Phase 1 Therapy

10.1055/b-0034-56522

Phase 1 Therapy

• Initial Treatment 2—Causal, Antimicrobial Therapy by the Dental Team

Traditional, Non-surgical Pocket Treatment
FMT—Pharmacologically Supported “Full Mouth Therapy”

Actual Phase 1 therapy—the second component of initial treatment—includes closed debridement of periodontal pockets. This is also referred to as conservative therapy, in contrast to periodontal surgery (p. 295), and also as “non-surgical” therapy. The following procedures comprise this aspect of treatment:

Debriding the root surfaces of plaque and calculus
Removing endotoxin-containing cementum layers (?)
Root planing
Possible soft tissue curettage
“Full mouth therapy”

Definitions

Nomenclature for these procedures is not internationally uniform. Presented here is a recapitulation of definitions (AAP “Glossary of Periodontal Terms,” 2001):

Debridement—Plaque and Calculus Removal (Scaling)

Removal of non-adherent and adherent biofilm as well as calcified plaque (calculus) from gingival or bony pockets, without modifying the root surface.

Detoxification of the Root Surface

Mechanical or chemical detoxification of the root surfaces. Removal of any remaining endotoxin-containing layers of cementum. This procedure is not necessarily differentiable from subgingival calculus removal on the one hand, or root planing on the other.

Root Planing

Smoothing the root surfaces using curettes and possibly also diamond burs. This procedure is also not a distinct entity vis-à-vis subgingival cleaning and planing of root surfaces.

Gingival Curettage

Removal of the pocket epithelium and infiltrated subepithelial connective tissue (often classified as surgical therapy).

Conservative Therapy—“Closed Curettage”

All of the above-defined procedures are performed without reflecting the soft tissue, i.e., without direct vision into the pocket or onto the root surface (as of today; cf. p. 282).

“Open Curettage”

After creating a gingival flap (modified Widman procedure, p. 300), the gingiva is reflected to such an extent that root planing can be performed with direct vision. This is classified as a surgical procedure.

“Full Mouth Therapy”—FMT

Definitive antimicrobial, closed, non-surgical, mechanopharmacologic pocket therapy of the entire oral cavity (FMD—“full mouth disinfection”) within 24 hr, to avoid re-infection and microbial transmission.

The differences between the treatment measures in Initial Therapy 1 (supragingival plaque and calculus removal) and Initial Therapy 2 (subgingival) are not sharply defined.

Non-surgical, Anti-infectious Therapy—Goals of Treatment

The goal of traditional, non-surgical therapy is the elimination of the microorganisms responsible for periodontal destruction, from the pocket and surrounding tissues. The creation of a clean tooth and a clean, biologically compatible root surface that is as smooth as possible, and the removal of diseased or infected tissues are essential to therapy (Frank 1980, Saglie et al. 1982, Allenspach-Petrsilka & Guggenheim 1983, O’Leary 1986, Adriaens et al. 1988, Peter-silka et al. 2002).

Removal of the pocket epithelium and portions of the infected connective tissues was a matter of controversy until recently; current research results clearly demonstrate the possibility of bacterial colonization of pocket epithelial cells (intracellular) and of connective tissue components. The most frequently encountered colonizers are A. actinomycetemcomitans, P. gingivalis, T. denticola and, in addition to the acknowledged pathogens, also Streptococcus constellatus (Socransky & Haffajee 2002).

Today’s question? Should the pocket epithelium be removed in addition to removal of biofilm from the soft tissue pocket wall?

**562** **Principles of Conservative Pocket Therapy** This stained histologic section through a gingival pocket (HE, 20×) will be used to illustrate *root planing* (*debridement*) and *soft tissue curettage*. Soft tissue curettage (2) is never used alone. True “causal” therapy includes the elimination of micro-organisms wherever they have become organized as a biofilm. It is imperative that the root surface be thoroughly debrided (1). **1 Scaling and Root Planing** The unilaterally sharp Gracey curette (1) removes plaque, calculus, endotoxin-containing cementum and sometimes dentin from the root surface. The arrow indicates the direction toward which the curette tip is pulled. **2 Gingival Curettage** A Gracey curette sharpened on its other edge (2) is used to remove pocket epithelium and remaining (apical) junctional epithelium, as well as the infiltrated connective tissue.

**563** **Subgingival Biofilm at the Base of a Pocket** Histologic section, plaque stained with toluidin blue and methylene blue, modified. Of special interest is the biofilm formation on the soft tissue wall. 1 *Biofilm*/plaque on the root surface 2 *Biofilm* attached to the soft tissue wall: *“red complex?”* D Dentin C Cementum **ICT** Infiltrated connective tissue Courtesy *M. Listgarten*

Antimicrobial Therapy—Combating the Reservoir

The answer to the question posed on the previous page would be: Yes. However, the AAP (2002) in its “Academy Statement Regarding Gingival Curettage,” concluded that soft tissue curettage has no additional effect beyond scaling and root planing.

In any case, it is most important that purely mechanical therapy as a means to achieve the ultimate goal—periodontal healing—should be enhanced by the use of all antimicrobially effective measures.

The initial question concerns the bacterial reservoirs in the ecosystem represented by the oral cavity. The diagram below (Fig. 564) demonstrates the possible niches, the plaque-retentive areas in which periodontopathic microorganisms may be harbored.

Such microorganisms can rapidly contaminate (re-colonize) a freshly-treated pocket, and thus compromise the treatment results. Therefore, such bacterial reservoirs must also be “treated,” especially in highly susceptible patients.

**564** **Oral Microbial Reservoirs** Increases in plaque accumulation occur wherever microorganisms find a secure and undisturbed niche with good nutritive sources. Clusters of microbial colonies are always found in the small scratches that remain following root surface debridement, as well as the deep crypts in tonsils and on the dorsal surface of the tongue; many such clusters harbor the well-acknowledged periodontopathic anaerobes. Even a 0.5 mm thick biofilm provides oxygen-free (anaerobic) conditions for these microbes. Modified from *P. Adriaens 1995*

**565** **P. gingivalis and A. actinomycetemcomitans in the Oral Reservoirs** Occurrence of the two species in 24 patients. The presence and relative concentrations support the thorough cleaning of the tongue surface (pp. 237 and 281), and not only for patients with halitosis. Modified from *Socransky et al. 1999*

Root Planing—With or without Curettage?

The primary goals in pocket treatment are removal of the biofilm and thorough debridement of the root surfaces.

Following elimination of non-adherent and adherent plaque, all subgingival calculus is removed. The superficial layers of the root cementum contain endotoxin. This lipopolysaccharide (LPS) from gram-negative bacteria can inhibit connective tissue regeneration and reestablishment of the periodontal ligament to the root surfaces. For this reason, root planing should be performed into “healthy” (hard) cementum or dentin layers.

After the root surface is thoroughly planed, the “peeling out” of the pocket epithelium and infiltrated connective tissue can be accomplished. If the curettes used for root planing are sharp on both edges (universal curettes), some soft tissue curettage will be accomplished inadvertently while the hard tooth structure is being planed.

The goals of these procedures include elimination of infection within the pocket and the pocket epithelium, and the ultimate healing of the periodontal lesion.

**566** **Root Planing and Curettage—Principles** A **Cleaning the Root and the Pocket** The root surface is treated (1), and the plaque (P) is removed from the pocket. B **Original Pocket** With calculus, adherent plaque and non-adherent microorganisms. C **Soft Tissue Curettage** In addition, but never as the sole therapy, pocket epithelium/infiltrate (2) and junctional epithelium (3) are removed.

Effects of Subgingival Debridement—Pocket Healing or Recolonization?

The goal of closed anti-infectious therapy is the complete healing of all periodontal pockets, but this goal is seldom achieved. Access and vision are severely limited during closed instrumentation. Almost always, here and there, residual pockets of varying depths persist (Badersten 1984; p. 280). The so-called “critical depth” of residual pockets is 4–5 mm. Such pockets offer anaerobic conditions, which provide the well-known pathogenic, gram-negative anaerobic microorganisms a favorable environment. Remaining deeper pockets can serve as a bacterial reservoir for the re-colonization of residual pockets. Patients who harbor residual pockets should be maintained in a strict recall schedule to control or eliminate such pockets.

Subgingival instrumentation (debridement) normally removes about 90% of the bacteria from a pocket, including both “favorable” and pathogenic flora: The processes of healing and recolonization are in competition with each other, and residual pockets usually persist.

The favorable effect of closed pocket treatment is that the non-pathogenic flora recolonizes the pocket faster than the pathogenic microorganisms (Fig. 567; Petersilka et al. 2002).

**567** **Pocket Instrumentation—Schematic of Residual Pockets** A **Untreated Pocket** Non-pathogenic (blue) and pathogenic (red) pocket flora. B **Following Instrumentation** The pocket flora is dramatically reduced. C **Recolonization + Shift** The percentage composition of the “blue” (non-pathogenic) has increased; in many cases, these and/or the host response will keep the “red” (pathogens) in check.

Closed Therapy—Indication, Instrumentation

It has been stated many times: Periodontal diseases should be prevented, or, failing prevention, should be diagnosed and treated early on.

Standard methods for the treatment of mild and moderate periodontitis include closed, non-surgical, anti-infectious pocket treatment (scaling and root planing). This approach is effective, tissue-friendly (minimal recession), less hemorrhagic, and routinely results in favorable treatment results. Perhaps even more important today, it is affordable for the (informed) patient.

With a technically adept and highly educated dental hygienist, closed therapy is the definitive therapy for uncomplicated cases, and represents the initial therapeutic approach for complex, advanced cases.

Contraindications for this approach are rare (patients on anticoagulant medications, risks for focal infection, systemic diseases).

**568-569** **Instrumentarium for Mechanical/Anti-infectious “Closed” Therapy** These types of instruments are required for all patient treatments: • **Periodontal probe** • **Sonic scaler—**supragingival • **Ultrasonic device**—pockets—subgingival • **Curettes**—scaling, polishing • **Motor-driven special instruments**—furcations, grooves, etc. **Chemical/Pharmacologic Adjunctive Therapy** The paradigm shift toward anti-infectious/antimicrobial therapy includes disinfectants and antibiotics more and more as co-therapeutic agents, above all for the treatment of aggressive cases. • **Disinfectant Agents** FMT (pp. 235, 283) • **Local CRD** “Controlled release drugs” (p. 292) • **Systemic Antibiotics** (p. 288)

Conclusions

The goals of subgingival scaling are simple:

Complete removal of biofilm and calculus
Root planing (to reduce new plaque formation)
Creation of a bioacceptable root surface (chemical conditioning with various substances, following mechanical treatment).

Subgingival scaling is a technically difficult endeavor, because it is performed without direct vision. Even the experienced hygienist will not always effectively treat all root surfaces, nor completely remove all plaque and calculus from all surfaces.

Today, the question is: How can we improve the “gold standard” of closed causal therapy and subgingival scaling? Most recently, in addition to the classical, mechanical instrumentation, topical antimicrobial agents have been successfully employed (disinfectants, antibiotics); however, such adjunctive measures will only be helpful when used in combination with thorough scaling and root planing! Systemic antibiotics may often be indicated in severe, aggressive cases (p. 287).

A new television technique may bring “light and vision” into the periodontal pocket! The Dental View device can dramatically reduce the amount of “missed” subgingival calculus.

Hand Instruments for Scaling and Root Planing—Curettes

For the removal of large subgingival calculus deposits, curettes are indicated, in addition to sonic and ultrasonic devices (p. 259). For root planing and soft tissue curettage, curettes are the instruments of choice.

Numerous manufacturers offer a myriad of hand instruments, which may vary with regard to quality (e.g., steel) and design. In this Atlas, we do not make recommendations concerning specific manufacturers or instrument sets, because it is acknowledged that every “school” as well as each and every hygienist has its/her/his favorite instruments.

Most important is that a set of curettes must provide effective approaches to all root surfaces, while providing the proper angle of application of the blade to the root surface (ca. 80°). Curettes must be sharpened before each use (p. 268).

It is important to note the difference between universal curettes, which have two cutting edges, and Gracey curettes, which have only one cutting edge. Gracey curettes are primarily indicated for debridement and root planing, and less often for soft tissue curettage.

**570** **Curettes** (Deppeler Co.) • **Universal Curettes, ZI 15** Yellow; for initial gross debridement • **Anterior Curettes, GX 4** Orange; for anterior teeth and canines, and sometimes premolars • **Posterior Curettes, M 23 A** Red; for premolars and molars *Right:* Working end of the paired posterior curettes, M 23A.

**571** **Minimum Gracey Set** In most clinical cases, a set consisting of four double-ended Gracey instruments is sufficient. Depicted here are color-coded curettes with soft grips (ADEC, Deppeler). • **Gracey 5/6** yellow • **Gracey 7/8** gray • **Gracey 11/12** red • **Gracey 13/14** blue *Right*: Double-bend shank and working end of the paired Gracey curettes 13/14.

**572** **Complete Set of Gracey Curettes: 7 Double-ended Instruments** (Hu-Friedy Co.) • **Gracey 1/2** • **Gracey 3/4** • Gracey 5/6* • Gracey 7/8* • **Gracey 9/10** • Gracey 11/12* • Gracey 13/14* * These four (double-ended) instruments comprise the minimum set (Fig. 571).

Powered Instruments for Debridement

In addition to the classical hand instruments, powered devices are finding increasing use in practice today for supra-and subgingival periodontal debridement. Included are:

Ultrasonic devices (20–50,000 Hz)
Sonic devices (up to 6,000 Hz)
Motor-driven devices incorporating diamond-coated tips.

The goal, with both hand instruments and powered devices, is to create biologically acceptable root surfaces. Calculus must be completely eliminated, but without creating root surface roughness; rough root surfaces are more quickly colonized by bacteria than smooth surfaces. If used properly, curettes and ultrasonic devices can achieve relatively smooth surfaces; on the other hand, sonic and motor-driven devices more often elicit roughness (Römhild 1986; Schwarz et al. 1989; Ritz et al 1991; Axelsson 1993; Kocher & Plagmann 1997). Rough but clean tooth surfaces, especially in the region of the gingival margin, should always be given the “finishing touch” with curettes to ensure smoothness, and to inhibit or delay re-infection of the pocket.

**573** **Ultrasonic Devices** Ultrasonic devices function in direct contact with the tooth surface according to the principles of cavitation and acoustic microstreaming. Examples: • **Dentsply** Pictured: Slimline attachments • **EMS** • **Satelec** *Left*: **Dual Select** (Dentsply). With this attachment, one can select water or one of two antimicrobial cooling solutions.

**574** **Sonic Devices—KaVo Sonicscaler—Insert No. 8 with Elongated Tip** No. 60, 61 and 62 are special tips for subgingival application. Examples of sonic devices: • **Sonicscaler, KaVo** • Airscaler, Titan-S • **Siroson, Siemens** *Left*: Working tips—overview. Diamond-coated tips for working in furcations.

**575** **Additional Motor-driven Instruments for Subgingival Application** • **Perioset—Diamonds** (Intensive SA) • **Scalex Tips** (Rotex) • **EVA-System—Proxoshape** (Instensiv SA) • **Peri-O-Tor** (Dentatus) • **Perioplaner, Periopolisher** (Mikrona) *Left*: Handpiece with the Peri-O-Tor attachment.

Gracey Curettes—Areas of Use

Complete Set

For closed (“blind”) subgingival scaling and root planing, special instruments are indicated that are adaptable to the most varied root shapes. As early as the 1930’s, Dr. C.H. Gracey, a dentist, together with an instrument maker by the name of Hugo Friedman (Hu-Friedy!), conceptualized a set of instruments that “…gives every dentist the possibility to treat even the deepest and least accessible periodontal pockets simply and without traumatic stretching of the gingiva. In addition, these curettes make it possible to completely remove all subgingival calculus, and to perfectly clean and plane every root surface, which will enhance subsequent tissue adaptation and re-attachment.”

Numerous modifications of the instruments led finally to the Gracey curettes of today. The use of these instruments has been described in detail (Pattison & Pattison 1979, Hell-wege 2002).