
• Characterized by: unique blade features and long flexible shanks
• "Gracey after-five" curettes — used for deeper pockets >5mm
• Some instruments have complex bends for access to complex root morphology

7.3 Powered/Sonic and Ultrasonic Scalers

• Hand instruments and ultrasonic scalers have been extensively compared
• Badersten and colleagues (1980s) reported that residual calculus remained on 44% of the surfaces in deeper pockets
• Studies ranging from 1 month to 2 years demonstrated up to 80% reduction in bleeding on probing and mean probing depth reductions of 2 to 3 mm
• "The percentage of periodontal pockets of 4 mm or deeper was reduced by more than 50% and in many cases up to 80%" — Newman & Carranza 14th Ed., Chapter 43

7.4 Planning Treatment Sessions

• General health and tolerance of treatment
• Number of teeth present
• Amount of subgingival calculus
• Probing pocket depths and attachment loss
• Furcation involvements
• Alignment of teeth
• Margins of restorations
• Developmental anomalies
• Physical barriers to access (limited opening or tendency to gag)
• Patient cooperation and sensitivity (requiring use of anesthesia or analgesia)

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SECTION 8: FULL-MOUTH DISINFECTION

"The concept, described by Quirynen et al., consists of full-mouth debridement (removal of all plaque and calculus) completed in two appointments within a 24-hour period. In addition to scaling and root planing, the tongue is brushed with a chlorhexidine gel (1%) for 1 minute, the mouth is rinsed with a chlorhexidine solution (0.2%) for 2 minutes, and periodontal pockets are irrigated with a chlorhexidine solution (1%)." — Carranza's 10th Ed., Chapter 49

Protocol:

• Complete scaling and root planing within 24 hours in two separate 4-hour appointments
• CHX gel (1%) applied to tongue for 1 minute
• CHX rinse (0.2%) for 2 minutes
• Pocket irrigation with CHX (1%)
• Twice-daily chlorhexidine rinses in oral hygiene routine
• Tonsils sprayed daily with CHX
• Disinfectant rinses continued daily for 2 months

Results:

• At 1 and 2 months after treatment: test group showed significantly higher reduction in probing pocket depth, especially for pockets that were initially deep (7–8 mm)
• Patients in test group had significantly lower pathogenic microorganisms after treatment compared with controls
• Another study: "results of both test groups (with and without chlorhexidine) were similar and were significantly better than for controls"

Current Position (Newman & Carranza 14th Ed.):

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SECTION 9: ADJUNCTIVE CHEMOTHERAPEUTIC AGENTS

9.1 Systemic Antibiotics

"'Adjunctive treatments' are those therapeutic interventions that are used in addition to conventional periodontal therapy."

• Periodontal infections are polymicrobial
• Reliable systems for comprehensive analysis of plaque bacteria are simply not available
• Risk of development of antibiotic resistance
• Systemic side effects

9.2 Local Drug Delivery

• Solutions
• Gels
• Fibers
• Chips (e.g., chlorhexidine chip)
• Controlled-release polymer (e.g., doxycycline polymer)

• Controlled release device — achieves therapeutic concentrations over a prolonged period of time (preferred)
• Sustained release device — provides drug delivery for only a few hours (less preferred)

• Localised recurrent pockets in a patient in supportive phase of periodontal care
• Non-responding sites following non-surgical periodontal therapy
• Peri-implantitis
• Localised suppurating pockets

CRITICAL POINT: "Using a local delivery system as a monotherapy is likely to be ineffective because of the inability of the therapy to disrupt the plaque biofilm, and the failure to remove calculus. Therefore, it is essential that locally delivered treatments are used as adjuncts to RSI." — Heasman et al., Chapter 6

9.3 Host-Modulating Agents

• Adjunctive use of host-modulating agents (local or systemic)

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SECTION 10: CORRECTION OF LOCAL CONTRIBUTING FACTORS (Step 3)

• Smoothing rough surfaces and removing overhangs from faulty restorations with burs or hand instruments
• Complete replacement of failing restorations if necessary

"Maximal healing from phase I treatment is not possible when local conditions retain biofilm and provide reservoirs for repopulation of periodontal pathogens." — Newman & Carranza 14th Ed., Chapter 43

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SECTION 11: STEP 4 — MANAGEMENT OF CARIOUS LESIONS

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SECTION 12: CURETTAGE — CURRENT POSITION

"Gingival curettage, the systematic removal of the soft tissue lining of the pockets, has not been shown to improve the results of treatment. Thorough plaque or biofilm removal and excellent root therapy result in conversion of the soft, edematous, inflamed gingival tissue to a healthier state without removing this tissue by using intentional soft tissue curettage. Therefore, curettage of the soft tissue pocket wall in phase I therapy is no longer advocated."

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SECTION 13: PHOTODYNAMIC THERAPY — CURRENT POSITION

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SECTION 14: LASER THERAPY — CURRENT POSITION

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SECTION 15: RISK FACTOR MANAGEMENT (Behavior and Risk Factor Modification — Step 1 of EFP CPG)

15.1 Smoking Cessation

• Smoking is "one of the most significant and prevalent risk factors for periodontal disease"
• "Most smokers have, at some time, made an attempt to quit the habit and many are willing to make further attempts when they learn of the link between smoking and periodontal disease"
• Supported at all steps in periodontal therapy including SPC
• "Rebound gingivitis": When smokers with periodontal disease successfully quit, "they often notice a 'rebound gingivitis' and an increase in gingival bleeding as the vasoconstrictive effect of nicotine on the gingival microvasculature is no longer present. Patients should be warned about this possibility." — Heasman et al., Chapter 7

15.2 Glycemic Control (Diabetes)

• Listed as a risk factor requiring modification in the EFP S3 Level CPG
• Systematic management of periodontal-systemic interrelationships as needed — Newman & Carranza 14th Ed., Chapter 44

15.3 Other Risk Factors

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SECTION 16: STEP 5 — TISSUE REEVALUATION

• Reassess gingival condition and pocket depth
• Rechecking for plaque, calculus, and caries
• Occlusion and tooth mobility
• Cementum surface — accessibility of root surface to instrumentation
• Further treatment needs (surgical vs. non-surgical)

• PD ≤ 4mm with no BOP = periodontal stability → advance to SPC
• PD ≥ 4mm with BOP = incomplete treatment → repeated subgingival instrumentation or consider surgery
• PD ≥ 6mm = surgery indicated

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SECTION 17: HEALING AFTER PHASE I THERAPY

• Healing of the gingival epithelium consists of the formation of a long junctional epithelium rather than new connective tissue attachment
• Long junctional epithelium occurs about 1 week after therapy
• Gradual reductions in: inflammatory cell population, crevicular fluid flow, repair of connective tissue
• "One or two millimeters of recession is often apparent as the result of tissue shrinkage"
• Connective tissue fibers require 4 or more weeks to reorganize and heal
• Transient root sensitivity frequently accompanies the healing process
• Patients should be warned about: teeth appearing longer due to tissue shrinkage; root sensitivity

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SECTION 18: CLINICAL OUTCOMES OF NON-SURGICAL TREATMENT

18.1 Evidence Base — The Badersten Studies

• "Clinical outcomes following non-surgical treatment" were extensively studied
• Demonstrated effectiveness in both anterior and posterior teeth

18.2 Documented Clinical Results

18.3 Limitations of Non-Surgical Therapy

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SECTION 19: SUPPORTIVE PERIODONTAL CARE (Phase IV / Step 4 SPC)

• Reinforcement of proper biofilm control through oral hygiene and modification if necessary
• Assessment and modification of risk factors for periodontitis (smoking cessation, evaluation of glycemic control for diabetes)
• Professional supragingival and subgingival biofilm and calculus control
• Re-evaluation of periodontal tissue at regular maintenance intervals — Newman & Carranza 14th Ed., Chapter 44

Factors Determining Recall Frequency

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SECTION 20: COMPARISON OF VIEWPOINTS ACROSS REFERENCES

On the Terminology for Subgingival Instrumentation

On the Extent of Cementum Removal

On Full-Mouth Disinfection vs. Quadrant Scaling

On Curettage

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SECTION 21: RECENT TERMINOLOGY CHANGES (EXAMINER-IMPORTANT)

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SECTION 22: ADVANTAGES OF PHASING TREATMENT

1. Preventive dentistry counseling and services precede reparative dentistry
2. Patients can more easily understand complicated treatment plans when the total array of services is segmented into smaller, more limited groups
3. Phasing ensures that periodontal health is achieved before reparative dentistry is undertaken
4. The phase I therapy reevaluation offers the dentist a second opportunity, after initial tissue healing, to adjust the details of the final treatment plan
5. Phasing ensures that once periodontal health has been achieved, long-term vigilance through a structured maintenance program will minimize the risk of recurrence of disease

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SECTION 23: TREATMENT PLANNING CONSIDERATIONS FOR PHASE I

• General health and tolerance of treatment
• Number of teeth present
• Amount of subgingival calculus
• Probing pocket depths and attachment loss
• Furcation involvements
• Alignment of teeth
• Margins of restorations
• Developmental anomalies
• Physical barriers to access (limited opening or tendency to gag)
• Patient cooperation and sensitivity (requiring use of anesthesia or analgesia)

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SECTION 24: ROLE OF THE DENTAL HYGIENIST

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QUICK REFERENCE SUMMARY TABLE

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1. Nomenclature — all synonyms documented with sources (Phase I, cause-related, etiotropic, initial, hygienic phase)
2. Objectives and Rationale — verbatim from Carranza 10th, Newman 14th, and Heasman et al., including the LPS removal percentages (39% water, 60% brushing = ~99% total)
3. Phases of Treatment Flowcharts — both the classic 4-phase model and the EFP S3-Level CPG 4-step algorithm
4. Components of Phase I — complete stepwise breakdown from all sources
5. Plaque Control — manual vs. powered brushes, all techniques (Bass, Modified Bass, Charters, Stillman, SBT), all interdental aids, chemical agents with mechanisms and properties of CHX
6. Root Surface Instrumentation — critical terminology change from root planing → RSI/debridement; full instruments section (scalers, files, curettes, Gracey curettes); Badersten study data; current position on cementum removal
7. Full-Mouth Disinfection — Quirynen et al. protocol in full; comparison of results across references
8. Adjunctive Chemotherapy — systemic antibiotics, local delivery (controlled vs. sustained release), host modulation; critical point that local delivery as monotherapy is ineffective
9. Curettage, Photodynamic, Laser — all now explicitly stated as "no longer advocated" or "insufficient evidence"
10. Risk Factor Modification — smoking cessation (rebound gingivitis), glycemic control, other risk factors
11. Reevaluation — timing, parameters, EFP endpoints (PD ≤4mm no BOP = stability)
12. Healing — long junctional epithelium, recession, transient sensitivity
13. Clinical Outcomes — documented statistics from Badersten
14. SPC — recall table with indications for frequency, 3-month interval rationale
15. Cross-reference comparison table on terminology, cementum removal, FMD
16. Recent terminology changes table
17. Comprehensive quick-reference summary table