Upload
dra-luz-de-guzman
View
83
Download
1
Tags:
Embed Size (px)
Citation preview
Page 1
Non–surgical TherapyLuz D. Villanueva D.M.D.
Page 2
Typical Tx regimen for periodontities Px Management
Page 3
Aims of Non-surgical Therapy
1. Eliminate both living bacteria in biofilm and calcified biofilm microorganism from tooth surface and adjacent soft tissues.
1. Create an environment in w/c the host can more effectively prevent pathogenic microbial recolonization using personal oral hygiene methods.
Page 4
Detection and removal of dental calculus
• WAERHAUG J ( 1952) The gingival pocket; anatomy, pathology, deepening and elimination .
• The rough surface of calculus does not in itself induce inflammation but that the deleterious effect of calculus relates to its ability to provide an ideal surface for microbial colonization.
Page 5
Detection and Removal of dental calculus
• Listgarten & Ellegaard ( 1973) Electron microscopic evidence of a cellular attachment between junctional epithelium and dental calculus. Journal of Periodontal Research, 8, 143-150
• Epithelial adherence to subgingival calculus can occur following its disinfection with chlorhexidine.
• Eliminate surface irregularities as much as possible
Page 6
Removal of tooth substance is not necessary???
• Hughes FJ, Smales FC. (1986) Immunohistochemical investigation of the presence and distribution of cementum-associated lipopolysaccharides in periodontal disease. J Periodontal Res. 1986 Nov;21(6):660-7.
• LPS ( Liposaccharides)Not bound to root surface
Page 7
Factors that influence complete calculus removal
• Extent of the disease• Anatomic factors• Skill of the operator• Instruments used
Page 8
Extent of the disease
• Waerhaug, J. (1978b)• Healing of the
dentoepithelial junction following subgingival plaque control. II. As observed on extracted teeth. Journal of Periodontoiogy 49, 119-134.
• more than 90% of cases, deposits of plaque and calculus remained in sites with pockets depths >5mm following SRP.
Page 9
Extent of the disease
• Rabbani A, Ash M, CaffeseR,
• The effectiveness of subgingival scaling and root planing in calculus removal J Periodontol 1981;52:119-123
Page 10
Skill of the operator
• Brayer et al ( 1989)
Scaling and root planing effectiveness: the effect of root surface access and operator experience. J Periodontol. 1989 Jan;60(1):67-72.
• more experienced operators produced a significantly greater number of calculus-free root surfaces than the less experienced operators in periodontal pockets with moderate and deep probing depths
Page 11
Anatomical factors
• Caffesse et al ( 1986)• Scaling and root
planing with and without periodontal flap surgery
• More residual calculus following non-surgical root debridement compared to root debridement as part of a surgical procedure,
• 50% or more of surfaces with
PD >7mm showed residual calculus irrespective of methodology.
Page 12
Anatomical factors
• Buchanan SA, Robertson PB.
• Calculus removal by scaling/root planing with and without surgical access.
• J Periodontol. 1987 Mar;58(3):159-63.
• There are more residual calculus following non-surgical treatment on molar and premolar tooth surfaces than non molar teeth.
Page 13
Instruments used
• Matia et al (1986)• Int J Periodontics
Restorative Dent. 1986;6(6):24-35.
• Efficiency of scaling of the molar furcation area with and without surgical access.
• No difference in quality of root debridement following evaluation of ultra sonic, sonic or hand instrumentation.
• None of these sites were totally free of calculus.
Page 14
• Sherman et al.• The effectiveness of
subgingival scaling and root planning. I. Clinical detection of residual calculus.
J Periodontol. 1990 Jan;61(1):3-8.
• If calculus is not detected clinically but may be present on a microscopic level.
• If detected clinically, the site is more likely to display ongoing inflammation.
Page 15
METHODS USED FOR NON-SURGICAL ROOT SURFACE DEBRIDEMENT
Page 16
Page 17
SCALING
• Removal of plaque and calculus from the tooth surface ( supra or subgingival instrumentation)
ROOT PLANING
• Instrumentation by which “softened cementum is remove and root surface is made hard and smooth.
• ROOT DEBRIDEMENT removal of plaque and calculus from the root surface w/o intentional removal of tooth structure
Page 18
debridement
It involves the non-surgical, mechanical removal of tooth surface irritants using manual and/or ultrasonic methods
is the treatment of gingival and periodontal inflammation through supra gingival and sub
gingival debridement and deplaquing within the gingival sulcus or periodontal pocket
Page 19
INSTRUMENTATION for SRP
Periodontal probes/ NASA ultrasonic perio probe Perioscopy Explorers Scaling, root planing and curetting instruments
- Sickle scalers
- curettes
-hoe, chisel and file scalers
- ultrasonic instruments
- lasers – LANAP/ new KEY Pulse technology ( Kavo short pulse feedback system)
Cleaning and polishing instruments
Page 20
Page 21
PROBES
Used to assess periodontal pocket depths, attachment levels, anatomy configurations and gingival bleeding.
Community Periodontal Index of Treatment Needs, PERIODONTAL SCREENING AND RECORDING
Page 22
Page 23
Page 24
Supra gingival scaling
Sickles- Macfarlane 4/5 Ultra sonic instruments
CurretesCurretes
Page 25
Periodontal Scaler
used to remove calculus and stain from the clinical crown of the tooth.
McCall 13-14S and 17-18S, Younger-Good 7/8,
Orban straight sickle 14, Crane-Kaplan 6, Towner U-15, Kirkland 13K/13KL, and Pritchard.
Page 26
Universal Curette Design triangular blade
are designed so that the working ends can be adapted to all tooth surfaces of all regions of the mouth with one double-ended instrument.
Page 27
Page 28
Periodontal Curette
Page 29
Page 30
Gracey curettes are area specific
1-2 1-2 Anterior Anterior teethteeth
3-4 Anterior 3-4 Anterior teethteeth
5-6 Anterior 5-6 Anterior and bicuspid and bicuspid teethteeth
7-8 Posterior 7-8 Posterior teeth - buccal teeth - buccal and lingual and lingual surfacessurfaces
9-10 Posterior 9-10 Posterior teeth -buccal teeth -buccal and lingual and lingual surfacessurfaces
11-12 11-12 Posterior Posterior teeth - mesial teeth - mesial surfacessurfaces
13-14 13-14 Posterior Posterior teeth - distal teeth - distal surfacessurfaces
Page 31
Page 32
Subgingival S and root planing using Universal or Gracey curette
Modified Pen grasp Adapt cutting edge to the tooth Insert blade under gingiva At the base, 45 to 90 degrees
working angulation Apply lateral pressure against
tooth surface coronal direction Confine only to “Instrumentation
zone”- portions where calculus is found on tooth surface
Page 33
Blade angulation
Page 34
Angulation of cutting edge
Page 35
Shank position
correct position of shank, parallel with long axis of tooth
engage apical or lateral edge of deposit with cutting edge of scaler
Enter facially and lingually with overlapping strokes
Page 36
Sickle, hoe and file
A. For supragingival debridement or scaling in shallow pockets
B- for supragingival scaling and subgingival calculus C. for smoothing roots in areas of stubborn deposits
sharpening of instrunments.DAT
Page 37
Principles for Subgingival instrumentation
• Local A• Explore root surface ( PD, root anatomy,
location of c. deposits)• Modified pen grasp• Finger rest• Proper cutting position• Strokes start from apical to coronal• Re-assess with probe• Cutting edge must undergo frequent sharpening
Page 38
Hand instrumentation vs. ultrasonic
• Good tactile sensation
• < risk of contaminated aerosol production
• > time• > tooth substance
removal• > technique sensitive• >instrument sharpening• <access to furcations
/deep PP
Page 39
Sonic and ultrasonic scalers
• Sonic scaler • Ultrasonic scaler
Page 40
Page 41
Magnetostrictive—CAVITRON
1950's as an electronic alternative to manual scaling.- ( 25,000 or 30,000 Hz) oscillating magnetic field across a conductive metallic stack.
Page 42
Page 43
Care and maintenance of inserts
Page 44
Page 45
Page 46
Page 47
Piezoelectric scalers
Page 48
Page 49
Magneto vs Piezo
• In magnetostrictive units, the pattern of tip movement is elliptical with all sides transferring energy
piezoelectric units feature linear tip movement with the lateral edge transferring energy.
This influences the positioning of the piezoelectric tip, since the lateral surfaces of the tip are most active during deposit removal.
Page 50
Diamond coated tips
• Thinnest tips- for Fine scaling and root planing in narrow furcations
• Figure 6: Piezoelectric Diamond Coated mini tips, from left to right: a) EMS HPL3 Perio Diamond tip for rough cleaning and odontoplasty; b) EMS DPL3 Perio Diamond tip for polishing; c) Satelec H2R for premolars and molars; d) Satelec H1 for anterior teeth and premolars; and e) Satelec H2L for premolars and molars.
Page 51
Piezo vs Magneto
• Piezoelectric units are predominately used in
Europe and Asia .
• Magnetostrictive devices are more widely used in the United States
http://www.dimensionsofdentalhygiene.com/ddhright.aspx?id=641
Page 52
Instructional video on the 1-S tip PIEZO
• http://www.youtube.com/watch?v=2Ve-_JBpTgI&feature=related
Page 53
Periosoft™ mini-tips PH1 tip
• http://www.youtube.com/watch?v=uPJuqd1sfJ0&feature=related
• PROSTHETIC AND IMPLANT MAINTENANCE
Page 54
Reciprocating instruments
• Less root surface loss and less time consuming( Obeid et al 2004).
- has nylon plastic inserts that can remove both plaque and calculus.
- ideal for supra- and submucosal debridement and areas that have limited access, such as a hybrid restoration (the abutments are supragingival and a denture-like restoration is attached) with heavy plaque and calculus.
Page 55
Page 56
NASA Ultrasonic perio probe
• Nondestructive Evaluation Sciences Laboratory at Langley Research Center
• adapted to the Periodontal Structures Mapping System, invented at Langley by John A. Companion,
•
• Research support was provided by NASA’s Technology Applications Engineering Program and by the Naval Institute for Dental and Biomedical Research
http://www.sti.nasa.gov/tto/Spinoff2008/hm_8.html
Page 57
Reevaluation
Every 4 weeks after completion of scaling and root planing procedures
To permit time for epithelial and connective tissue healing and time to assess oral hygiene skills of Px
Page 58
Response to non-surgical treatment- guidelines
IDEAL SATISFACTORY UNSATISFACTORY
Plaque score <15 % >15-40% >40%
Probing depths 1-3mm Most 1-4 few 4-6mm
Many >6mm
Furcation involvement
None Early grade/incipient
Grade II/III
Bleeeding score for non smokers
<10% >10% < 40% depending on susceptibility
>40%
Future treatment options
Simple maintenance
1. Maintenance with subgingival removal from residual pockets and
re-evaluation in 1 year
2. Surgery if plaque scores are low.
1. Improve plaque scores and re treat.
2. Extract untreatable teeth
3. Maintain as best as possible.
Page 59
PERIOSCOPY
Page 60
Perioscopy makes use of a
technology similar to the
orthoscopic and endoscopic procedures used in medicine for many years.
If perioscopy is properly paired with regenerative proteins, and anti-inflammatory medication, bone loss damage can be reversed. This unique synergistic protocol is known as RPE - Regenerative Periodontal Endoscopy.
Page 61
1 meter in length and .99 mm in diameter. It is made up of 10,000 optical and 19 illumination elements.
Page 62
RPE: Regenerative Periodontal Endoscopy.
Non-surgical periodontal disease treatment
RPE is an advanced non-invasive periodontal procedure combining fiber optic microscope technology with regenerative proteins.
RPE is a conservative treatment program. RPE can dramatically reduce or even eliminate the need for
aggressive periodontal surgery, as well as the need for multiple rounds of antibiotics and deep cleanings.
In addition, all dental disease conditions can be pinpointed much earlier, preventing further problems.
Page 63
Subgingival endoscopy, DV2 Perioscopy System
miniature fiberoptic camera , 24-48x magnification.
light, water irrigation, a digital processor, and video monitor .
foot-activated control system.
magnifies root surfaces, furcations, and soft tissue in the pocket.
It pinpoints residual calculus remaining after traditional instrumentation and
allows for more thorough removal of tenacious deposits
Page 64
Perioscope technique
http://www.youtube.com/watch?v=lqBSIsY2pRE&feature=related
http://www.youtube.com/watch?v=e2ZTeTmgmIE
Page 65
Subgingival micro ultrasonic endoscopic periodontal debridement
Periodontal Endoscopic Subgingival Debridement is a minimally invasive non-surgical periodontal treatment.
Page 66
Benefits of Dental Endoscopy to the General Dentist
High Patient AcceptancePerioscopy is a comfortable and well-tolerated
minimally-invasive procedureMost patients who are aware they are
periodontally-involved are compelled by a way to save their teeth that can possibly avoid surgery
The dental endoscopy option gives your patients the choice to be treated in the setting where they are most comfortable – your office
Page 67
Clinical Treatment Results and User Skills Will Improve
Periodontist is able to see exactly where other non-invasive therapies are being applied and better monitor how they are progressing
Superclean Perioscopy root surfaces are highly likely to reduce or stop tissue inflammation
Page 68
QUIXONIC……………………….
SCALERS……………. ……….
Page 69
Page 70
Manual vs Ultrasonic Scaling
Shigeru O et al. Current concepts and advances in manual and power- driven instrumentation. Periodontology 2000, Vol. 36,2004 page 45=58.
• Hand and Power-driven instruments are equally effective in reducing the probing depth, attaining attachment level gains and reducing inflammation by removal of plaque bacteria, calculus, and endotoxin.
• Ultrasonic debridement is more effective than manual scaling in Class II and Class III furcation invasion
Page 71
Ablative Laser Therapy
Page 72
ablate
Page 73
Light Amplification by Stimulated Emission of
RAdiation
MAIMAN 1960
Page 74
CO2 laser
• Targets both soft and hard tissues of the periodontium
• Has bactericidal and detoxification effects
• Can remove epithelium lining and granulation tissue within the periodontal pocket thus promotes healing.
• Curettage of granulation tissues had no added benefit over SRP (Lindhe & Nyman 1985)
• Laser therapy is capable of removing plaque and calculus with extremely low mechanical stress and no formation of smear layer on root surfaces
Page 75
Adjunct to Scaling and Root Planing (SRP)
1. After SRP, the diode laser is used on the soft tissue side of the periodontal pocket to remove the inflamed soft tissue and reduce the pathogens.(Kreisler, et al 2005)
2. Increased reduction of bacteria (especially specific periopathogens) when diode lasers are utilized after SRP (Moritz et al 1997, Haranszthy et al 2006)
3. Significant improvement in decontamination and effective treatment of peri-implantitis also occurs with the addition of diode laser therapy.19
• Gingival health parameters are significantly improved with the addition of the diode laser to SRP. Studies have shown decreased gingival bleeding,17, 20 decreased inflammation and pocket depth,16, 17 as well as decreased tooth mobility and decreased clinical attachment loss.16 This improvement in gingival health remains more stable than with conventional SRP treatment alone and tends to last longer21. Moreover, patient comfort is significantly enhanced during the post operative healing phase, with the addition of diode laser therapy.7
Page 76
Page 77
Various types of lasers
Page 78
Page 79
Page 80
Page 81
Page 82
ER:YAG AND ER:YSGG LASER ABLATION
• Er:YAG laser was evaluated for removal of subgingival calculi in periodontal treatment
• further pulsed Erbium laser, the Er:YSGG laser was proposed for treatment of dental hard tissue.,During perforation of dentin slice, the temperature increase is more pronounced for the Er:YSGG
COMPARISON OF ER:YAG AND ER:YSGG LASER ABLATION OF DENTAL HARD TISSUES Karl Stock, Raimund Hibst, Ulrich Keller* Institut für Lasertechnologien in der Medizin und Meßtechnik an der Universität Ulm and *University of Ulm, Dental School Dep. for Oral Surgery and Radiology Ulm, F.R.G. SPIE Vol. 3192; 0277-786X/97
Page 83
Er:YAG Laser
• http://www.youtube.com/watch?v=mAr3NlWH3Hg
• KaVo KEY III Laser Feedback System Demo
This video demonstrates the use of the KaVo KEY III Er:YAG Laser with feedback system. Calculus is detected and selectively ablated. The healthy root cementum substance remains untouched by the Er:YAG laser.
Page 84
Laser treatment protocols
LANAP (laser-assisted new attachment procedure)
LPT (Laser Periodontal Therapy) from Millennium Dental Technologies,
WPT (Wavelength-optimized Periodontal Therapy) from Lares Dental Research
LAPT (Laser-Assisted Periodontal Therapy) from other companies such as Biolase, Kavo, and HOYA ConBio -
Page 85
CHOICE OF DEBRIDEMENT METHOD
1. periodontal healing response
2. Debridement time
3. Root surface loss
4. Technique sensitive
5. Access
6. Removal of debris
7. Tactile sensation
8. Aerosol contamination
9. comfort
Page 86
Hand instrumentation
• Minimize the risk of contaminated aerosol production
Page 87
Lasers and SRP
• Results compared with SRP
• Damage from reflection• Tissue destruction• cost
Page 88
Effects of non-surgical therapy
Page 89
The influence of mechanical debridement on subgingival
biofilms
Page 90
The influence of mechanical debridement on subgingival
biofilms
Page 91
Implication of furcation involvement
• Patient performed home care and professionaly performed subgingival debridement become more difficult(Wylam et al 1993)
• Clinical improvement was found to be less pronounced in furcation sites than in other locations (Loos et al 1989)
Page 92
Socransky et al 1998
• Microorganism do not exist in isolation but rather as members of communities.
• Periodontitis- where red and orange complexes identified
Page 93
Page 94
The RED COMPLEX
Page 95
Haffajee et a 2006
• A reemergence of these species 3-12 months post debridement means ongoing attachment loss
Page 96
Repopulation of subgingival habitat
• From residual subgingival plaque deposits• Radicular dentinal tubules or cementum• Pocket epithelium and connective tissue• Supragingival plaque deposits• Subgingival deposits of adjacent teeth• From other intraoral soft tissue sites
Page 97
Pain and discomfort following non-surgical therapy
Page 98
Page 99
Page 100
Pain and discomfort following non-surgical therapy
• Pain which is highly variable from individual to individual reported to peak in intensity between 2 to 8 hours post-op and on average lasted for 6 hours (Philstrom et al 1999)
Page 101
Pain and discomfort following non-surgical therapy
Page 102
Re- evaluation
• Measurement made at baseline , and 3 months
1.Plaque scores
2.Bleeding on probing
3.Suppuration on probing
4.Probing pocket depth
5.Recession
6.Probing attachment level
7.mobility
Page 103
Interpretation of probing measurements at re-evaluation
Page 104
Interpretation of longitudinal changes at individual sites
1. Lack of reproducibility due to
-probing force
-probe tip diameter
-angulation of probe
-position in the mouth
-probing depth
-inflammatory status itself
2. Variations in changes may just reflect changes in inflammatory status at the base of the pocket rather than true connective tissue gain or loss.
Page 105
Probing measurements should be interpreted with CAUTION
Page 106
Prediction of outcome and evaluation of treatment
• Patient level– Extent of baseline bleeding scores, probing attachment
loss and probing depths have been found to relate to future probing attachment loss in untreated patient
– No LA- risk of further attachment loss.
– Level of sites >6mm at re evaluation bears a direct relationship to future periodontal breakdown.
Page 107
Prediction of outcome and evaluation of treatment
• Site level
- bleeding on probing is a moderate predictor of future attachment loss
- Absence of bleeding on probing has been demonstrated as a useful indicator of health( Lang et al 1990)
- Deep residual probing depth was of limited predictive value when observed over short periods
Page 108
Tx planning methods
Single appointments- for small amounts of calculus and healthy tissues
One or two long appointments to remove pathogens from entire mouth as quickly as possible so as not to re-infect previously instrumented areas. ( 45 min to root plane 7 teeth with moderately deep pockets)
Page 109
Full mouth disinfection FMD
• 1995 Quirynen et al
• Full mouth scaling and root debridement within 24 hour treatment period
• Subgingival irrigation with 1% chlorhexedine gel ( 3 x within 10 min)
• Tongue brushing with 1%Cgel and mouth rinsing with 2 % Cgel
Page 110
th
Results of phase I therapy and maintenanceCase : Severe Chronic periodontitis after 3 weeks and 18 monthsWith non surgical perio dontal treatment- scaling, root planing and plaque control therapy
p. 607 Clinical Perio, Carranza
Page 111
Page 112
These innovations will raise the standard of instrumentation in education and practice and improve the success of nonsurgical therapy and maintenance.
Page 113
Page 114
Sogndalstrand
That;s all for now and thank you for your attention…