Phase I Periodontal Therapy PDF

PHASE I PERIODONTAL THERAPY Prof. Dr. Halil İ. Taşer  Phase I therapy or cause-related therapy is the first in the chronologic sequence of procedures that constitute periodontal treatment. The objective of phase I therapy is to alter or eliminate the microbial etiology and factors that...

PHASE I PERIODONTAL THERAPY Prof. Dr. Halil İ. Taşer  Phase I therapy or cause-related therapy is the first in the chronologic sequence of procedures that constitute periodontal treatment. The objective of phase I therapy is to alter or eliminate the microbial etiology and factors that contribute to gingival and periodontal diseases to the greatest extent possible, thereby halting the progression of disease and returning the dentition to a state of health and comfort. Phase I therapy is referred to by a number of names, including: - initial therapy, - nonsurgical periodontal therapy, and - cause-related therapy. All terms refer to the procedures performed to treat gingival and periodontal infections and include tissue reevaluation, which is the point at which the course of ongoing care is determined. Rationale Phase I therapy is defined as the initiation of a comprehensive daily plaque or biofilm control regimen, management of periodontal-systemic interrelationships as needed, and thorough removal 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 factors such as elimination of defective restorations and treatment of carious lesions. These procedures are a required part of periodontal therapy, regardless of the extent of disease present. In many cases, only phase I therapy is required to restore periodontal health, or it constitutes the preparatory phase for surgical therapy.  Briefly, cause-related phase I periodontal therapy has been stated as the approach aimed at removal of pathogenic biofilms, toxins, and calculus and the reestablishment of a biologically acceptable root surface. Phase I therapy is a critical aspect of periodontal treatment. Data from clinical research indicate that the long-term success of periodontal surgical treatment is dependent on maintaining the plaque or biofilm control results achieved with phase I therapy. In fact, patients who do not have adequate plaque or biofilm control will continue to lose attachment regardless of what surgical procedures are performed. In addition, phase I therapy provides an opportunity for the dentist to evaluate tissue response and provide reinforcement about home care, both of which are crucial to the overall success of treatment.  Based on the knowledge that microbial plaque or biofilm is the major etiologic agent in gingival inflammation, one specific aim of phase I therapy for every patient is 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 if the tooth surfaces are free of calculus deposits and other irregularities 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 supragingival and subgingival calculus 3. Correction or replacement of poorly fitting restorations and other prosthetic devices 4. Restoration or temporization of carious lesions 5. Orthodontic tooth movement 6. Treatment of food impaction areas 7. Treatment of occlusal trauma 8. Extraction of hopeless teeth 9. Possible use of antimicrobial agents, including necessary plaque or biofilm sampling and sensitivity testing Treatment Sessions After careful analysis and diagnosis of the specific periodontal condition present, the clinician must develop a treatment 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 cases, patients require several treatment sessions for complete debridement of the tooth surfaces. All the following conditions must be considered when determining the phase I treatment plan: General health and tolerance of treatment Number of teeth present Amount of subgingival calculus Probing pocket depths Attachment loss Furcation involvement Alignment of teeth Margins of restorations Developmental anomalies Physical barriers to access the dentition (i.e., limited opening or tendency to gag) Patient cooperation and sensitivity to therapy (requiring use of anesthesia or analgesia) Abstract This initial phase of therapy is crucial in determining the total outcome of therapy, because it is this part that will help determine the compliance of the patient toward their understanding of the concept of self-cure. Patient education, initial root therapy (scaling and root planing), and reevaluation to determine if surgical therapy is necessary is all decided at the end of this phase of therapy. Sequence of Procedures Step 1: Plaque or Biofilm Control Instruction Plaque or biofilm control is an essential component of successful periodontal therapy, and instruction should begin at the first 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 to the patient. Once the patient understands the nature of periodontal disease and the etiology, it will be easier to teach the hygiene that he or she must practice. The patient must be instructed on the proper technique to remove the plaque or biofilm; this means focusing on effective toothbrushing to remove plaque.  Instructions are also initiated for interdental cleaning with dental floss and interdental brushes and other interdental cleaning devices. The use of the multiple appointment approach to phase I therapy is favored by many clinicians because it permits the use of numerous appointments to evaluate, reinforce, and improve the patient’s oral hygiene skills. Step 2: Removal of Supragingival and Subgingival Plaque or Biofilm and Calculus Removal of calculus is accomplished using scalers, curettes, ultrasonic instrumentation, or combinations of these devices during one or more appointments. Evidence suggests that the treatment results for chronic periodontitis are similar for all instruments, which could be hand instrumentation or other mechanical instruments, such as ultrasonic devices. Most clinicians advocate the combination of hand instruments (scalers, curettes) and ultrasonic devices.  In addition to calculus and plaque or biofilm removal, cementum exposed to the pocket environment should be removed. At one time it was thought that the removal of all cementum was necessary to attain a smooth, glassy, hard surface. The rationale was that cementum became necrotic from penetration of endotoxins from the microbial biofilm and would interfere with healing. Current studies have indicated that endotoxins do not penetrate into the cementum as deeply as once believed and complete removal of the cementum may not always be necessary, but removal of the plaque or biofilm and calculus is absolutely necessary. In a clinical situation, it is difficult to know whether the removal of some or all of the cementum is achieved.  An interesting approach to calculus removal and debridement is full-mouth disinfection. In this technique, full-mouth treatment is performed during multiple sessions within a few days. Disinfectants are used after therapy, with the intention of preventing reinfection of treated sites from untreated sites. 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 and agreed on by the patient and the dentist based on the amount of disease present and the patient’s tolerance to the therapy. Staged therapy has the advantage of evaluating and reinforcing the oral hygiene status of the patient, but the one- or two-appointment approach can be more efficient 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 plaque or biofilm retentive areas, 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 failing restorations may be necessary. All these steps are important to remove the risk factors that 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 or permanent restorations are indicated 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 cannot repopulate the microbial plaque. Step 5: Tissue Reevaluation After scaling, root planing, and other phase I procedures, the periodontal tissues require approximately 4 weeks to heal. This time allows the connective tissues to heal, and accurate probe depths can be measured. Patients will also have the opportunity to improve their home care skills to reduce gingival inflammation and adopt new habits that will ensure the success of treatment. At the reevaluation appointment, periodontal tissues are probed, and all related anatomic conditions are carefully evaluated to determine whether further treatment, including periodontal surgery, is indicated. Additional improvement from periodontal surgical procedures can be expected only if phase I therapy results in gingival tissues that are free of overt inflammation and the patient has adopted effective daily plaque 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 treatment is both effective and reliable. Studies ranging from 1 month to 2 years in length demonstrated up to 80% reduction in bleeding on probing and mean probing depth reductions of 2 to 3 mm. Additional individual treatments, such as caries control and correction of poorly fitting restorations, clearly help the healing gained by good plaque or biofilm control and debridement by making tooth surfaces accessible to hygiene procedures. Fig. 47.3 demonstrates the effects of an overhanging amalgam restoration on gingival inflammation in an otherwise healthy periodontium. Maximal healing from phase I treatment is not possible when local conditions retain biofilm and provide reservoirs for repopulation of periodontal pathogens. Healing Gradual reductions in inflammatory cell population, crevicular 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 tissue shrinkage. Connective tissue fibers require 4 or more weeks to reorganize and heal, 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 few patients become highly sensitive, this problem can be disturbing or disstressing to patients. The extent of the sensitivity can be diminished with good plaque or biofilm removal, but this may take several weeks to months. Patients should also be warned and educated before the therapy is undertaken regarding the potential outcomes of several changes, such as the teeth appearing longer due to shrinkage of the periodontal tissues and root sensitivity. Knowledge of these changes before therapy will prevent the possibility of the patient complaining if they should occur. Unexpected and possible uncomfortable consequences of treatment may result in the patient’s distrust and loss of motivation to continue therapy. Conclusion The major goal of phase I therapy is to control the factors responsible for periodontal inflammation; this involves educating the patient in the removal of bacterial plaque or biofilm. Phase I therapy also includes scaling, 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 can achieve periodontal disease control with phase I therapy alone and do not require further surgical intervention. For patients who require surgical intervention, phase I therapy is an advantageous element of treatment in that it permits tissue healing, thus improving the surgical management and healing response of the tissues. Periodontal surgical intervention should be considered for patients with deep pocket depths and those with 5 mm or more of attachment loss after phase I therapy. Patients who do not demonstrate the ability to control plaque or biofilm on a daily basis effectively are poor candidates for surgery and should be closely monitored on a recall maintenance program unless conditions change.  After Phase I therapy we categorize our patients in 3 groups: 1- A patient with proper hygiene standart, no gingival inflammation ( no bleeding on probing), few sites with deepened pockets and several sites which exhibit gain in probing attachment. In such a patient, no further periodontal treatment may be indicated.The patient should be enrolled in a maintenance program (Supportive Periodontal Therapy). 2- A patient who has proper standart of self-performed plaque control, but in whom a number of gingival sites still bleed on probing, and in whom a significant reduction of the probing depth at such sites has not been achieved. In such a patient, the additional treatment may include surgical means in order to gain access to root surfaces for more comprehensive debridement. 3- A patient who, despite repeated instruction on self-performed plaque control, has poor standart of oral hygiene. This patient evidently lacks motivation or ability to exercise proper home care and should not be regarded as a candidate for periodontal surgery. The patient must be made aware of the fact that even though the professional part of the initial therapy has been performed to perfection, reinfection of the periodontal pockets may sooner or later result in recurrence of destructive periodontal disease.