root planing
DESCRIPTION
root planing/ root debridement, instrumentation,TRANSCRIPT
ROOT PLANING
• Marginal periodontitis is induced by
bacterial plaque deposits and maintained by
subgingival plaque and calculus present on
root surfaces.
• Therefore therapy of periodontally involved
teeth is primarily directed towards removal
of these accretions from root surfaces in
order to allow for healing.
Non surgical therapyNon surgical therapy is defined as “plaque removal,
plaque control, supra and sub gingival scaling, root
planing and the adjunctive use of antibiotics.”
(Ciancio 1989,1992)
Scaling is the process by which plaque and calculus are removed from both supragingval and subgingival tooth surfaces .
Root planing: instrumentation to remove the microbial flora on the root surface or lying free in the pocket, all flecks of calculus and all contaminated cementum and dentin.( O Leary, 1977)
• DCNA
Meticulous instrumentation of the cemental
surface of the root during periodontal treatment
for the purpose of removing all the dental
accretions(calcified and noncalcified) to render the
surface biologically clean and clinically smooth
CLOSED DEEP SCALING
ROOT SURFACE
DEBRIDEMENT
ROOT SURFACE INSTRUMENTATION
ROOT DETOXIFICATIO
N
SYNONYMS
ROOT SURFACE DEBRIDEMENT OR
ROOT SURFACE INSTRUMENTATION
Debridement of the root surface with only
few strokes, and not to undertake
aggressive instrumentation to remove the
endotoxin and other root surface
irregularities
• This term has appeared recently in the literature to better describe periodontal instrumentation associated with periodontal therapy.
• “the treatment of gingival and periodontal inflammation through mechanical removal of tooth and root surface irritants to the extent the adjacent soft tissues maintain or return to a healthy , non inflamed state”
SCALING ROOT PLANING PERIODONTAL DEBRIDEMENT
Removal of calculus from all tooth surfaces and removal of cementum from root surfaces
Removal of plaque biofilms and calculus from tooth surface and within the pocket space
Aggressive instrumentation removes significant amounts of cementum
Conservation of cementum is a goal; bacterial products are removed with ultrasonic instruments or light instrumentation strokes
Hand activated instrumentation A combination of hand activated and ultrasonic instrumentation preferred
CLARITY OR CONFUSION- BEST WAY TO DEBRIDE
ROOT SURFACES
• “Root planing implies removal of cementum (and possibly dentine) exposed within the pocket to maximise the chance of removing all components of the subgingival plaque....
• Subgingival scaling is the removal of deposits of subgingival calculus
• “....in reality the procedures are similar and the term ‘root surface debridement’ is often used as a more generic term.”
• Subgingival Plaque Control - The Clinician( BDJ)
RATIONALE OF ROOT PLANING
REMOVAL OF DISEASED
CEMENTUM
GLASSY SMOOTH TOOTH SURFACE
NEW ATTACHMENT
Stripped of periodontal attachment
Contains remnants of embedded calculus, whole bacteria, and the products of microbial life.
Exposed to septic contents of periodontal pocket
DISEASED/ALTERED/NECROSED CEMENTUM
CHANGES IN DISEASED
CEMENTUM
STRUCTURAL CHANGES
• Hypermineralization/ Demineralization
• Presence of pathological granules
CHEMICAL CHANGES
• Changes in conc of Ca, Mg, Phosphate
• Adsorption from saliva
CYTOTOXIC CHANGES
• Adsorption of endotoxins
• Invasion of bacteria• Cell mediated
resoption lacunae
• Polson and Caton( 1982)
Role of reduced Periodontium and altered root surface
Role of altered root surface on wound healing
Experimental Periodontitis
Rhesus monkey
Block sections of periodontium evaluated after 40 days
• RESULTS
No new CT attachment . pathologically
altered root surface although placed in
healthy periodontium
• CONCLUSION
pathologically altered root surface rather
than reduced periodontium – prevented
regeneration
ENDOTOXINS• THE MOST COMMONLY STUDIED SEPTIC
COMPONENT IN DISEASED CEMENTUM IS ENDOTOXIN.
• THEY ARE LIPOPOLYSACCHARIDE OF GRAM NEGATIVE BACTERIA.
ROLE OF ENDOTOXINS
PYROGENICITYATTRACTION OF INFLAMMATORY
CELLS
ACTIVATION OF COMPLEMEMT
SYSTEM
STIMULATION OF
OSTEOCLASTIC ACTIVITY
MITOGENIC ACTIVITY
FIBROBLAST CYTOTOXICIT
Y
• Aleo et al. (1974)
LIMULUS LYSATE ASSAY
Periodontally involved root surfaces contained an
endotoxin-like material capable of depressing cell
growth of tissue culture fibroblasts.
Conclusion led to the long accepted concept that
endotoxin lies within cementum, and that cementum
removal during periodontal therapy might be
appropriate.
HATFIELD AND BAUMHAMMERS( 1971)
Periodontally involved roots which had been washed
and scaled (not root planed) and placed these roots in
sterile tissue cultures.
Controls - uninvolved third molar roots.
Results: After 24 to 96 hours, cell cultures over control
roots showed irreversible morphologic changes.
Conclusion: presence of some toxic factor, possibly
endotoxin, which had penetrated the diseased root and
was capable of upsetting cell attachment.
Jones and O’leary (1978)
• Effect of vigorous root planing on quantity of
endotoxin.
• 50 root surfaces each of
Diseased 146.8ng
Healthy roots(0.05-0.45ng)
• Meticulous instrumentation was performed.
• RESULT: Root planed roots contained only
about 1 ng more endotoxin than healthy
root surfaces. This small difference can be
accounted for small flecks of calculus
remaining after planing.
• Conclusion: Root planing performed in the
study was able to render diseased root as
free of endotoxin as healthy root.
ENDOTOXIN PENETRATION
• Endotoxin and whole bacteria may be found as deep as 12 microns beneath the cemental surface.
• Zander (1953)Penetration of calculus bacteriaCalculo-cementumMust be removed
• Selvig (1969)Normal appearing areasAreas of decreased radio- opacity & cavitationAreas of partial decalcification (300µ)Highly mineralized areas
ENDOTOXIN DOES NOT PENETRATE BUT LOOSELY
ATTACHED SUPERFICIAL LAYER
Nakib et al (1982)• Weakly adherent• No penetration into cementum• Brushed away
Nyman et al (1986)• Study on dogs• Endotoxins did not interfere with healing
following flap surgery once soft deposits were removed
• Endotoxin removed with bacteria during polishing
within cementum. Neutralized by inflammatory response
OPPOSING STUDIES
• Moore & coworkers (1986)
Toxins(LPS) weakly bound to root
surface
Washing for 1 minute removes 40%
Brushing for 1 minute removes 60%
Remainder1%
REMOVAL OF DISEASED
CEMENTUM• The portion of root exposed to the disease
process has little or no fibroblast cells attachment to the remainder of root surface. Following the mechanical removal of diseased cementum and the bacterial endotoxin, the cells attached normally on the planed root surfaces. The cementum bound endotoxin is capable of both cell death and decreased cell proliferation ( Simon, Goldman 1971)
LOPEZ et al,1980
• Inflammatory potential of diseased cementum
• Histologic results showed –
Implanted fragments from roots that had been scaled
caused the most response with acute inflammation up
to 14 days and chronic inflammation to 21 days.
Autoclaved Fragments- the acute inflammation was
not as severe.
• Autoclaved and planed roots- even less acute inflammation was seen in the 7-day specimens while some chronic inflammation persisted in the 21-day specimens.
• Implants from healthy roots evoked no response.
• The inflammation caused by the autoclaved diseased cementum: attributed to thermo-stable endotoxin.
• Conclusion- Necessary to remove all of the cementum exposed to the pocket to eliminate its potential for inducing inflammation
CONTRADICTORY STUDIES
• Nyman et al. (1986) demonstrated in beagle dogs that
the removal of diseased cementum was not necessary
for successful periodontal therapy.
• In a later study in humans, Nyman et al. (1988)
showed that the same degree of improvement of
periodontal status was achieved regardless of whether
cementum was removed or not.
• Results : Intentional root cementum removal is not
necessary for optimal postoperative healing.
ROOT SMOOTHNESS• EMPHASIS IN ROOT PLANING HAS ALWAYS BEEN ON
THE ELIMINATION OF PLAQUE AND CALCULUS ALONG
WITH SMOOTHENING THE ROOT SURFACE.
• HOWEVER THE IMPORTANCE OF ROOT SMOOTHNESS
NOT ESTABLISHED.
Jens Waerhaug(1956)
Effect of rough surfaces upon gingival tissue,
EXPERIMENT IN DOGS Described the irritating effect of calculus that is caused by bacteria or toxin.
• Emphasized - rough surface facilitates the retention
of bacterial plaque and stressed the needs of well
polished restoration below the gingival margin.
• Supported by :Lindhe et al1984Lekens KN 1996Quiryen N 1995
Rosenberg & Ash(1974)
Profilometer
Sig diff b/w curretted & control teethNo significant diff in mean plaque scores/inflammatory indicesRoot roughness not significantly related to mean inflammatory index
Khatiblou & Ghodssi (1983)Healing following surgical RxHealing not affected by root roughness
Hunter et al (1984)Gouges/ ripples ≤ 50µ smoothBiologically lack of evidence relating smooth surfaces to plaque formationRough area favor plaque & calculusSmoothness only indicator of calculus removal
OPPOSING STUDIES
PREPARATION FOR NEW
ATTACHMENT• Removal of contaminated root surface
Root surface demineralization with citric acid
Pre requisite for new connective tissue attachment
Accelerates new attachment in healing periodontal wounds
• Removal of hypermineralized surface- Prerequisite for effective demineralization.
• ROOT PLANING –
Prepared root surface for demineralization
New attachment
• Garrett et al (1978)
SEM & TEM
Citric acid- no effect on unplaned roots
Planed root surfaces- 4nm wide areas of demineralization
Failure- hypermineralized areas on diseased roots
• Polson et al (1984)
Root planing (smear layer)2-15µm thick
Citric acid (ph1 for 3 min)
Removal of smear layer
Fibrous mat like structure
Not evident on unplaned roots
OBJECTIVES OF ROOT PLANING
Restore health• Remove elements that provoke
gingival inflammation
Remove pathogenic microflora
• O’ LEARY
Biologically acceptable root surface
Probing depth
Resolving inflammation
Facilitating oral hygiene
Improving & maintenance of
attachment levels
Preparing tissues for surgical
procedures
INSTRUMENTATION
Hand instruments
• HOE
Blade, bowed -2 point contact instrument
Single blade 99-100, bevelled at 45o
Macalls type and Holst type
FILES
Series of cutting edge lined up on a single base
Series of hoes mounted on the base
Mode of use- held parallel to calculus and crushed,
Use of curette
• CHISEL
Only instrument used with the push motion
No more used for root planing
• CURETTES
Instrument of choice for root planing
Curved blade and rounded toe better adapted to the
root surface
2 TYPES –AREA SPECIFIC AND UNIVERSAL
• Universal curettes have limited adaptability:
Deep pocketsRoot convexities, and Developmental depressions
Gracey curettes are the new modifications
which are area specific and specially designed for
subgingival scaling and root planing in periodontal patients.
• Gracey curettes are a set of area-specific instruments .
• Designed by Dr. Clayton H. Gracey of Michigan in the mid-1930s
Four design features make the Gracey curettes unique: (1) They are area specific, (2) Only one cutting edge on each blade is used, (3) The blade is curved in two planes, and(4) The blade is “offset
Extended-Shank Gracey Curettes
• 3 mm longer in the terminal shank
• Deep pockets on maxillary
and mandibular posterior teeth,
Mini-Bladed Gracey Curettes
Mini-bladed Gracey curettes, such as the Mini Five
curettes and the Gracey Curvettes,
Terminal shank that is 3 mm longer than the standard
Gracey curettes
Blade that is 50% shorter.
Micro Mini Five curette blades are 20% smaller than Mini
Five curette blades
Standard Gracey curet vs a “Mini- Gracey
curet”.
GRACEY CURETTEMINI GRACEY CURETTE
• Micro Mini Five Gracey curettes (Hu-Friedy)
• Blades that are 20% thinner and smaller than the Mini Five curettes
• These are the smallest of all curettes,
• Provide exceptional access and
adaptation
• Deep, or narrow pockets; narrow
furcations; Developmental depressions;
line angles; and deep pockets on facial,
lingual, or palatal surfaces.
Langer and Mini-Langer Curettes
• Set of three curettes• Combining the shank design of the standard Gracey
#5-6, 11-12, and 13-14 curettes with a universal blade honed at 90
Marriage of the Gracey and universal curette
QUENTIN FURCATION CURETTE
• Shallow half moon radius that fits in to the roof or floor of the furcation
• Shanks are slightly curved• Available in two width, BL1 & MD1 – small and fine
0.9 mm width• BL2 & MD2- larger 1.3 mm
Diamond coated files• Coated with fine grit diamond . Do not have cutting
edge• Sharply abrasive – produce smooth, even clean
surface• Particularly used along with the endoscope• Disadv : can cause over instrumentation
• Diamond-coated ultrasonic instruments will
effectively plane roots, and that caution should be
used during periodontal root planing procedures.
Additionally, the diamond-coated instruments will
produce a rougher surface than the plain inserts or
the hand curettes.
( Vastardis 2005)
ULTRASONIC AND SONIC
INSTRUMENTS• Magnetostricitve & Piezoelectric• Air or sonic• Operated by the air line usually connected to air
turbine
COBB et al 2002• “When one considers the demands of clinical skill,
time and stamina, the instrument of choice for
universal application would appear to be either a
sonic or ultrasonic scaler.”
PERIOSCOPY SYSTEM
• The Perioscopy system consists of a 0.99-mm-diameter, reusable fiberoptic endoscope over which is fitted a disposable, sterile sheath.
Allows clear visualization deeply into subgingival
pockets and furcations
Permits operators to detect the presence and location
of subgingival deposits and guides them in the
thorough removal of these deposits.
Magnification ranges from 24X to 48X, enabling
visualization of even minute deposits of plaque and
calculus
PERIO TOR• Specially designed to optimize cleaning and planing
of the rough root cementum and • Prevent further removal of root cementum once the
surface is clean and smooth.
PERIOTOR
CURETTE ULTRASONIC/HANS SCALER
Vector™ system • Specially devised to reduce the amount of tooth
surface loss and treat the periodontal tissues less aggressively.
• Uniqueness of this system lies in the oscillations produced by the ultrasonic tip.
• Ultrasonic tip of this system vibrates
parallel to the tooth surface, which leads to
less removal of the tooth structure.
• Reduction in pain perception of the patient.
This may be attributed to vertical vibrations
of the ultrasonic tip.
AUTHOR STUDIES RESULTS
SCULEAN et al 2004 (Vector-ultrasonic system) or scaling and root planing (SRP) using hand instruments.
Non-surgical periodontal therapy with the tested ultrasonic device may lead to clinical improvements comparable to those obtained with conventional hand instruments.
DAHIYA et al 2011,2012
Gracey curette, ultrasonic tip and rotary bur, compared for root debridement
Favored the use of rotary instruments for root planing to achieve a smooth, clean root surface; however, the use of rotary instrument was more time consuming,
MARDA et al ,2012 Compare the remaining calculus, loss of tooth substance, and roughness of root surface after root planing with Gracey curette, ultrasonic instrument (Slimline® insert FSI-SLI-10S), and DesmoClean® rotary bur.
Slimline™ insert was shown to be better than the other methods as assessed by the indices scores and the instrumentation time.
Ana Chapper,2005 Compared the clinical effects of hand or ultrasonic scaling and root planing on the treatment of chronic periodontitis. ( BOP, PD,CAL)
Methods of subgingival instrumentation were equally efficacious in the improvement of the studied clinical parameters.
LASERS• ABLATIVE LASER THERAPY
Removes plaque and calculus with low mechanical stress
No smear layer
Can be reached to all the areas
Photoablative and Photodynamic diode laser in adjunct to
scaling -root planing (SRP) Diode laser treatment
(photoablation followed by multiple photodynamic cycles)
adjunctive to conventional SRP improves healing in
chronic periodontitis patients.
AUTHOR STUDIES RESULTS
Liu CM,1999 Nd:YAG laser treatment versus scaling/root planing (SRP) treatment on crevicular IL-1beta levels
SRP was found to have a superior IL- 1beta response,
Matthias Kreisler,2005
Clinical efficacy of semiconductorlaser periodontal pocket irradiation as an adjunct toconventional scaling and root planing.
Lasers can be recommended as anadjunct to conventional scaling and root planing.
Schwarz F,2001 Effectiveness of an Er:YAG laser to that of scaling and root planing for non-surgical periodontal treatment.
Er:YAG laser may represent a suitable alternative for non-surgical periodontal treatment
AIR POLISHING• The air-abrasive technology uses an abrasive powder
introduced into a stream of compressed air to clean or polish a surface by removing deposits attached to it or smoothing its texture.
PERIOPLANER/PERIOPOLISHER
• The system involves two motor driven handpieces.
One handpiece works with curettes and hoes
(Perioplaner) and the other works with diamond-
layered instruments (Periopolisher)
• Study has shown that the use of the Perioplaner and
Periopolisher results in about the same loss of root
substance as the use of hand instruments.
• Schweiz MZ, 1991
ROOT PLANING PROCEDURE
SUBGINGIVAL CALCULUS TENACIOUS
VISION OBSCUED BY BLEEDING
MUST RELY ON TACTILE SENSITIVITY
SRP COMPLEX THANSUBGINGIVAL SCALING
INSTRUMENT SELECTION
BEGIN WITH SMALL FILES/ HOES
LOWER POWER SET ULTRASONIC/SONIC SCALER OR RIGID CURET
FINISH WITH FINISHING CURET
STRATEGIES FOR INSTRUMENTATION
• SELECTION OF CURET
FINE SET: NON RETRACTABLE TISSUE
HEAVY SET: RETRACTABLE TISSUE
MEDIUM SET: RETRACTABLE TISSUE
• FINGER REST/GRASP
Grasp- modified pen and stable finger rest
Identify the cutting edge of curette
• ACTIVATION OF INSTRUMENT
Adaptation- lower shank parallel
Angulation- 45- 90 degree established
• STROKES
Stroke length
Stroke direction
Stroke activation
Terminal shank parallel to tooth long
axis.
• STROKE DIRECTION
Vertical and oblique strokes are most effective
strokes for root planing and exploring.
VERTICAL OBLIQUE HORIZONTAL
• STROKE LENGTHRoot planing strokes extend from the base of the pocket to the cemento enamel junction.
• STROKE ACTIVATIONWrist forearm motion is the fundamental means of activation.
CHANNELS OF INSTRUMENTATION
• FORCE MAXIMIZED BY SCALING IN CHANNELS AND
BY CONCENTRATING PRESSURE ONTO LOWER ONE
THIRD OF THE BLADE.
• Overlapping , short powerful stroke- Large calculus
removal( Carranza,10th ed)
• Root planing stroke- Long lighter overlapping with
less lateral pressure( Carranza,10th ed)
TERMINAL FEW MILLIMETERS OF THE BLADE ENGAGES THE LATERAL EDGE OF THE DEPOSIT
WITHOUT WITHDRAWING THE INSTRUMENT, LOWER THIRD OF THE BLADE ADVANCED LATERALLY AND REPOSITIONED TO ENGAGE THE NEXT PORTION
CHANNELS ON TOOTH
SURFACE
• HEAVY LATERAL PRESSURE WITH SHORT
CHOPPY STROKES AFTER CALCULUS
REMOVAL- ROOT SURFACE WITH NICKS
AND GOUGES
• HEAVY LATERAL PRESSURE WITH LONG
STROKES- SMOOTH BUT DITCHED OR
GOUGED ROOT SURFACE
NUMBER OF STROKES
• Root modification using periodontal curette- 10 to 70 strokes
• 20 strokes are sufficient for removing cementum • Aggressive root planing involves -10 or 20 strokes
more
• Study used a piezo-electric receiver
mounted into the upper shank of a curet in
Gracey 1/2 design.
• Results - 40 strokes at low force removed
148.7 μ and at high forces 343.3 μ .
With an increasing number of strokes the
amount of substance removed per stroke
became less. (Zappa et al,1991)
• Oda (1992)Series of in vitro studies
2 scaling strokes with a sharp manual scaler – enough to remove endotoxin
• Moore (1986)Gentle washing in water for 1 min or brushing with slowly rotating brush is enough to remove endotoxin
Ultrasonic scalers with its cavitational effect considered effective for removal of Endotoxin
Manual scalers
• Horning(1987) -57.8μ/40 strokes• Coldiron et al(1990) - 60μ/20 strokes
• Ishizuker and co workers(1980)3.9μ with 750g lateral pressure with 50 strokesFine curettes- 9.1μ with clinically applied force/working stroke
CEMENTUM REMOVAL
• U.S scaler-1 to 7.2 μ
• Sonic-4.3 to 7.8 μ
• Diamond file- 7.9 to 15.5μ
• Fine curette- 5 –22μ/stroke
ULTRASONIC SCALERS REMOVE LESS CEMENTUM BUT
LEAVE A ROUGHER SURFACE.( KOCHER ET AL 2001)
Pain and discomfort during SRP
• Tissue trauma due to inadvertent curettage
Philstrom( 1999)
• Pain of significant duration, peak in intensity
between 2 and 8 hrs post SRP- almost 25 % self
medicated
• Small portions of patients noted root sensitivity ,
reduction occurred over 4 weeks . Tammaro et al
( 2006)
• Steenburgh et al ( 2004)
1/3 of patients taking analgesia
1/2 of the total patients revealed gingival soreness
2/3 complained problem while eating.
• Ettin et al ( 2006)
Pre-emptive analgesics (ibuprofen arginine)may have
some beneficial effect.
LA DURING ROOT PLANING
• Usually do not require.
• Patients vary in their ability to tolerate pain.
• LIDOCAINE 25mg/g can be an useful alternative to injections anesthesia in pain sensitive patients. (Magnusson 2003)
• Perry DA et al,2008
Transmucosal lidocaine patches provided sufficient
anaesthesia for therapeutic quadrant scaling and root
planing procedures.Lidocaine patch (46.1mg/2m)
compared to placebo patch VA scale for pain
Results greater pain relief with treatment patches after
15 min and at the end of treatment.
• Scotelberg JL(2007)
Compared 20% topical benzocaine gel to 2%
injected lidocaine
21 patients – divided 2 groups
Results
• The injected anaesthesia had less pain
• 11 participants preferred topical – fear of injection
• Lidocaine plus prilocaine in a thermosetting agent
also has been shown to be effective in controlling
intra-operative pain during scaling and root
planing (Jeffcoat et al. 2001, Donaldson et al.
2003, Magnusson et al. 2003).
• Topical anaesthetics may be preferred over
injected anaesthetics .
EVALUATION OF SRP
• ROOT SMOOTHNESS
• HEALING OF SOFT TISSUE FOLLOWING SRP
ROOT SMOOTHNESS• RELATIVE SMOOTHNESS OF THE ROOT SURFACE IS THE
BEST IMMEDIATE CLINICAL INDICATION OF ADEQUATE
INSTRUMENTATION.
• Hu friedy 3-A
• No 17 or orban
• Pig tail (no 3ML)
• generally thin and good tactile sensitivity, working end
is curved, permits easy adaptation, enough to extend
to deep pocket
ODU- 11-12,
• Adapted from the gracey curette 11-12 by faculty of
old Dominion university
• Combines pigtail design with a long shank – deep
pockets
• Smoothness- does not guarantee the complete
removal of calculus
HEALING SEQUENCE
Histologic studies –humans and primatesLong junctional epithelium – repairNew dentogingival junction firms within 2 weeks
• Sequence
• 1-3 days • Hyperaemia, change in color& edema
PERIODONTAL DEBRIDEMENT
1 -2 weeks
• Resolution of edema
• Shrinkage of the gingival margin
• Color is about to normal
• Little or no bleeding/suppuration
2-3 weeks
• Color is normal
• Consistency firm ,no bleeding
• Reduced tooth mobility
• Histologically- connective tissue maturation-21 to
28 days, establishment of GM- 3-6 months
HEALING- CLINICAL END POINTS
• CLINICAL EVALUATION OF SOFT TISSUE RESPONSE
INCLUDING PROBING NOT CONDUCTED PRIOR TO
2 WEEKS FOLLOWING SRP.ASSESSMENT 4-6
WEEKS AFTER THERAPY.REPAIR CAN CONTINUE
FOR ADDITIONAL 9 MONTHS.
• RE EPITHELIAZATION OF THE WOUND CREATED
DURING INSTRUMENTATION TAKES FROM 1 TO 2
WEEKS.
MOST COMMON END POINTS EVALUATED:
• PROBING POCKET DEPTH
• CLINICAL ATTACHMENT LEVEL
• REDUCTION IN BLEEDING SITES AND EDEMA IS A
SURROGATE INDIACTOR FOR THE RESOLUTION OF
GINGIVAL INFLAMMATION.
Hajol(2004)
• True end point- relief of pain, esthetics, and chewing
comfort
• Surrogate end point- No B.O.P. , pocket closure,
attachment gain, and tooth loss
Probing depth and CAL
A)Clinical attachment levels:
• Loss of attachment low initial PD
• Gain Deeper PD
Proye et al (1982):
• Recession after 1 wk (0.84mm)
• Gain after 3 wks (0.52mm)
• Probing depths reduced to1.36mm
COBB 1996
• 1-3 MM PD RED OF 0.03MM CAL 0.34MM
• 4-6MM PD RED OF 1.3MM WITH GAIN OF 0.55MM
• >7MM PD RED 2.6MM WITH GAIN OF 1.19MM
• SIMILAR RESULTS REPORTED BY VENDER WEJDEN ET
AL, 2002
• HALF OF THE DECREAE IN PROBING DEPTH
ATTRIBUTED TO ATTACHMENT GAIN AND THE
REMAINING DECREASE IS THE RESULT OF
CHANGE IN GINGIVAL MARGIN POSITION.
Critical probing depth ( LINDHE et
al,1982)
BELOW- LOSS OF ATTACHMENT LEVELABOVE- GAIN IN ATTACHMENT LEVEL
2.92mm- Root planing4.2mm- Flap debridement surgery
Creeping attachment
• Goldman proposed the term mainly following FGG
• Coronal shift in the position of the gingival margin
Aimetti et al (2005)
• Coronal shift of 0.40 to 0.89 mm ( several
other studies reported same)
• This achieved complete root coverage
45.83% in 12 month
Reasons for root coverage in root
planing
• Initially thick gingiva will have better root coverage
• Reduction in the convexity of the root and m-d
distance between the periodontal space
• Plaque free and flat root surface helps in easy
regrowth of the marginal tissue
MICROBIOLOGICAL CHANGES
• DECREASE IN GRAM NEGATIVE MICROBES
ACCOMPANIED BY AN INCREASE IN GRAM POSITIVE
COCCI AND RODS.
• DOMINANCE BY BENEFICIAL SPECIES RESULTS IN:
DECREASE IN GINGIVAL INFLAMMATION
DECREASE IN PROBING DEPTH
DECREASE IN BLEEDING ON PROBING
COBB ET AL,2002
CUGNI ET AL 2000DNA PROBE COUNT STUDY
• DECREASE IN T.FORSYTHUS, P.GINGIVALIS,
T.DENTICOLA AND INCREASE IN ACTINOMYCES
SPS, STEPTOCOCCI, F.NUCLEATUM,VEILONELLA.
• SIMILAR RESULTS REPORTED BY HAFFAJEE1997,
MOMBELLI 2000.
Teles et al ( 2006)• Bacterial count decreased from 91+ 11x 105 to
23+6 x 105
Darby et al ( 2005) • Decreased T. forsythia and T.denticola several
week following SRP
Bickler et al ( 2004)• if home care not followed, re-establishment of the
pathogenic flora and rebound in the clinical parameters occur.
Haffejee( 2006) • Increase in the Streptococci and Actinomyces
species 3 months past SRP • Also noted re-emergence in the red complex and
orange complex 3 to 12 months results in the increase loss of attachment
Re-emergence can occur from following locations;
• Residual subgingival plaque deposit
• Radicular dentin or cementum
• Pocket epithelium or connective tissue
• Supragingival plaque deposits
• Subgingval deposits of adjacent teeth and from
intraoral soft tissue sites
EFFECT ON DENTIN AND PULP
• Minor structural alterations of both root surface and
restoration margins.(Lee SY,1995,Eberhard ,2003)
• Dentinal tubules are exposed, leading to direct
avenues to the pulp for bacteria and bacterial
elements present in the oral environment
(Bergenholtz
• & Lindhe 1978).
• Root sensitivity occurs in approximately half of the
patients following subgingival scaling and root
planing. The intensity of root sensitivity increases for
a few weeks after therapy, after which it decreases.(
Von Troil,2002- systematic review)
• Unnecessary excessive root substance loss (hour-
glass shaped roots),
• Root fracture or Pulpitis
SRP IN COMBINATION WITH PHOTODYNAMIC
THERAPY• SRP in combination with PDT seems to be
effective and Is therefore suitable as an adjuvant therapy to the mechanical conditioning of the periodontal pockets in patients with chronic periodontal diseases. (Berakdar 2012)
SRP WITH AND WITHOUT PERIODONTAL
FLAP
• Mean accessible depth by curettes – 4.6 mm
Supported by:
• RABBANI et al,1981 concluding that curettes can
not reach to a depth of more than 4 mm.
• CLIFFORD,1999: Available depth for curettes has
been re-ported to be 3.45 mm .The maximum
accessible depth was found to be 6 mm in distal
and buccal surfaces
• 1.Periodontal flaps for access provide a means for
greater reduction of residual calculus.
• 2. Periodontal flaps for access provide a means to
achieve more tooth surfaces free of calculus in
pockets >3 mm.
• 3. The % of residual calculus is related to probing
depth, despite the treatment approach.
• 4. Anterior and posterior teeth respond similarly.
CAFFESSE 1986
WYLAM ET AL 1993• Sixty multi-rooted teeth were assigned to one of
three groups:
Untreated controls,
Closed scaling/root planing, and
Open flap scaling/root planing.
• No significant difference in the percent stained
residual plaque and calculus in shallow areas of the
• Furcation regions demonstrated heavy residual
stainable deposits for both treatment methods, with
no significant differences between techniques.
QUIRYNEN ET AL Full mouth disinfection vs PDS vs full mouth root planing
Greater gain in clinical attachment and less bleeding upon probing with FRP and FDISReduced motile forms by 20%
BOLLEN ET AL 1998 FDIS VD PDS Better gain in clinical attachment levels with fdisFdis reduced motile rods and spirochetes reduced by 10% whereas pdis reduced by 20%
AUTHOR STUDIES RESULTS
Eberhard et al (Cochrane SR 2008)
Full-mouth disinfection for the treatment of adult chronic periodontitis
The treatment effects of FMD compared with conventional SRP are modest and the implications for periodontal care are not profound.”
Sanz & Teughels 6th (EWP 2008)
FMD and chronic periodontitis
Need to investigate the impact of different mechanical debridement protocols on patient centred outcomes and cost-effectiveness using appropriate methodology”
NON SURGICAL THERAPY VS SURGICAL THERAPY
Meta analysis
• Knowles( 1979)• Split mouth design• RP, RP+curettage, MWF, APF• 3 month maintenance, 6 yr follow up• Surgical technique better pocket depth reduction• All tech. yielded gain in attachment in deeper
• Kaldahl (1988, 1996)
• Split mouth
• Root Planing Vs Modified widman flap
• 6 yr follow up
• Result favored non surgical treatment
Conclusion:
• Shallow pocket- no significant difference of ---0.02
mm after 6 years
• Medium pockets- no significant difference of –
0.22 mm after 6 years
• Deep pockets – the difference is 1.03 mm after 6
months to 0.22 mm after 6 years
SRP VERSUS CURETTAGE
• CurettageClosed definitive surgical procedure aimed at pocket elimination, reattachment or new attachment.Removes pocket epithelium intentionally
WORLD WORKSHOP IN CLINICAL PERIODONTICS,1989Gingival curettage as a separate procedure has no justifiable application during active therapy during chronic preriodontitis.
Without clean, hard roots results of curettage are limited.(Cohen,2007)
Limitations
Anatomy of rootsDepth of pocketsPosition of teethInadequate instruments for diagnosisInadequate instruments for treatmentArea of mouth being treatedSize of mouthElasticity of cheeksRange of openingDexterity of operator
• Total substance removal by instrumentation
includes calculus and root substance removal.
• Calculus removal seems to require less than 20
working strokes to be complete, relative to a
standard area of 1-mm width on the
circumference of the root. The following strokes
serve only to remove root substance, which
seems to be unnecessary.
• Endotoxin removal is nearly completed after the
same number of working strokes, reaching levels
similar to periodontally healthy teeth. Clearly
these levels are low enough to enable good
clinical healing.
• Aggressive scaling and root planing might be
counterproductive for the future health of the
periodontally diseased tooth.
SUMMARIZE
Deep Endotoxin penetration
Endotoxin as a superficial layer
ROOT DEBRIDEMENTROOT CONDITIONING
• Clinicians should choose the modality of
debridement according to the needs and the
preferences of the patient, their personal skills
and experience, the logistic setting of the
practice and the cost-effectiveness of the therapy
rendered”
Thank you