SECTION IV: NONSURGICAL TREATMENT CHAPTER 47 Phase I Periodontal Therapy Henry H. Takei CHAPTER OUTLINE Rationale Treatment Sessions Sequence of Procedures Results Healing Phase I therapy or causetelated therapy" isthe frst in the chronologic sequence of procedures that constitute periodontal treatment, The objective of phase I therapy is to alter or eliminate the microbial ‘tiology and factors that contribute gingival and periodontal diseases to the greatest extent possible, thereby halting the progression of disease and retuming the dentition to a state of health and comfort.” Phase | therapy i rlered to by a number of names, including inital therapy. nonsurgical periodontal therapy." and eause-related ‘therapy All tems refer fo the procedures performed to treat gingival and periodontal infections up to and including 1 Which is the point at which the course of ongoing care is determined, Rationale Phase I terapy’is defined by the evidence-based American Associaton of Periodontology practice guidelines’ asthe ination of a comp hensive daily plaque or biofilm control regimen, management of Periodontal-systemic interrelationships as needed, and thorough emoval of supragingival and subgingival bacterial plaque or biofilm and calculus. Other problems that must be managed include the use of chemotherapeutic agents as necessary, and local actors“ su 1s elimination of defective restorations and treatment of carious lesions." These procedures area required part of periodontal ‘therapy, regardless ofthe extent of disease preset, In many’ cases, only phase I therapy is required to restore periodontal health, or it constitutes the preparatory phase for surgical therapy: igs. 47.1 and 47.2 show the results of phase I therapy in two patients with chronic periodontitis, Causesrelated phase I periodontal therapy has been succinctly stated as the approach aimed at removal of pathogen biofilms, toxins, and calculus and the reestablishment ofa biologically spable root surface.” Phase T therapy is a ‘tical aspect of periodontal treatment Data from clinical research indicate that the long-term success of periodontal surgical eatment is dependent on maintaining the plague or biofilm control resulls achieved with phase I therapy. In fact, patients who do not have adequate plaque or biofilm control will ‘contin fo lose attachment regardless of what surgical procedures are performed. In addition, phase I therapy provides an opportunity {or the dentist to evaluate tissue response and provide reinforcement about home cate, bath of which are erucial to the overall success of treatment 506 Decision to Refer for Speci Treatment Conelusion [Based on the knowledge that microbial plague or biofilm isthe ‘major etiologic agen in gingival inflammation, one specific aim of ‘hase [therapy for every patient i effective daily plaque or biofilm removal at home. These home care procedures can be complex and time-consuming, and often require changing long-standing habits, {Good oral hygiene is more easily accomplished i the tooth surfaces are free of celoulus deposits and other regularities so that they are easily accessible. Management of all contributing local factors is required in phase I therapy. The following list of elements makes up phase I therapy 1. Patient education and oral hygiene instruction 2 Complete removal of supragingival calculus (see Chapters 50 and 51) ‘Correction of replacement of poorly fiting restorations and other prosthetic devices (see Chapter 70) Restoration or temporization of carious lesions Orthodontic tooth movement (see Chapter 56) ‘Treatment of food impaction areas Treatment of occlusal trauma (see Chapter $5) Extraction of hopeless teeth Possible use of antimicrobial agents, including ne “orbiovilm sampling and sensitivity testing (see ary plaque aptcrs Band 52) Treatment Sessions ‘After careful analysis and diagnosis of the specifi periodontal ‘condition presen, the clinician must develop a treetment plan that includes all required procedures to treat the periodontal involvement and an estimate of the number of appointments necessary to complete phase I therapy. In most eases, patients require several treatment sessions for complete debridement of the tooth surfaces. All the Tollowing conditions must be considered when determining the phase | treatment plan" + General health and tolerance of treatment + Number of teeth present + Amount of subgingival ealeulus + Probing pocket depths + Attachment Joss + Purcation involvement + Alignment of teeth + Margins of restorations + Developmental anomaliesAbstract This inital phase of therapy is crucial in determining the ttl outcome of therapy; because it is this part that will help determine the compli- ance of the paticnt toward their understanding of the concept of selfeeute. Patient education, initial oot therapy, and_ reevaluation to determine if surgical therapy is necessary is all decided atthe end ofthis phase of therapy: Keywords plaque biofiom calculus critical probing depth acachment loss reevaluation debridement CHAPTER 47 Phase | Periodontal Therapy 50CHAPTER 47 Phase | Periodontal Therapy NEE Fig. 47.1 Results of phase I therapy, se probe chronic periodontitis (A) 25-year-old patient with deop oth, bane loss, cover sling, and redness uf the gingival tissues, (2) Resuks 2 wooks ater tho Completion of phase | therapy. Note thatthe gingval issue has retumed to anormal contour, wth redness and swoling dramatically reducod. Fig. 47.2 Results of phase I therapy, moderate chronic sin the te Bim ange Not tha the ging va appears pricbecause tal pockets but disguised by te foie moderate attachment loss and probe itis fibrotic. Infammatin is present in the pri riodontitis. (A) A S2-yearold patient with sve, Bleeding ‘occurs on probing. (Lingual view ol the patient wth more visible infanmation and heavy cleulus deposits. + Physical barriers to access the dentition (i, limited opening or tendency to gag) + Patient cooperation and sensitivity to therapy (requiring use of anesthesia or analgesia) Sequence of Procedures Step 1: Plaque or Biofilm Control Instruction Plague or biofilm contol is an essential component of successful Periodontal therapy, end instruction should begin athe fis treatment appointment. Before oral hygiene instruction, the patient must understand the reason that he or she must actively participate in therapy. The explanation of the etiology of the disease must be presented tothe patient. Once the patent understands the nature of periodontal disease and the etiology, it will be easier to teach the hhygiene that he or she must practice. The patent must be instructed ‘onthe correct technique to remove the plague or biofilm: tis means and {0} At 18 months ater phase |cherapy th same areas show sign can improvement in gingival health The patient returned for regular maintenance visits at &-ronth intervals focusing on applying the bristles atthe gingival tind of the linea ‘rovns, where the tooth meets the gingival margin. This technique is sometimes refered to as targeted oral ngiene (Takei H: Persons ‘communication, 2009) and is synonymous with the Bass technique Instructions are also initiated for interdental cleaning with dental floss and interdental brushes. The use ofthe multiple appointment approach to phase I therapy is favored by many elnicians because it permits the use of numerous appointments to evaluate reinforce, and improve the patents oral hygiene skills. (Chapter 48 details plague and biofilm contol options.) Step 2: Removal of Supragingival and ‘Subgingival Plaque or Biofilm and Calculus Removal of calcuhss is accomplished using sealers, crete, ultrasonic instrumentation, or combinations of these devices during one or ‘more appointments. Evidence suggests that the treatment results for cchroni periodontitis are similar forall instruments, which could beEXEWee) PART2 CLINICAL PERIODONTICS hand instrumentation or other mechanical instruments, such as tultasonic sealers." Most clinicians advocate the combination of hand insruments (sales, euretes) an ultrasonic deviees, In alton to caleulus and plague oF biofilm removal, cementum exposed to {Ge pocket envionment should be removed. At one time it was ‘ought thatthe removal ofall cementum was necessary to attain 8 smooth, glassy ard surface The rationale was that cementum became necratie from penetration of endotoxins from the microbial biofilm snd would interfere with healing, Curent studies have indicated that endotoxins do not penetrate into the cementum as deeply as once believed and complete removal of the cementum may’ not aways bbe necessary, but removal of the plague or biofilm and caleulus is absolutely nevessary. In a clinical situation, itis dificult to know ‘wheter the removal of some or all of the cementum is achieved. Laser treatment has also been advocated for periodontal therapy by some clinicians’ However, some reviews suggest that further well-designed studies are nveded to confirm the outcomes. In addition, ingival curettage, the systematic removal ofthe soft tissue lining ofthe pockets has not been shown to improve the results of eatment, ‘Thorough plague o biofilm removal and excellent root therapy result in conversion of the sof, edematous, inflamed gingival tissue 10 8 healthier state without removing this tissue by using intentional soft tissue curettage, Therelore curettage of the soft tissue pocket wall fn phase I therapy is no longer advocated, Photodynamic therapy has also been presented as an adjunct to scaling and root planing, Ths therapy uses lasers at specific wa Tengths to “target microorganisms treated with a photosensitizer.” ‘Studies have not found this intervention to be use as an alternative to scaling and root planing to improve treatment outcomes, Further researc is necessary to ascertain the eflcacy of this treatment.” ‘Another interesting approach to calculus removal and debridement fs fallemouth disinfection. In this technigue, full-mouth treatment is performed during one session or mulple sessions within afew days, Disinfectants are used after therapy, wth the intention of preventing reinfection of treated sites from untreated sits."""" This treatment approach is used during phase I therapy by some clinicians, but the results have not been shown to be superior to those of any other phase I therapy.!" Multiple approaches are used to plan and perform nonsurgical phase I therapy. Decisions on how to proceed should be discussed snd agreed on by the patient and the dentist based on the amount ‘of disease present and the patient’ tolerance tothe therapy." Staged therapy has the advantage of evaluating and reinforcing the oral hhypene slaus ofthe patient, bul the one- or trappoinimentepproac can be more eflicent in reducing the number of office visits the patient is required to attend Step 3: Recontouring Defective Restorations and Crowns Corrections of restorative defects, which are plague or bof retentive teas, may be accomplished by smoothing the rough surfaces and removing overhangs from the faulty restorations with burs or hand instruments, or complete replacement of the falling restorations may bbe necessary. All these steps are important to remove the risk factors ‘hat perpetuate the inflammatory process. These procedures can be completed concurrently with other phase I procedures. Step 4: Management of Carious Lesions Removal of the carious lesions and placement of either temporary lor permanent restorations are indicted in phase I therapy because of the infectious nature of the carious process. Healing of the periodontal tissues is maximized by removing the reservoir of bacteria in these lesions so that they eannot repopulate the microbial plaque, Step 5: Tissue Reevaluation After scaling, root planing and other phase I procedures, the peri= ‘odontal tissues require approximately 4 weeks to heal, This time allows the connective tissues to heal, and accurate probe depths can ‘be measured, Patents will also have the opportunity to improve their home care skills to reduce gingival inflammation and adopt ‘new habits that will ensure the succes f treatment tthe revaluation appointment, periodontal tissues are probed, and all elated anatomic conditions are carefully evaluated to determine whether further treatment, inchuding periodontal surgery, is indicated. Additional ‘mpravement from periodontal surgical procedures can he expected nly if phase I therapy resulls in gingival tissues that are free of ‘overt inflammation and the patient has adopted effective daily plague ‘or biofilm control procedures. Results ‘Scaling and root planing therapy have been studied extensively to evaluate their effects on periodontal disease. Many studies have {indicated that this weatment is both effective and reliable. Studies ranging from 1 month fo 2 years in length demonstrated upto 80% reduction in bleeding on probing and mean probing depth reductions fof 2 to 3 mm, Other studies demonstrated that the percentage of | periodontal pockets of 4-mm or deeper was reduced by more than 50% an in many cases up to 80%” Fes. 47.1 and 47.2 show examples of the effectiveness of phase I therapy. Tn addition, deeper probing depths present the dentist with greatly ‘increased instrumentation challenges due to the complexity of root ‘anatomy and dificully accessing the root surfaces. Badersten and colleagues” repored inthe 1980s that residual calculus remained on ‘44% of the surfaces in deeper pockets. Other studies have confirmed ‘hese findings including studies comparing the use of hand instruments ‘with that of powered sealing instruments." ‘Additional individual treatments, such cares control and cor- rection of poorly fitting restorations, clearly help the healing gained by good plague orbioilm control and debridement by making tooth surfaces accessible to hygiene procedures. Fig. 473 demonstrates the effects ofan overhanging amalgam restoration on gingival nflam- ‘mation in an otherwise healthy periodontium. Maximal healing from ‘phase I treatments not possible when local conditions retain biofilm provide reservoirs for repopulation of periodontal pathogens. Healing of the gingival epithelium consists of the formation of @ Jong junctional epithelium rather than new connective tissue attach- rent to the root surfaces, This long junctional epithelium occurs aout 1 week aller therapy. Gradual reductions in inflammatory’ cell population, erevicular fluid flow, and repair of connective tissue result in decreased clinical signs of inflammation, including less redness and swelling. One or two millimeters of recession is often apparent as the result of dssue shrinkage.” Connective tissue fibers are disrupted and lysed by the disease process and also by the inflammatory teaction to treatment. These tissues require 4 or more ‘weeks to reorganize and heel, and many cases may require several ‘weeks for complete healing. ‘Transient root sensitivity frequently accompanies the healing process, Although evidence suggests that relatively few teeth in a ‘Tew patients become highly sensitive, this problem can be dsconcer- {ng lo patents. The extent ofthe sensitivity ean be diminished with ‘200d plaque or biofilm removal, but this may take several weeks to months." Patients should also be wamed and educated before theCHAPTER 47 Phase | Periodontal Therapy EZ 47.3 Efi of overhanging amalgam margin on interproximal gingiva of maxillary frst molrn others healtry mouth A) Clinical appearance of rouph regula, and ovecontoured amalgam. (2) Gentle probing of interproximal pocket (C) Extensive bleeding elicited by gentle pring indicating severe infarvmation inthe therapy is undertaken regarding the potential outcomes of several changes, suchas the teth appearing longer duc to shrinkage of the periodontal tissues and root sensitivity. Knowledge ofthese changes before therapy will preven the possibility of the patient complaining if they should occur. Unexpected and possible uncomfortable cone sequences of treatment may result inthe patients distrust ané loss fof motivation to continue therapy: Decision to Refer for Specialist Treatment. tis fortunate that many periodontally involved cases do not require ny Surther therapy beyond phase I therapy. Therefore, these patients can be seen by general dentists for routine maintenance therapy However, advanced or complicated cases benefit from specialist cate Heitz-Mayfield and Lang’ demonstrated tha surgical realment in deep pockets, those >6 mm, gained 0.6 mm more probing depth reduction and 02 mm more finial attachment gain then did deep pockets trated with scaling and root planing alone. This study also confirmed that in pockets of 4 to 6 mm probing depth, scaling and root planing resulted in 0.4 mim more allachment gain than surgical procedures, and shallow pockets of 1 to 3 mm hed 0.5 mm less attachment loss compared wit surgical results." It i eritical to be skilled in determining which patients would benefit from specialist care and deciding when a patient should be refered The concept of the critical probing depth of 5.4 mm has been advanced to assis in making the determination to proceed to surgical finervention, This is the measurement above which therapy will result in clinical attachment gain and below which it will result in clinical atachment loss. This determination was made based on statistical analysis of sutpical outcomes data” A. similar 5-mm standard bas been commonly used as a guideline for identifying candidates for surgical referal based on the understanding that the ‘ypical root length is about 13 mm and the crest of the alveolar bone {sata level approximately 2 mm apical tothe boom of the pocket, Apex Fig. 47.4 The S:mm standard fr referal to a periodontist is based on root length, probing depth, and clinical atament oss. he standard serves ‘as areasonable guideline to analy the case for refer or specialist cre, (EJ, Comentoenamal union, (Roavm with permission fem Armitage ‘editor: Periodontal mantenance therapy, Berkeley, CA, 1974, Praxis) ‘When there is $ mm of clinical attachment loss, the erest of bone {about 7 mm apical tothe cementoenamel junction, and therefore ‘only abost half ofthe bony suppor forthe tooth remains. Periodontal surgery ean help improve support for teeth in these eases through pocket reduction, bone augmentation, and regeneration procedures Fig 47-4 depts the relationship of clinical attachment loss to tooth suppor.EXC) PARTS CLINICAL PERIODONTICS Inadditon to the S-mm probing depth criterion, ther factors must be considered in the decision to refer to a periodontal specialist 1, Eutent of the disease and generalized oF localized periodontal involvement, The amount of bone loss, even in localized area, suggests the need for specialized surgical techniques. 2. Root length. Shortvoted teeth are jeopardized toa preater extent by the S-mm clinical attachment loss eriterion than teeth with Jong roots. 3. Hypermabili Excessive tooth mobility suggests that coneibuting facors may be responsible fo the mobility. The extent of mobility could mean thatthe prognosis forthe tooth may be guarded to poor, 4. Dificuty of sealing and rot planing. The presence of deep pockets and foreations makes instrumentation difficult, but the results| can often be improved with surgical access. 5, Restorabilty and importance of particular teth for reconstruction, Long-term prognosis of each toth is important when considering extensive restorative work. 6. Age of the patient. Younger patients with extensive attachment loss are more likely to have aggressive forms of disease that require advanced therapy: 1. Lack of resolution of nlammation afer thorough plague or biel removal and excellent scaling and rot planing. I intammation | and progressive deepening of the pocket continue, further therapy will be necessary. Such eases require an understanding of the etiology to determine the best course of teatment. Every patent is unique, and the decision process foreach patient | {is complex and difficult, The considerations presented inthis chapter should provide guidance for understanding the significance of phase 1 therapy and making referral decisions. Conclusion The major goal of phase I herapy isto contol the factors responsible {or periodontal inflammation; tis involves educating the patient in the removal of bacterial plague or biofilm. Phase 1 therapy also includes sealing, root planing, and other therapies such as caries control, replacement of defective restorations, occlusal therapy, ‘orthodontic tooth movement, and cessation of confounding habits such as tobacco use. Comprehensive reevaluation after phase I therapy is essential to determine treatment options and establish a prognosis, ‘Many patients ean attain periodontal disease contol with phase I therapy alone and do not require further surgical intervention, For patients who require surgical intervention, phase I therapy is an advantageous clement of treatment in that t permits tissue healing, thus improving the surgical management and healing response of the tissues. Periodontal surgical ntervetion shouldbe considered for patients with deep pocket depths and those with S mm or more of atachment Joss after phase I therapy. Periodontal specialists can best provide treatment to preserve the teeth for patients with advanced disease ‘Moreover, patients who do not demonstrate the ability to control plaque or biofilm on a daily basis effectively are poor candidates {or surgery and should be closely monitored on a recall maintenance program unless conditions change. References References for this chapter are found on tha companion website wivwexpertconslt.com.Bea) AASV UY al CHAPTER 57 Phase II Periodontal Therapy Henry H. Takei CHAPTER OUTLINE Objectives of the Surgical Phase Pocket Elimination Versus Pocket Maintenance Indi Therapy fr periodontal disease, which encompasses many’tecniques and procedures, depends on the disease status and objective of the final outcome. Faly problems can be corrected with successful phase | therapy, consisting of biofilm removal by the patient on a daly basis, sealing, and root planing when necessary ‘Many moderate to advanced cases cannot be resolved without surpcally gaining access to the root surface for root planing and reducing or eliminating pocket depth to allow the patient to remove biofilm. The surgial phase of red 10 as phase the surgical techniques used for the following purposes: + Controlling or eliminating periodontal disease + Correcting anatomic conditions that favor perio impair aesthetics, or impede placement of prosthetic appliances + Placing implants to replace los teeth and improving the environ ‘ment for ther placement and function Many cases are successfully treated and maintained by phase I therapy. The chapters in Section V discuss the techniques and concepts used to treat periodontal diseases that require a surgical approach to reduce or eliminate pockets and obtain access tothe root surface Objectives of the Surgical Phase The surgical phase of periodontal therapy has the following ojectives 1. To improve the prognosis for teeth and their replacements 2. To improve aesthetics Surgical techniques are sed for pocket therpy and for correction of related morphologic problems (i.., mucogingival defects) In ‘many eases, therapies ae combined to provide one surgical interven- ‘ion thet fills both objectives urical techniques (1) increase acces to the root surface, allowing the clinician to remove lita; (2) reduce or eliminate pocket depth, making it possible fr the patent to maintain the root surfaces fee of biofilm: and (3) reshape soft and hard tissues to attain & harmonious topogra ive of regenerative surgery, or both, fs used to edce pocket depth (Box 571) (See Chapters 60 to 61). The second objective of phase I therapy isto correct anatomic defects that favor plaque or biofilm accumulation and pocket recur rence or impair aesthetics. The aim of corectng anatomic problems isto alter defects ofthe gingival and mucosal issues that predispose Reevealuation After Phase | Therapy Critical Zones in Pocket Surgery ns for Periodontal Surgery Methods of Pocket Therapy Conclusions ‘these areas to disease. Three types of noninfamed tissues and inthe absence Box 57.1) + Plastic swrgery techniques are used to create or widen te allached keratinized gingiva by placing grafts of various types + Aesthetic surgery techniques are used t0 cover denuded root surfaces resulting from recession and to recreate lost papillae. + Pre-prostheic techniques are used to modify the periodontal and neighboring tissues to receive prosthetic replacements, They include crown lengthening, ridge augmentation, and vestibular deepening, Fig. 57.1 provides a threestiered classification of the surgical procedures used in periadontes: pocket reduction surgery, periodontal plastic surgery, and pre-prosthetc surgery. Pocket reduction surgery consists of resective and regenerative procedures, and periodontal plastic surgery includes aesthetic and gingival augmentation (anatomic) procedures. Crown lengthening, ridge augmentation, and implant procedures are listed under pre-prosthtie surgery Plastic and aesthetic surgery techniques are explored in Chapter 65, and pre-prostetie techniques are diseussed in Chapter 6. Periodontal surgical procedures also are available forthe placement of dental implants: They include implant placement techniques and 4 variety of surgical procedures to modify neighboring tissues for the placement of implants. Bone augmentation of the sinus Noor or for a narrow edentulous ridge is an example (see Box 57-1). These topies are discussed in Chapters 79 and 80 uniques are performed on periodontal pockets (se Surgical Pocket Therapy Surgical pocket therapy can be used to gain access tothe diseased root surfice to ensure the removal of calculus located subgingivally ‘before surgery and to eliminate or reduce the depth of the periodontal pocket Successful periodontal therapy completely climinates calculus, plaque or biofilm, and diseased cementum from the tooth surface ‘Numerous investigations have shown that the difficulty ofthis ask increases as the pocket becomes deeper” The iregularties and concavites on the root surface also increase, which adds to the lificulty of instumentng the oot surfaces.” Purcations also create problems for sealing and root planing in these areas' (See Chapier 50) ‘Mast of these problems can be remedied by resecting or displacing the soft tissue wall of the pocket, which increases the visibility 585Abstract: After completion of phase I therapy, which consist of patent educa ‘ion, biofilm control, and thorough root therapy, the involved peri- ‘odontal areas are reevaluated. Many cases may not require phase II therapy when gingival tissue shrinkage eliminates or reduces the Periodontal pockets. Phase II therapy becomes necessary when access {or root therapy is required or correction of anatomic of morphologic defects is nevessary. Placement of dental implants ean be part of this therapy. Keywords periodontal reevaluation plastic surgery aesthetic surgery resecive surgery regenerative surgery CHAPTER 57 Phase Il Periodontal Tharapy coPART 3 CLINICAL PERIODONTICS (os Pocket Reduction Surgery ' Resectve (ec. ginivectomy, apically cisplaced flap, undsplaced flap with or without osseous resection) © Regenerative (e.g, fans wit grafts, membranes) Correction of Anatomic or Morphologic Defects Plastic surgery techniques used to widen attached gingiva (o. free gingival stats} Estate surgery (e.g, root coverage, recreation of gingival papillae) Pre-prosthetic techniques (e9.,ccown lengthening ge ‘augmentation, vestibular deepening) Placement of dental implants, incluting techniques for site development formants (9, guided bone regeneration, sinus rats) eas ro |ronr) | pete | Fig, 57.1 Classification of periodontal suger. The surgical procedures Plaqus ‘Gingival ‘accumulation Iinlammation Pocket ? deepening Fig. 57.2 Accumulation of plaque leads to gingival infammation and pocket doopaning, which increas to ara of plaque accumulation, and accessibility of the root surface.’ The surgical Nap tecanique allows the clinician to overcome these problems of accesso the root surface, Pocket elimination is another important consideration. It consists ‘of reducing the depth of the periodontal pocket to that ofa physiologic suleus to enable cleaning by the patient. By proper ease selection, + regenerative techniques can he wed to ascomplish this goal-A pocket makes it impossible forthe patient to remove biofilm, ‘whieh is part ofthe vicious eyele depicted in Fig. 57.2, Results of Pocket Therapy A periodontal pocket canbe in an active state or a period of inactivity ‘or quieseence. In an active pocket, underlying bone is being lost (ig, 973, op lef) Ie often is diagnosed clinically by bleeding that ‘occurs spontencously’or in response to probing. After phase I therop, inflammatory changes in the pocket wall subside, rendering the pocket inactive and reducing its depth (see Fig. 57.3, top center) The extent of this reduction depends on the depth before treatment Inactive Healed Heathy sulcus Restored periodontium Fig. $7.3 Possible results of pocket therapy ar shown An active pocket can become inactive and heal by means ofa log junctional entelium, Surgical poket therapy can esl ina heathy sulcus, with or without gain of attachment Improved gingival attactment promotes restoration of bone height, with reformation of perocontal Iigament fibers and layers of and the degree to which the depth is the result of the edematous and inflammatory component of the pocket wall (Le, pseudopocke ‘Whether the pocket remeins inactive depends on the depth, the individual characteristics of the plague ot biofilm components, and the host response. Recurrence ofthe initial activity is likely Tnactve pockets sometimes heal wih long junctional epithelium (Gee Fig. 573, op right) This condition ean be unstable, and the chance of recurrence and r-formation athe orginal pocket remains ‘because the epithelial union withthe tooth is weak. However, one sudy in monkeys showed that the long junetiona epithelial union sould be as resistant to biofilm infetion as 3 attachment.” Several studies reported that inactive pockets could be mainiained {or long periods with lle loss of alachment by means of frequent therapy" "and by excellent plague or biofilm removal by the patient ‘om @ daly basis. A more reliable and stable result is obtained by transforming the pocket into & healthy sulcus. The bottom of t balthy suleus can be located where the bottom of the pocket was localized or coronal to it, In the fist case (See Fig, 57.3, bottom left), there is no gain of atachment, and the area of the root that connective tissue‘was previously the tooth wall ofthe pocket becomes exposed. Rather than causing recession, periodontal treatment uncovers the recession previously caused by disase ‘The healthy suleus ean be located coronal to the bottom of the preexisting pocket (see Fig. 57.3, bottom center and right). This is conducive to a restored marginal periodontium: the result isa suleus ‘of normal depth with «gain of attachment. The creation ofa healthy suleus and a restored periodontium entails total restoration of the slalus that existed before periodontal disease began, which isthe ‘deal result of treatment. The bone regeneration diagram in Fig. 573, (bottom center and right) is for illustrative purpose only because bone regeneration without an osseous wall i seldom achieved (see Chapter 24), Pocket Elimination Versus Pocket Maintenance Pocket elimination (i... depth reduction to gingival suleus levels) has traditionally been considered a type of periodontal therapy. It ‘was considered vital because ofthe need to improve access to root surfaces for the therapist during treatment and forthe patient after healing. Prevailing opinion considers deep pockets after therapy to represent a greater risk of disease progression than shallow sites, Individual probing depths are not good predictors of future clinical attachment loss. Conversely, the absence of deep pockets in treated patients is an excellent predictor ofa stable periodontium.” Longitudinal studies of different therapeutie modalities over the pst 30 years have produced conflicting results," probably because of problems created by the split-mouth design. After sugicl therapy, ‘pockets thr rebound toa shallow or moderate depth can be maintained in healthy state and without radiographic evidenee of advancing bone loss by maintenance visits consisting of sealing and rot planing, ith oral hygiene reinforcement performed at regular intervals of 3 ‘months or less. In these patients, the residual pocket can be examined with a thin periodontal probe without pain, exudate, or bleeding, ‘This indicates that biofilm hs not formed on the subgingival root surfaces ‘These findings donot alter the indications and nee for periodontal surgery because the results are based on surgical exposure of the oot surfaces for thorough elimination of instants, However, the findings also emphasize the importance of the maintenance phase ad close monitoring of the level of attachment and pocket depth along with the other clinical variables (e.g, bleeding, exuda- ‘ion, tooth mobility). Transformation of the initial deep, active pocket into a shallower inactive, maintainable packet requires some form of definitive pocket therapy and constant supervision thereafer Pocket depth san extremely useful and widely employed clinical determination, but it must be evaluated togeter withthe level of ‘tachment and degree of bleeding, exudation, and pain. The most ‘important variable for evalwating whether @ pocket is progressing fs the evel of attachment, which is measured in millimeters from the cementum-enamel juction. Apical displacement of the level of ‘tachment places the toot in jeopardy, not the increase in pocket dept, which may be caused by coronal displacement ofthe gingival margin, Pocket depth remains an important clinical variable in making ‘decisions about treatment. Linde and colleagues" compared the effet of root planing alone or using a modified Widman flap with the resultant level of attichment and in relation to initial pocket depth. They reported tat scaling ad root planing procedures induced Joss of attachment if performed in pockets shallower than 2.9 mm, ‘whereas gain of atachment accurred in deeper pockets. The modified CHAPTER 57 Phase! Periodontal Thorapy (UME Widnan fap induced loss of attachment if performed in pockets shallower than 4.2 mea bur resulted in a greater gain of attachmen ‘han root planing in pockets deeper than 4,2 mm, The loss is a trae loss of connective tissue attachment, whereas the gain ean be con- Sered a false gain because of reduced penetrability of connective tissues apical to the bottom of the pocket after treatment" Probing depths established about 6 months after active therapy and healing can be maintained, remain unchanged, or he reduced even further during a maintenance period involving careful reevalu- ation, plague o bof removal, and root therapy as necessary every’ 3 months Ramfjord* and Rosling'* and their colleagues reported that a certain pocket depth recurs regardless of the surgical technique used for porket therapy. Maintaining this depth without any further loss of atachment becomes the goal Reevaluation After Phase | Therapy ‘Longitudinal studies found that al patents should be tested intally with scaling root planing, and plague or biofilm contol and that a final decison on the need for periodontal surgery should be made only ater a thorough evaluation ofthe effects of phase I therapy. ‘Assessment typically is mae no less han 1 o 3 months and sometimes as much as 9 months after the completion of phase 1 therapy. Reevaluation of the periodontal condition includes repeat probing ofthe entire mouth. Calculus, root ares, defective restorations, and signs of persistent inflammation should also be evaluated. Critical Zones in Pocket Surgery Criteria fr the seletion of a surgical technique for pockst therapy are based on elinieal findings i the soft tissue pocket wall, tooth surface, underlying bone, and attached gingiva. Zone 1: Soft Tissue Pocket Wall ‘The clinician should determine the morphologic features, thickness, and topography of the soft tissue pocket wall and persistence of inflammatory changes in the wall Zone 2: Tooth Surface ‘The clinician should idem the deposits on and alterations of the ‘cementum surface and determine the aecessibility ofthe root surface to instrumentation, Phase I therapy should have solved many or all ‘of the problems on the tooth sutface. Evaluation of the results of | phase [therapy can determine the need for further therapy and the ‘method tobe used, Zone 3: Underlying Bone ‘The clinician should establish the shape and height ofthe alveolar bone next to che pocket wall through careful probing and elinical and radiographic examinations. The numberof osseous walls—one, ‘wo, or three—helps to determine whether resective or regenerative therapy can be used (see Chapter 24). Bony eraters, horizontal or angular bone loses, and other bone deformities also are important criteria in selection ofthe treatment technique, Zone 4: Attached Gingiva ‘The clinician should eoasider the presence or absence of an adequate band of keratinized, atached gingiva when selecting the pocket treatment method. Diagnostic techniques for mcogingival problems are deseribed in Copier 65, An inadequate atacked gingiva can be caused by a high frenum attachment, marked gingival recession, or 1 deep pocket that reaches the level of the mucogingival junction,Ertyee) PART2 CLINICAL PERIODONTICS All of these conditions should be explored and their influence on pocket therapy considered Indications for Periodontal Surgery ‘The following findings can indicate the need fora surgical phase of therapy’ 1. Areas with imegular bony contours, deep craters and other defects usually require a surgical approach 2, Pockels around teth where access to the r00t surface for come plete removal of root iitans isnot clinically possible are an indication for surgery. This occurs frequently around molars and premolars 3, Fureation involvement of grade II or II may require surgteal approach to ensure the removal of iitants around root surfaces [root resection or hemisection is necessary, surgical intervention will be needed 4, Intrabony pockets distal tothe last molaes, whieh in many eases ate complicated by mucogingival problems, often requite surgery 5, Persistent inflammation in areas after past procedures that have moderate to deep pockets may requie a surgical approach. These ace usually areas where all ofthe subgingival calculus could not be removed. Cases with shallow pockets and good hygiene but bleeding on probing can be eaused by mucogingival problems in areas where there is no ertinized tissue, Trauma to these areas can cause bleeding, Methods of Pocket Therapy ‘The methods for pocket therapy can be classified as follows: 1. New attachment techniques offer the ideal result because they climinate pocket depth by reuniting the gingiva withthe tooth at a position coranal to the botiom of the preexisting pocke. ‘New attachment involves regeneration of bone, connective tissue, Periodontal ligament, and cementum 2. Removal of the pocket wall is the most common method. The wall of the pocket consists of soft tissue and can include bone Inthe case of inrabony pockets. Itcan be removed by the following methods: + Retraction or shrinkage, where plague or biofilm removal by the patent and scaling and root planing resolve the inam- ‘matory process, can occur The gingival sve shrinks, reducing the pocket depth ‘Surgieal removal of the pocket is dane by gingiveclomy or the undisplaced lap technique + Apical displacement ofthe flap is performed with an apically displaced ap, 3. Removal ofthe tooth side of the pocket, which is accomplished by tooth extraction or by partial tooth extraction inthe case of fureation involvement (ie. hemiseetion or root resection), The techniques, what they accomplish andthe factors governing their selection are discussed in Chapters 0 through 65, Criteria for Selection of the Method of Surgical Therapy entific criteria to establish indications fr the use ofeach technique are dificult wo determine. Criteria are based on longitudinal studies that follow a significant number of cases over a number of years, standardization of multiple factors, and long-term clinical experience, Jection of a technique for treating a particular periodontal lesion is based on the following considerations: 1, Characteristics of the pocket: depth, relation to bone, and configuration Accessibilty to instrumentation, including furction involvement Existence of mucogingival problems Response to phase I therapy Patient cooperation, including the ability to perform effective oral hygiene and stop smoking ‘Age and general health ofthe patent 7. Overall diagnosis ofthe case: various types of gingival enlargement and types of periodontitis (e., chronic marginal periodontitis, localized aggressive periodontitis, generalized periodontitis) 8, Aesthetic considerations 9. Previous perindontal treatments Each variable is analyzed in relation to the pocket therapy techniques available. A specific technique is then selected. The one ‘most likely to successfully solve the problem with the Fewest undesit- able effects should be selected, Clinicians who adhere to one technique to solve all problems do not ake advantage of the wide repertoire of techniques that are at their disposal Approaches to Specific Pocket Problems Therapy for Gingival Pockets Gingival pockets do not have an osseous component (Le. no attache ‘ment loss) and usually have edematous or fibrotic gingival tissue ‘Two factors are taken into consideration: the character of the pocket wall and the accessibility of the pocket ‘The pocket wall can be edematous or fibrotic, Edematous tissue shrinks afte the elimination of local factors, reducing or totally climinating pocket depth, Sealing and root planing is the teshnique of choice far these eases. Pockets with 2 /brotic wall are not appreciably redueed in depth aller scaling and rot planing, These pockes are eliminated or reduced bby surgical therapy, In the past, gingivectomy was frequently used to reduce these pockets. Ths Solved the problem, but in cases of ‘marked gingival enlargement (eg. severe phenytoin-lated enlarge+ ‘ment, treatment could leave a lage, open wound, and the patient hha to endure a painful and prolonged healing process. Currently, a ‘modified flap teclanique is used, and fewer postoperative problems are associated with primary closure of the wound (see Chapier 61), ‘Some clinicians have advocated the use of laser therapy to manage singival enlargement (see Chepter 68), Therapy for Incipient Periodontitis In patients with slight or ineipiet periodontitis with minimal atach- ‘ment and bone loss, the pocket depths are shallow ar a moderate depth. In these patients, the conservative approach of good oral hygiene, scaling, and root planing when necessary usually suf fices to control the disease. Incipient periodontitis that recurs in previously treated sites with good hygiene may require thorough analysis of the recurrence, which may be caused by remnants of calculus that were missed during previous treatment or other ‘actors such as open margins of a restoration located subgingival ‘Occasionally, a surgical approach may be required to correct these problems Therapy for Moderate to Severe Periodontitis in the Anterior Sector Because the maxillary anterior teeth are important aesthetically, techniques that cause the leat amount of visual root exposure should bbe considered. However, each patient has different expectations regarding the final result of therapy. The clinician mast explain that the therapy may be a compromise between complete pocket elimina- ‘ion and achieving anaesthetic result that is acceptable tothe patient. The patient must be educated before therapy thatthe result may besome degree of gingival recession and some loss ofthe interdental papilla (see Chapter 65) The anterior dentition has two advantages for using a conservative (nonsurgical) approach: (1) the teth are all single ooted and eas aveessible for subgingival scaling and root planing, and (2) patie ‘compliance and thoroughness in plaque of biofilm control may be easier to attain, Nonsurgical therapy is therefore the technique of choice for the maxillary anterior dentition, In some situations, surgical therapy may be necessary fo improve accessibility for root planing, or regenerative therapy may'be possible, ‘Chapters 59, 60, and 63 discuss the surgical aspects in detail. The papilla preservation flap or modified papilla preservation flap can bbe used for both purposes and oflers a better postoperative result with less recession and redueed sof tissue crater formation inerproximally = ‘When the interdental space is minimal, papilla preservation techniques may not he feasible, Instead, a technique that splits the papilla and retains as much of the papilla as possible i the appropriate sutpical tectnique ‘When the aesthetic outcome isnot the primary consideration and flap procedure is necessary for root surface aceess, the modified ‘Wdman flap can be selected. This technique uses a internal bevel incision about 1 t0 2 mm from the gingival margin without thinning the flap. This procedure may result in minor recession ofthe sut- rounding gingival tissue In cases with advanced osseous involvement, bone contouring may be needed despite the resultant root exposure. The technique of choice isthe apically displaced fan with asseous bone contouring. The clinician must educate the patient before therapy about the possibility of aesthetic difficulties due to the expected recession of gingival tissue. Therapy for Moderate to Severe Periodontitis in Posterior Areas Treatment for the maxillary and mandibular premolars and molars does not ental aesthetic problems but frequently involves difficult aveess for root therapy. Bone defects occur more olen inthe posterior area than the anterior, with many areas having deep infrebony lesions and anatomic root problems with concevities, such as the mesial surface ofthe maxillary first premolar. dificul problem encountered in the posterior area is the fureation lesion. Because this area can pose insurmountable problems for instrumentation unless fap is reflected, surgery is frequently indicated, ‘Surgery is used in the posterior area for enhanced access to the root surface or far definitive pocket reduction requiring osseous CHAPTER 57 Phasel Periodontal Therapy [UMNEES] surgery. Aveess can be obtained by an undisplaced or apically dis- placed flap (see Chapter 60). ‘Most patients with moderate o severe periodontitis have developed ‘osseous defects that require some degree of bone remodeling or reconstruction, For osseous defects amenable to reconstruction, the papilla preservation flap oF modified papilla preservation flap isthe fechnique of choice because i better protects the interproximal areas where defects frequently occur. Second and third choices are the sulcular flap and modified Widman flap, maintaining as much ofthe papilla as possible, For osseous defects with no possibility of reconstructive therapy, such as intedental craters, the technique af choice isan undisplaced ‘or apically displaced fap wih osseous contouring. All surgical Dap procedures are discussed in Chapters $7, 59, and 60. Surgical Techniques for Correction of Morphologic Defects ‘The rationales and objectives for techniques performed to correct ‘morphologic defects (1.,, mucogingiva, aesthetic, and pre-prosthtic) are described in Chapters 60 and 62. Surgical Techniques for Implant Placement and Related Problems ‘The rationales and objectives for techniques performed for implant placement and related problems are described ia. Chapters 78 ‘rough 80. Conclusions ‘Many’steps are requited to achieve and maintain heathy periodontal status. After completion of phase I therapy, which consists of patient education, biofilm contro, and thorough root therapy, the involved periodontal areas are reevaluated. The necessity of phase I therapy, ‘whiet isthe surgical phase of teatment, depends on the success of the intial phase and the severity of the periodontal condition Periodontal surgery, which includes plastic, aesthetic, resective, and regenerative procedures, becomes necessiry when aecess for root therapy is required or correction of anatomic or morphologic defects js necessary. Placement of dental implants canbe part of this therapy References for this chapter are found on the companion ‘website wivwexpertconsul.com,