Generally, dental treatment begins with pain management, if needed, and progresses through acute disease control, definite treatment, and maintenance phases. The acute disease control phase consists of biopsy and initial management of suspicious oral lesions, removal of hopeless teeth, initial root canal treatments, caries control, and initial treatment of periodontal disease. Initial periodontal disease treatment aims to control periodontal inflammation, which is a prerequisite for most restorative procedures and often the first treatment step in patient care. This chapter addresses how periodontal inflammation can be controlled nonsurgically with scaling and root planing (SRP) procedures, adjuncts, oral hygiene methods, and tobacco cessation counseling. These methods are also applied in the maintenance phase in order to prevent periodontal inflammation and tooth loss.
Learning Objectives
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Given clinical findings, develop a comprehensive periodontal treatment plan that aims to reduce periondontal inflammation.
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Describe how to perform efficient and effective scaling and root planing (SRP).
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Describe the benefits and risks of adjunctive agents used during SRP.
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Given a patient’s oral hygiene needs, develop personalized oral hygiene instructions.
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Develop a strategy to assist a patient with tobacco cessation.
Case
A 30-year old healthy Hispanic male presented complaining of “hurting gums” and “cavities” (see Fig. 5.1 and Fig. 5.2 for initial presentation). He saw a dentist 2 years before this visit, but did not remember what was done. He stated that he brushes regularly twice daily with a manual brush and fluoridated toothpaste, but does not floss “since it makes his gums bleed.” Oral examination showed no pathology other than slight marginal and moderate papillary erythema, accompanied by generalized gingival bleeding, deep pocketing, and heavy calculus. Idiopathic osteosclerosis was found in some areas of the mandible during the radiographic exam. More significantly, mild generalized bone loss was found along with occlusal caries at some posterior teeth.
Initial findings in the periodontal chart are as follows:
Oral hygiene instruction was provided for using interproximal brushes. All teeth were thoroughly scaled and root planed, followed by sulcular irrigation with chlorhexidine gluconate. Any carious lesions were restored. This resulted in gradual reduction of pocketing and inflammation over time, with only one 5-mm pocket remaining after 2 years. The patient’s condition appears stable as there was no additional radiographic bone loss since the patient was seen initially (see Fig. 5.2 “2 year” radiographs).
Probing depths after 2 years are as follows:
What can be learned from this case?
The key to successful management of periodontal disease is to remove irritating factors causing or contributing to gingival inflammation. In this case, the patient’s periodontal disease can be described in the dimensions given in Table 5.3.
The dimensions of the periodontal disease described in this case match best with a mild periodontitis (Stage II, Grade B)-type scenario based on the presence of moderate inflammation and generalized signs of mild attachment (1–2 mm)/ bone loss (within coronal third of root length). The presence of few local contributing factors (plaque and calculus) and the absence of specific microbial and systemic contributing factors provide a plausible explanation for the observed disease severity. Removal of plaque and calculus did generally restore periodontal health (except at one site), generally demonstrating effective treatment and complete removal of factors that lead to periodontal disease on most teeth.
The single residual pocket at tooth no. 31 is a concern since bleeding on probing and pocketing predicts potential for future attachment loss, and further treatment is needed. It is likely that this site contains residual subgingival plaque associated with either remnant calculus or another contributing factor such as the mild tipping of this tooth, shallow root concavity, or food impaction leading to enhanced inflammation there.
Controlling Periodontal Inflammation
Common periodontal disease is caused by a disease-causing microbial community within the periodontal sulcus, and periodontal treatment aims to remove and prevent the establishment of a disease-causing microbial community. Initial periodontal disease and periodontal maintenance therefore involves the following:
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Mechanical removal of plaque and calculus, which removes and disrupts the original disease-causing microbial community.
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Removal or control of factors that promote periodontal disease or tissue injury.
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Oral hygiene instruction and other preventive dental treatment that prevents the growth of a disease-causing microbial community.
Initial treatment planning therefore involves taking up the problem list of and local factors collected during periodontal assessment and correlating these factors with the following treatments:
For, treatment usually involves consultation and collaboration with a physician or medical specialists (Table 5.4a). Dentists can and should provide at least limited tobacco cessation and nutrition counseling since they interact with patients more often than physicians. There are appropriate Current Dental Terminology (CDT) codes dentists can use for insurance reimbursement. Patients should also be referred to a physician for these counseling services as medications and referrals to dietitians and other specialists may be covered through medical insurance if prescribed by a physician.
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