Guided By :

Dr. Balaji Manohar

Dr. Ravikiran N.
Dr. Neema
Presented By :
Dr. Aditi Mathur
Dr. Barkha Makhijani
Dr. Abhishek Gaur
 Periodontitis is an infectious inflammatory destructive
disease initiated by the microbial biofilm in a susceptible
host.
The effect of dental plaque on gingival health has been
early considered.
Periodontal disease is initiated by an infection;
however, it appears to behave not like a classic infection but
more like an opportunistic infection.
As a biofilm-mediated disease, periodontal disease is
inherently difficult to treat. One of the greatest challenges in
treatment arises from the fact that there is no way to
eliminate bacteria from the oral cavity, so bacteria will
always be present in the periodontal milieu.
 In addition, the bacteria within the biofilm
are more resistant to antimicrobial agents and
various components of the host response.

When certain, more virulent species exist in

an environment that allows them to be present in
greater proportions, there is the opportunity for
periodontal destruction to occur.

Although it is apparent that plaque is

essential for the development of the disease, the
severity and pattern of the disease are not explained
solely by the amount of plaque present.
In the 1960s , Loe and co-workers started a series of
experiment, beginning with his gingivitis study, proving that
plaque is the main etiological factor of the disease.
However, at the time, all plaques was consider bad,
regardless of the type of bacteria present. This is termed
“nonspecific plaque hypothesis”.

By the 1970s, specific bacteria changes was specified in

health and disease site, thus leading to the idea of “specific
plaque hypothesis”. This specific plaque hypothesis is
supported by present day approach to periodontal therapy.

Loe H, Theilade F, Jensen SB. Experimental gingivitis in man. J

Periodontology 1965:36:177-187.
 Emergency phase
Preferred sequence of Periodontal Therapy

Preferred sequence of Periodontal Therapy

Non-Surgical phase

Maintenance phase

Surgical phase Restorative phase

Treatment of Emergencies :
• Dental or Peri-apical
• Periodontal
• Other
Extraction of hopeless teeth and provisional replacement if needed (may be postponed to a
more convenient time)

Plaque control & Patient Education.

• Diet control.
• Removal of calculus and root planing.
• Correction of restorative & prosthetic irritational factors.
• Excavation of caries & restorations.
• Antimicrobial Therapy.
• Occlusal Therapy.
• Minor orthodontic movement
• Provisional splinting & prosthesis.
Evaluation of response to non-surgical phase
Rechecking :

Pocket depth & gingival inflammation.

Plaque & Calculus, caries.

Periodontal therapy, including placement of implants.

Endodontic therapy.

Final Restorations.
Fixed & removable prosthodontic appliances.
Evaluation of response to restorative procedures.
Periodontal Examination.
Periodic rechecking :

• Plaque & calculus

• Gingival condition (pockets & inflammation)
• Occlusion, tooth mobility
• Other pathologic changes.
 Dietary supplement use may modify the risk for the
development and progression of periodontal disease.
The antioxidant activity of nutrients such as vitamin C, and α-
tocopherol, and the anti-inflammatory activity of
polyunsaturated fatty acids may attenuate the development of
periodontal disease.

Studies using the NHANES III-a large cross-sectional

survey study-have demonstrated that lower vitamin C intake is
associated with a higher risk (OR 1.19) of having periodontal
disease, and that higher vitamin C intake is associated with a
reduced risk (OR 0.53) of severe periodontitis.

Chapple I.L., Milward M.R., Dietrich T. The prevalence of inflammatory periodontitis is negatively
associated with serum antioxidant concentrations. J. Nutr. 2007;137:657–664.
 In addition to maintenance of periodontal health, a
few studies have shown that diet may assist with wound
healing from periodontal procedures.

These few studies have shown that micronutrients

(vitamin D and the B vitamins) and macronutrients can
improve patient recovery following periodontal therapy.

Bashutski J.D., Eber R.M., Kinney J.S., Benavides E., Maitra S., Braun T.M., Giannobile W.V.,
McCauley L.K. The impact of vitamin D status on periodontal surgery outcomes. J. Dent. Res.
2011;90:1007–1012.
 Scaling and root planing treatments are only performed after a
thorough examination of the mouth.
Depending on the current condition of the gums, the amount of
calculus (tartar) present, the depth of the pockets and the progression
of the periodontitis, local anesthetic may be used.

Scaling – This procedure is usually performed with special dental

instruments and may include an ultrasonic scaling tool. The scaling
tool removes calculus and plaque from the surface of the crown and
root surfaces.
Root Planing – This procedure is a specific treatment which serves to
remove cementum and surface dentin that is embedded with unwanted
microorganisms, toxins and tartar. The root of the tooth is literally
smoothed in order to promote good healing. Having clean, smooth
root surfaces helps bacteria from easily colonizing in future.
The long term effectiveness of scaling and root planing depends
upon a number of factors.

These factors include patient compliance, disease progress at the

time of intervention, probing depth, and anatomical factors like
grooves in the roots of teeth, concavities, and furcation involvement
which may limit visibility of underlying deep calculus and debris.
Overcotoured restoration makes the professional and individual cleaning
impossible.
The overcontoured restorations protects only the plaque accumulation.

Effect of bad restoration quality on

periodontal health
Sub-gingival microbiological samples coming from the overhanging
margins composed a micro-flora resembling that of chronic periodontitis.
Increased proportions of Gram-negative anaerobic bacteria, black-
pigmented Bacteroides (Porphyromonas and Prevotella species) and an
increased anaerobe : facultative ratio were noted.
The overhanging restorations disturb the ecological balance in the
periodontal pocket and allow a group of disease associated organisms.
Lang P. N., Kiel A. R. , Anderhalden: Clinical and microbiological effects of subgingival restorations with overhangings or clinically perfect
margins. J. Clini Periodontol 1983; 10: 563-578.
 Goals of Non-Surgical
Periodontal therapy
The goal of therapy can be classified as :

1. Immediate
2. Ideal
3. Pragmatic
4. Ultimate goal
The immediate goal of therapy is to prevent, arrest, control, or
eliminate periodontal disease.

The ideal goal aims to promote healing through regeneration of lost

form, function, esthetics, and comfort.

When the ideal can not be achieved, the pragmatic goal of therapy
would be to repair the damage resulting from disease.

ultimate goal of therapy is to sustain the masticatory apparatus -

especially teeth, or their analogues, in the state of health.
Removal or disruption of DENTAL DEPOSITS and plaque-
retentive DENTAL CALCULUS from tooth surfaces and within
the periodontal pocket space without deliberate removal of
CEMENTUM as done in ROOT PLANING and often in
DENTAL SCALING.

The goal is to conserve dental cementum to help maintain

or re-establish healthy periodontal environment and eliminate
PERIODONTITIS by using light instrumentation strokes and
nonsurgical techniques (e.g., ultrasonic, laser instruments).
The disruption or removal of sub-gingival
microbial plaque and its byproducts from
cemental surfaces and the pocket space.
 PATIENT
EVALUATION/EXAMINATION
Evaluation of the patient’s periodontal status requires obtaining a
relevant medical and dental history and conducting a thorough clinical
and radiographic examination with evaluation of extra-oral and intra-
oral structures.

A medical history should be taken and evaluated to identify

predisposing conditions that may affect treatment, patient management,
and outcomes. Such conditions include, but are not limited to, diabetes,
hypertension, pregnancy, smoking, substance abuse and medications,
or other existing conditions that impact traditional dental therapy.

A dental history, including the chief complaint or reason for the visit,
should be taken and evaluated. Information about past dental and
periodontal care and records, including radiographs of previous
treatment, may be useful.
Extraoral structures should be examined and evaluated. The temporo-
mandibular apparatus and associated structures may also be evaluated.

Intraoral tissues and structures, including the oral mucosa, muscles of

mastication, lips, floor of mouth, tongue, salivary glands, palate, and
the oropharynx, should be examined and evaluated.

The presence and distribution of plaque and calculus should be

determined.

Periodontal soft tissues, including peri-implant tissues, should be

examined. The presence and types of exudates should be determined.

Probing depths, location of the gingival margin (clinical attachment

levels), and the presence of bleeding on probing should be evaluated.
 Muco-gingival relationships should be evaluated to identify
deficiencies of keratinized tissue, abnormal frenulum insertions, and
other tissue abnormalities such as clinically significant gingival
recession.

The presence, location, and extent of furcation invasions

should be determined.

In addition to conventional methods of evaluation; i.e.,

visual inspection, probing, and radiographic examinations, the
patient’s periodontal condition may warrant the use of additional
diagnostic aids. These include, but are not limited to, diagnostic casts,
microbial and other biologic assessments, radiographic imaging, or
other appropriate medical laboratory
tests.
All relevant clinical findings should be documented in the patient’s
record.

Referral to other health care providers should be made and

documented when warranted.

Based on the results of the examination, a diagnosis and proposed

treatment plan should be presented to the patient.

Patients should be informed of the disease process, therapeutic

alternatives, potential complications, the expected results and their
responsibilities in treatment.
 Precision-thin tip
advantages
Thinner and smaller than the working-end
of a curet.
Standard Gracey curets are too wide to
enter the furcation area of more than 50%
of all maxi. and mandi. first molars.
Precision-thin tips have been shown to
reach 1mm deeper than hand instruments
and to teach the base of the pocket in 86%
of 3-9mm pockets
Gain in attachment level
Repopulation of Pockets
Clinical skill & time spent
 Furcations

Root anatomy

Pocket depths
Beck et al., 2009
1. Carranza 10th Edition
2. NON-SURGICAL PERIODONTAL THERAPY – Stephen
M. Huppert.
3. Minimally-Invasive Non-Surgical Periodontal Therapy –
Philip Ower, May 2013.
4. J Clin Periodontol 2012; 39: 1065–1074.
5. NONSURGICAL PERIODONTAL THERAPY Instructed
by Kelli R. Illyes, R.D.H, M.D.H.
6. Nonsurgical Approaches for the Treatment of Periodontal
Diseases Maria Emanuel Ryan, DDS, PhD, Dent Clin N
Am 49 (2005) 611–636