Table of Contents

Title Page

Copyright Page

Foreword

Preface

Acknowledgements

Chapter 1 The Goals and Clinical Outcomes of Non-Surgical Treatment

Aims

Outcome

The Periodontal Pocket – A Pathological Environment

The Aims of Non-Surgical Treatment

Elimination of Calculus

The Concept of Full-Mouth Disinfection

Healing Following Periodontal Treatment

Clinical Outcomes Following Non-Surgical Treatment

Hygiene versus instrumentation phases

The Badersten studies

An evidence base for non-surgical treatment

Summary

Conclusions of Clinical Importance

Further Reading

Chapter 2 Hygiene Phase Therapy

Aims

Outcome

Plaque Control Programmes

Mechanical plaque control

Manual Toothbrushes

Powered Toothbrushes

Toothpastes

Toothbrushing techniques

Bass Technique

The Charters’ Method

Interproximal Cleaning Aids

Dental Floss and Tape

Superfloss

Interspace Brushes (Fig 2-6)

Interdental Brushes (Fig 2-7)

Woodsticks (Fig 2-8)

Chemical Plaque Control (Fig 2-9)

Cationic agents

Quaternary ammonium compounds (QACs)

Phenols

Listerine™

Triclosan™

Plax™

Sanguinarine

Heavy metal salts

Zinc salts

Tin salts

Enzymes

Lactoperoxidase-hypothiocyanite

Key Points of Clinical Importance

Further Reading

Chapter 3 Instruments and Instrumentation

Aim

Outcome

Introduction

Hand Instruments

Chisel Scaler or Push Scaler (Guy’s G1 or G2, Cushings or Watch-Spring)

Trihedral Scalers (H6, H7, G3, G4, J1 and H5)

Periodontal Hoes

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

Curettes

Universal Curettes (Columbia 2R/2L; Columbia 13/14; Langers 1/2; Langers 5/6, and Langers)

Area-specific curettes/site specific curettes

Recommended Protocol for Root Surface Instrumentation (RSI)

Mechanised Instruments

Ultrasonic Units

Magnetostrictive Units

Inserts for magnetostrictive units

Piezoelectric Ultrasonic Units

Inserts for piezoelectric units

Sonic Handpieces

Inserts for sonic handpieces

Air-Abrasive Systems

Ultrasonic Techniques

Periodontal Explorer

Repetitive Strain Injury

Conclusions of Clinical Importance

Further Reading

Chapter 4 Managing Systemic Risk Factors

Aim

Outcome

Definitions

Risk Factor Identification

Genetic Risk Factors for Periodontitis

Genetic Susceptibility Testing

What do genetic test results mean, and what is their impact on the patient?

Environmental Risk Factors for Periodontitis

Drugs Associated With Gingival Overgrowth

HIV Disease

Behavioural Risk Factors for Periodontitis

Smoking

Life-style Risk Factors for Periodontitis

Stress

Metabolic Risk Factors for Periodontitis

Diabetes Mellitus

Other Systemic Risk Factors for Periodontitis

Conclusions of Clinical Importance

Further Reading

Chapter 5 Managing Local Risk Factors

Aim

Outcome

Definitions

Trauma from occlusion

Traumatic Incisor Relationships

Occlusal Interferences

Anatomical Risk Factors

Furcation Involvement

Enamel Pearls

Cervical Enamel Projections

Root Morphology

Gingival Recession

Furcation Ridges

Dental Anatomy and Tooth-Arch Relationships

Iatrogenic Risk Factors

Overhanging Restorations

Poorly Designed Partial Dentures

Orthodontic Appliances

Defective Crown Margins

Defective Bridge Pontics

Conclusions of Clinical Importance

Further Reading

Chapter 6 Adjunctive Treatments

Aim

Outcome

Definitions

Systemic Adjunctive Treatments

Systemic Antibiotics

Antibiotics and Specific Periodontal Conditions

Chronic Periodontitis

Aggressive Periodontitis

Refractory Periodontitis

Acute Periodontal Abscess

Necrotising Ulcerative Gingivitis and Periodontitis

Systemic Antibiotics – Summary

Host Modulatory Therapy

Non-Steroidal Anti-Inflammatory Drugs

Subantimicrobial Dose Doxycycline

Bisphosphonates

Local delivery adjunctive treatments

Tetracycline Fibres

Minocycline Gel

Metronidazole Gel

Chlorhexidine Chip

Doxycycline Polymer

Which local delivery product to use, and when?

Adverse reactions and local drug delivery

Monotherapy or adjunctive use of local delivery systems?

Key points of clinical importance

Further Reading

Chapter 7 Supportive Periodontal Care

Aims

Outcome

Definitions

The Rationale for Supportive Periodontal Care

The Goals of Supportive Periodontal Care

Components of Supportive Periodontal Care

Medical, Dental and Social Histories

Clinical Examination and Updating Records

Radiographic Examination

Communication

Reinforcement of Plaque Control

Supragingival Prophylaxis and Subgingival Instrumentation

The Need for Further Treatment

Re-instrumentation of the Roots

Adjunctive Antimicrobials

Commencement of the Supportive Periodontal Care Phase

Frequency of Visits for Supportive Periodontal Care

Managing Risk Factors During Supportive Periodontal Care

Compliance with Supportive Periodontal Care

Ways to improve patient compliance

Conclusions of Clinical Importance

Further Reading

Foreword

Successful periodontal therapy is, for many, fundamental to the goal of teeth for life. With a state-of-the-art non-surgical approach to periodontal therapy, success is dependent on a plethora of interrelated factors and influences, including the complexity of the disease process, predisposing risk factors, diagnostic skills and techniques, patient management and motivation, knowledge of modern instrumentation, techniques and adjunctive treatments, not to forget clinical acumen both during active treatment and the equally critical long-term supportive periodontal care. Can all of this be covered effectively in a slim, easy-to-read book? Yes, it can: the authors of Volume 16, Periodontology 3 in the Quintessentials of Dental Practice Series have achieved this feat, with plenty extra packed in by way of a bonus.

It is proving to be a great learning experience being Editor-in-Chief of the Quintessentials of Dental Practice Series, the present book having added greatly to my new enlightenment. Dental students, trainee hygienists and therapists and practitioners of all ages, not to forget everyone’s patients, will benefit enormously from this timely contribution to the existing literature. I hope you enjoy and learn from this excellent book as much as I did.

Nairn Wilson
Editor-in-Chief

Preface

This text is the third of five books that aim to provide the general dental practitioner with an illustrated practical and contemporary guide to the management of patients with gingival and periodontal diseases. This book is entitled Successful Periodontal Therapy: A Non-Surgical Approach. Initially it presents the reader with recognised goals and objectives of non-surgical treatment. Subsequent chapters cover the clinical protocols and methods for achieving these goals: hygiene phase; scaling and root surface instrumentation; the instruments used for scaling and root surface debridement; managing common and well-established risk-factors; and the use of treatments that are considered to be adjunctive to conventional methods of scaling and root surface instrumentation. The final chapter reviews the importance of supportive periodontal care, which is highly relevant for general dental practitioners, for both those patients that they have treated in the primary care setting and those who may have received their non-surgical management by a specialist or in a hospital environment.

The Aim

It is hoped that having read this book on periodontal therapy the reader will be able to:

• understand the healing events that follow non-surgical treatment

• realise the limitations of non-surgical treatment

• have knowledge of the range of mechanical and chemical products that are available to improve personal plaque control

• be aware of the range of instruments that are available for removing tooth deposits

• understand the importance of identifying and managing systemic and local risk factors for periodontal diseases

• understand the importance of identifying and managing local anatomical and iatrogenic factors that may predispose to periodontal disease

• be aware of systemic and locally-delivered adjunctive treatments that are available and know how to reach informed decisions regarding the most appropriate product for any specific clinical situation

• understand the goals of supportive periodontal care and how they might be achieved

• appreciate the need for patient compliance and understand how poor patient compliance might be identified and improved.

Peter Heasman
Philip Preshaw
Pauline Robertson
Iain Chapple

Acknowledgements

The authors would like to acknowledge with sincere thanks the following people: Janet Howarth of the Department of Dental Photography at Newcastle Dental Hospital for her photographic expertise; Dr David Jacobs for Fig 5-1; Dr Shakil Shahdad for Figs 5-2 and 5-3; Dr Robert Wassell for Fig 5-5; Dr Dean Barker for Figs 5-8, 5-9 and 5-10; Dentsply UK for Figs 3-4, 3-6, 3-7, 3-9, 3-10 and 3-14. We are grateful also to Professor Iain Chapple for Figs 3-15, 5-7 and 5-11 and Mrs Suzanne Noble for use of Figs 3-16, 3-17 and 3-18. Permission has been granted to reproduce the following: Fig 2-4 (from Heasman, Millett, Chapple. The Periodontium and Orthodontics in Health and Disease. Oxford; Oxford University Press: 1996); Fig 5-5 (from Barnes, Walls. Gerodontology. Oxford; Wright: 1994); Fig 5-20 (from Heasman, Preshaw, Smith. Periodontology Colour Guide. London; Churchill Livingstone: 1997). Thanks to Iain Chapple and Damien Walmsley for the cover photograph and to George Warman Publications, publishers of Dental Update, for permission to reprint part of this image.

Professor Heasman would like to acknowledge the support of Lynne, Sophie and Christopher, during the preparation of this book. Dr Preshaw would like to thank his wife, Sarah, for her help and support. Pauline Robertson would like to acknowledge the support of her husband, Brian, and family.

Chapter 1

The Goals and Clinical Outcomes of Non-Surgical Treatment

Aims

This chapter aims to outline the goals of non-surgical periodontal treatment and to provide an overview of the clinical outcomes that are expected following treatment.

Outcome

After reading this chapter the practitioner should have an understanding of:

• the healing events that follow non-surgical treatment

• the magnitude of the clinical changes and outcomes expected following the hygiene (or initial) and instrumentation (or corrective) phases

• the limitations of non-surgical treatment.

The Periodontal Pocket – A Pathological Environment

A periodontal pocket is a pathologically deepened gingival crevice. The lateral and apical boundaries of the pocket are the ulcerated epithelial lining of the pocket wall and the junctional epithelium respectively. The remaining “wall” of the defect comprises the diseased root surface – the “target” for periodontal treatment.

The diseased root surface is contaminated with subgingival calculus deposits and a layer of dental plaque, which contains the periodontal pathogens that constantly challenge and compromise the host’s defence mechanisms. Dental plaque is now regarded as a biofilm, which essentially is an organised community of bacteria that forms on a non-shedding surface such as a tooth. Bacteria attach to the tooth and produce a matrix of extracellular polymers to help bind them together. Microcolonies form and new species join the biofilm which then contains diverse species and metabolic states. Gingival crevicular fluid (GCF) flows through the many channels in the aggregation to provide nutrients and to remove some of the waste products. The biofilm is viable and bacteria can proliferate to establish new colonies on other parts of the root surface.

The majority of bacteria in an established biofilm are recognised, 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 of the total LPS may cause subsurface contamination, in particular at sites of root surface irregularities, root grooves or resorption lacunae. Subgingival calculus on the root surface may also be contaminated with LPS. Diagrammatic representations of a diseased root surface are shown in Fig 1-1.

The Aims of Non-Surgical Treatment

The overall aim of non-surgical treatment is to create an environment that is biologically compatible with healing of the periodontal tissues. This is most likely to be achieved by:

• 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.

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. Such a hypothesis of course makes the assumption that the patient is able to access the entire depth of the pocket during cleaning. This is seldom achieved for pockets that are greater than 5mm in depth. Indeed, the deeper the pocket, the more residual, undisturbed biofilm is likely to remain.

The need for professional intervention is, therefore, crucial and this includes 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). Root surfaces that have no detectable subgingival calculus may be instrumented by passing an instrument such as an ultrasonic scaler lightly over the surface. This will remove the loosely associated toxins and the majority of the outermost, necrotic cementum on the root surface (Fig 1-2). Research shows that the most effective use of ultrasonic instruments involves multiple light passes of the instrument over the root surface. The presence of tenacious, subgingival calculus will, however, necessitate the use of greater pressure to the root, although the belief that the root surface has to be meticulously “planed” until it is hard and smooth is now largely outdated.

Elimination of Calculus

Calculus is not the cause of periodontal disease, but may be regarded as a contributory factor, for several reasons including:

• all calculus has a coating layer of dental plaque

• supragingival calculus impedes toothbrushing and interdental cleaning

• subgingival calculus may act as both a barrier to subgingival cleaning and a focus for the colonization of bacteria during the first stage in the formation of a biofilm

• subgingival calculus may absorb bacterial endotoxins

• supra- and subgingival calculus may impede the passage of periodontal probes, thereby falsifying borderline probing depth measures.

For these reasons, it is important to try to remove as much of the calculus as possible, although some residual, isolated deposits of subgingival calculus are likely to be compatible with periodontal healing. This observation is consistent with studies that have shown that even under optimal conditions of access during periodontal surgery absolutely calculus-free root surfaces following root surface instrumentation are hardly ever achieved. With the understanding that pockets with probing depths of >5mm are exceptionally difficult to render plaque and calculus free, it is almost certain that residual deposits are more likely to be the rule rather than the exception with a non-surgical approach.

The Concept of Full-Mouth Disinfection

The importance of eliminating the biofilm and bacteria that have freedom of movement around the oral cavity, and are the cause of periodontal infections and re-infections, has been recognised by the introduction of full-mouth disinfection as a novel treatment strategy for periodontal diseases. Full-mouth disinfection involves the conventional removal of root surface deposits, usually over two visits within 24 hours of one another. Instruction in oral hygiene procedures is also given at one or both visits. This treatment recognises, however, that many of the potent pathogens, such as Porphyromonas gingivalis and Actinobacillus actinomycetemcomitans, are also commonly found at non-periodontal sites such as on the dorsum of the tongue, on the oral mucosa, in saliva, or on the mucosal surface of the tonsils. Re-infection of treated pockets is, therefore, likely unless an attempt is made to eliminate the organisms from all of these niches and as quickly as possible. The fewer the number of visits, the less chance there is for re-infection from (as yet) untreated sites.

Different preparations of chlorhexidine gluconate have also been used in an attempt to achieve adjunctive disinfection immediately after the completion of root surface instrumentation (Table 1-1). There is little evidence, however, to support the clinical value of the adjunctive use of chlorhexidine over mechanical instrumentation alone during full-mouth disinfection.

Healing Following Periodontal Treatment

One of the principal signs of a healing pocket is the reduction in probing depth that follows treatment. This reduction is largely a result of the resolution of gingival inflammation leading to shrinkage of the gingival tissues and the formation of a new, long junctional epithelium (Fig 1-3).