Introduction

Nonsurgical treatment is aimed at the removal of plaque and plaque-retentive factors from the tooth surface. Plaque-retentive factors include calculus and may also include factors such as overhanging restorations and other iatrogenic factors. Removal of plaque-retentive factors is an important part of disease control because it facilitates the establishment of regular effective plaque control measures by the patient. In addition, all patients with periodontal pockets will require the removal of plaque and calculus from subgingival sites because these areas are inaccessible for cleaning by the patient. Consequently, mechanical nonsurgical periodontal therapy is always combined with appropriate oral hygiene instruction (OHI). Successful nonsurgical therapy will result in control of the microbial plaque biofilm, which in turn results in resolution of inflammation and healing of the pocket, creating a local environment that encourages periodontal health and greatly decreases the likelihood of disease recurrence and further progression. The evidence of its clinical efficacy is overwhelming and thus nonsurgical treatment has been the mainstay of successful periodontal practice for well over half a century.

The aim of this chapter is to explain the application of nonsurgical treatment of periodontitis, focusing on the requirements for successful subgingival debridement.

What is nonsurgical treatment?

A course of nonsurgical treatment includes the following elements:

In addition, during this phase of treatment, management of other modifiable risk factors, such as smoking cessation, should be introduced. In specific circumstances, this treatment may be supplemented with adjunctive chemical antimicrobial therapy, either with antiplaque agents to help manage plaque control or, rarely, with systemic antibiotics (see < ?xml:namespace prefix = "mbp" />Chapter 14).

As discussed in Chapter 9, a course of nonsurgical treatment should be followed up by a reassessment of the patient’s response to treatment and by further decision making about appropriate further treatment needs.

At this point, it is important to note some of the terms used to describe this treatment modality. The term scaling is used to describe the removal of calculus from the tooth surface, either supra- or subgingivally. The term root planing is a more accurate description of removing both calculus and root surface irregularities during treatment, whereas the term root surface debridement (RSD) has become more widely used to describe the process of atraumatically removing plaque, calculus, and any root surface irregularities within a pocket.

By definition, RSD is a “blind” procedure. When instrumenting below the gingival margin into a pocket, it is not possible to see exactly where the tip of the instrument is located, so it is generally not possible to visualize just how successful the instrumentation has been. As such, RSD is a technically demanding procedure and requires careful, thorough instrumentation to achieve a clean root surface. In the absence of being able to visualize the root surface, one of the aims of nonsurgical treatment is to make the tooth/root surface uniformly hard and smooth, relying on feel to assess the root surface; often, the word “glassy” is used to describe how the root surface should feel after instrumentation. A WHO ball-ended probe is excellent at detecting residual calculus and root surface roughness after RSD.

Scaling technique

There are two main types of scaling instruments—hand scalers and ultrasonic scalers. The ultrasonic scaler has a tip that vibrates in the ultrasonic frequency and effectively shakes and breaks the calculus off of the root surface, partly by its direct mechanical effect but particularly by generation of a “cavitational effect” in which microscopic bubbles in the water irrigant around the tip are formed and then implode to release energy.

There is a wide array of different types of hand instruments that are designed for use either supra- or subgingivally and that have a variety of tip shapes to access all the different areas of the mouth. These instruments are summarized in Table 8.1. Those most commonly used for RSD are periodontal curettes, which either cut on both sides of the tip (universal type) or cut on one side only (Gracey type). To be effective, hand instruments need to be kept sharp by very regular use of sharpening stones or tungsten carbide “whittlers.” Most hand scaling instruments are made of high-quality stainless steel or carbon steel, and they can be effectively sharpened with sharpening stones. A few instruments, particularly most periodontal hoes, have tungsten carbide tips and thus keep their sharpness longer, but because they require diamond sharpening tools, they are very difficult to sharpen once they become dull. Principles of scaling include using a finger rest that is as close to the tooth being treated as possible, keeping the cutting edge of the tip at an approximately 90° angle (the so-called “rake” angle), and always scaling in an apical-to-coronal direction. The different curves of the various instruments are designed to maintain a suitable rake angle for the tip of the instrument when accessing different teeth. In general, those that are designed for posterior teeth have the most pronounced curves in their shanks, whereas those for anterior teeth may be closer to being straight in line with the handle of the instrument (Figures 8.1–8.4).