Periodontal therapy 1 laq according to carranza

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Periodontal Therapy - Long Answer Question (Carranza)

Definition

Periodontal therapy refers to all procedures directed toward the elimination of periodontal disease and/or the maintenance of the periodontium in a state of health. According to Carranza's Clinical Periodontology, the overall goal is to preserve the natural dentition by eliminating the etiologic factors of periodontitis and creating conditions favorable for healing.

Overall Goals of Periodontal Therapy

Eliminate inflammation
Eliminate or minimize the depth of periodontal pockets
Stop attachment loss and bone loss
Restore lost periodontal tissues (regeneration) where possible
Maintain function and esthetics
Prevent recurrence of disease (maintenance phase)

Phases of Periodontal Therapy

Carranza divides treatment into a logical phase-based sequence to ensure systematic and complete management:

Phase I - Etiotropic (Cause-Related) Therapy

Also called initial/preparatory/non-surgical phase. Directed at controlling etiologic factors.

Components:

Patient education and oral hygiene instructions (OHI)
Supragingival scaling and polishing
Subgingival scaling and root planing (SRP) - the cornerstone
Elimination of plaque-retentive factors (overhanging margins, faulty restorations)
Extraction of hopeless teeth
Caries control (excavation, temporary restorations)
Occlusal therapy (adjustment/splinting if indicated)
Antimicrobial/antibiotic therapy (adjunctive, systemic or local)
Treatment of endodontic involvement
Correction of systemic factors

Re-evaluation after Phase I (after 4-8 weeks):

Assess residual pocket depths
Assess gingival inflammation
Assess plaque control
Determine whether surgical phase is needed

Phase II - Surgical Phase (Corrective Phase)

Indicated when Phase I fails to achieve adequate results (residual pockets >5 mm, furcation involvement, defective bone anatomy).

Surgical procedures include:

Resective Surgery (reduces pocket depth)

Gingivectomy/gingivoplasty - for suprabony pockets with adequate attached gingiva
Osseous resective surgery - flap with osteoplasty/ostectomy to create positive bone architecture
Apically positioned flap - repositions tissue apically to reduce pocket without bone removal

Reconstructive/Regenerative Surgery (restores lost tissue)

Bone grafts - autografts, allografts (DFDBA, FDBA), alloplasts (HA, beta-TCP), xenografts (Bio-Oss)
Guided Tissue Regeneration (GTR) - barrier membranes (resorbable: collagen; non-resorbable: e-PTFE) to allow selective repopulation by periodontal ligament cells
Enamel Matrix Derivative (EMD/Emdogain) - promotes regeneration by mimicking Hertwig's root sheath
Growth factors - rhPDGF-BB (GEM21S), rhBMP-2

Mucogingival/Plastic Surgery

Free gingival graft, connective tissue graft
Pedicle grafts (laterally positioned, coronally positioned)
Frenectomy
Vestibuloplasty
Ridge augmentation

Periodontal Implant Surgery

Placement of implants to replace missing teeth

Phase III - Restorative Phase

Permanent restorations
Fixed/removable prostheses
Implant-supported restorations
Orthodontic therapy
This phase is carried out after periodontal stability is confirmed

Phase IV - Maintenance Phase (Supportive Periodontal Therapy - SPT)

Also called periodontal maintenance or recall phase. This is a lifelong phase essential to prevent disease recurrence.

Components of SPT visit:

Update of medical/dental history
Oral examination (plaque scores, BOP, pocket depths, furcation, mobility, recession, radiographs as needed)
Removal of supragingival and subgingival deposits (SRP)
Polishing
Fluoride application
Reinforcement of OHI
Assessment of risk factors

Frequency:

Standard: every 3 months initially, then based on risk level
High-risk patients: every 2-3 months
Low-risk patients: every 6 months

Non-Surgical Periodontal Therapy (NSPT)

Scaling and Root Planing (SRP)

The gold standard of non-surgical treatment.

Scaling: Removal of plaque, calculus, and stain from tooth surfaces (supragingivally and subgingivally).

Root planing: Removal of cementum or surface dentin that is rough or impregnated with calculus, toxins, or microorganisms to produce a smooth, hard, clean root surface.

Instruments used:

Hand instruments: sickle scalers, Gracey curettes (area-specific), universal curettes
Powered instruments: ultrasonic (magnetostrictive, piezoelectric), sonic scalers

Healing after SRP:

Long junctional epithelium forms (repair, not regeneration)
Reduction in probing depth: average 1-2 mm for shallow pockets, 2-3 mm for deep pockets
Gain of clinical attachment: 0.5-1 mm for shallow, 1-2 mm for deep pockets
Best results in pockets 4-6 mm

Adjunctive Antimicrobial Therapy

Systemic Antibiotics (adjuncts to SRP, not monotherapy)

Indication	Antibiotic
Aggressive periodontitis	Amoxicillin + Metronidazole (500 mg TID x 7 days)
Refractory periodontitis	Metronidazole, Ciprofloxacin
Actinobacillus-associated	Amoxicillin + Metronidazole
Penicillin allergy	Clindamycin or Azithromycin

Local Drug Delivery

Arestin (minocycline microspheres 1 mg) - placed in pockets after SRP
Atridox (doxycycline hyclate 10%) - biodegradable polymer system
PerioChip (chlorhexidine gluconate 2.5 mg) - biodegradable chip
Elyzol (metronidazole 25% dental gel)

Antiseptics

Chlorhexidine gluconate (0.12-0.2%) - gold standard antiplaque agent; substantivity of 8-12 hours; reduces plaque and gingivitis; side effects: staining, taste alteration, calculus formation
Povidone-iodine, hydrogen peroxide (adjuncts)

Laser in Periodontal Therapy

Nd:YAG, CO2, Diode, Er:YAG lasers
Used for sulcular debridement, soft tissue curettage, pocket reduction
LANAP (Laser Assisted New Attachment Procedure) uses Nd:YAG

Occlusal Therapy in Periodontics

Traumatic occlusion acts as a co-destructive factor in the presence of periodontitis
Occlusal adjustment, splinting of mobile teeth, night guards
Bruxism management: occlusal splints

Endpoints and Re-evaluation Criteria

After Phase I, re-evaluate (4-8 weeks later):

Probing depth: pockets ≤4 mm with no BOP = healthy
BOP (Bleeding on probing): most reliable indicator of inflammation
Plaque index: patient compliance
Radiographic bone levels

Criteria for successful treatment:

No BOP
Probing depths ≤4 mm
No further bone loss
Patient compliance with OHI and maintenance

Healing of Periodontal Tissues

Types of healing after periodontal surgery:

Repair - long junctional epithelium forms (most common outcome)
Regeneration - new cementum, new PDL, new alveolar bone (true regeneration)
New attachment - union of connective tissue or epithelium with a root surface that has been deprived of its original attachment apparatus

New Attachment vs. Reattachment

Reattachment - reunion of connective tissue with a root surface on which connective tissue was present but was detached mechanically/surgically
New attachment - formation of new cementum with inserting collagen fibers on a previously diseased root surface

Periodontal Regeneration

The ideal goal of periodontal therapy. Requires:

Exclusion of epithelium and gingival connective tissue (GTR concept)
PDL cells must repopulate the root surface first (Melcher's hypothesis)
Adequate blood supply and clot stability

GTR Membranes:

Non-resorbable: expanded PTFE (e-PTFE), titanium-reinforced - require removal
Resorbable: collagen (BioGide), polyglycolic acid (PGA), polylactic acid (PLA) - no removal needed

Bone substitutes for grafting:

Autograft (iliac crest, intraoral bone) - gold standard, osteogenic
Allograft (DFDBA, FDBA) - osteoinductive/osteoconductive
Xenograft (bovine hydroxyapatite - Bio-Oss) - osteoconductive
Alloplast (beta-TCP, HA, bioactive glass) - osteoconductive

Summary Table: Phases of Periodontal Therapy

Phase	Name	Purpose
I	Etiotropic/Initial	Eliminate etiologic factors (plaque, calculus)
II	Surgical/Corrective	Correct residual defects, regenerate tissue
III	Restorative	Restore form and function
IV	Maintenance (SPT)	Prevent recurrence, lifelong monitoring

Key Carranza Principles to Remember for LAQ:

Periodontal therapy is cause-related before it is defect-corrective
Re-evaluation is mandatory between Phase I and Phase II
Maintenance is not optional - it is a distinct, permanent phase
The sequence must be followed: non-surgical first, surgical only if needed
Goal is regeneration, but repair (long junctional epithelium) is the more common outcome
Patient compliance with OHI and SPT determines long-term success

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