بريو

• Scaling


  The process by which biofilm & calculus are removed from both supragingival & subgingival tooth surfaces
• Root planing


  The process by which residual embedded calculus and portions of cementum are removed from the roots to produce a smooth, hard & clean surface
• Scaling and root planing are not separate procedures and can be carried out in sessions
• Scaling and root planing

  • Aims to restore gingival health by completely removing elements that provoke gingival inflammation (biofilm, calculus & endotoxin) from the tooth surface
  • Creates a clean & hard root surface that is as smooth as possible to inhibit further plaque retention and promote tissue healing
• Probing pocket depth (PPD)

  The distance from the gingival margin to the most apical penetration of the periodontal probe inserted into the gingival crevice or periodontal pocket without pressure or force, measured in mm
• Scaling and root planing

  1. Identify probing pocket depth

  2. Identify anatomy of the root surface

  3. Identify location of the deposits
• Subgingival calculus is porous and harbors bacteria and endotoxin and therefore should be removed completely
• When dentin is exposed, biofilm bacteria may invade dentinal tubules, so scaling alone is insufficient to remove them
• Removal of extensive amounts of dentin and cementum is not necessary to render the roots free of toxins and should be avoided
• Closed procedure


  Subgingival instrumentation without displacement of the gingiva, thus less trauma, pain, bleeding and minimal recession
• Open procedure


  Exposure of the affected root surface by the displacement of the gingival tissue, thus gingiva is incised and reflected to facilitate access for the instrument and visibility for the operator
• Instruments used for scaling and root planing


  • Hand instruments
  • Ultrasonic & sonic instruments
  • Motor driven devices incorporating diamond-coated tips (reciprocating instruments)
  • Rotating instruments
  • Laser-instruments
• Recent guidelines did not suggest the use of lasers in periodontitis treatment due to low evidence available
• Plaque retentive factors


  Faulty dentistry (overhang filling, defective crown margin & improperly situated clasp of P.D.)
• Removal of plaque retentive factors

  Correction or replacement of the prostheses & restorations to prevent accumulation of plaque & facilitate self-performed tooth cleaning
• Recontouring defective restorations and crowns

  Smoothing the rough surfaces and removing overhangs from the faulty restorations with burs or hand instruments, or complete replacement of the failing restorations
• Caries control


  Encouraging the use of fluoride-containing toothpaste daily, using higher-concentration fluoride toothpaste or gel for high-risk patients, periodic chlorhexidine rinsing, and evaluating and modifying diet and salivary flow
• Risk factor control


  Controlling smoking and diabetes as proven risk factors in the etiopathogenesis of periodontitis
• Evaluation of the effect of the initial, cause-related therapy

  1. Reevaluate the patient's periodontal conditions & caries activity no earlier than 4 weeks following the last session of the scaling and root planing procedures

  2. Clinical evaluation of the soft tissue response to scaling and root planing, including probing, should not be conducted earlier than 2 weeks postoperatively

  3. Repeat probing of the entire mouth, evaluate calculus, root caries, defective restorations, and signs of persistent inflammation
• Clinical endpoints of treatment success

  No bleeding on pocket probing and "pocket closure" or reduction, that is a PPD of ≤4mm
• Smoking negatively affects the outcome of all modalities of periodontal therapies
• Evaluation of the results of treatment

  • Improvement of the self-performed plaque control
  • Reduction in plaque level (OLeary index)
  • Resolution of gingival inflammation includes less bleeding (bleeding on probing)
  • Shrinkage of the gingival soft tissue (recession)
  • Increased resistance to probe tip penetration by the tissues at the base of the pocket
  • Reduction of probing pocket depth, and if possible, changes in probing attachment level as a result of gingival shrinkage and formation of long junctional epithelium
  • Reduced tooth mobility
• Bleeding on probing (BOP)


  A periodontal probe is inserted to the bottom of the gingival crevice or periodontal pocket at six points around tooth surface, if bleeding occurs within 30 seconds the site gives score (1) and for non-bleeding site, score (0)
• Clinical attachment level (CAL)

  The distance from the cementoenamel junction (CEJ) to the location of the inserted periodontal probe tip (bottom of gingival crevice or periodontal pocket)
• Possible outcomes after treatment evaluation

  • Patient with improved oral hygiene, no gingival inflammation, no bleeding on probing with a marked reduction in probing pocket depth ≤4 mm (no further periodontal treatment required, advanced to maintenance phase)
  • Patient with proper standard of oral hygiene but having some sites of bleeding on probing with no significant reduction in probing depth (may need to be advanced to the corrective phase including periodontal surgery)
  • Patient with inadequate oral hygiene due to lack of motivation or ability (should be remotivated and reinstructed to improve their oral hygiene)
• Chemical plaque control


  An adjunctive means to overcome inadequacies of mechanical cleaning
• Ideal features of chemical plaque control agents

  • Specificity (wide spectrum of action including bacteria, viruses, and yeasts)
  • Substantivity (prolonged antimicrobial effect)
  • Biocompatibility (no adverse effects on oral tissues)
  • Ease of use (acceptable taste, minimal staining, and easy application)
• Lack of motivation or lack of ability to do proper home care


  Patient should be remotivated and reinstructed to improve their oral hygiene
• If oral hygiene is not improved

  Periodontal disease will recur even after periodontal surgery
• Chemical plaque control


  Adjunctive means to overcome inadequacies of mechanical cleaning
• Mechanism of action of chemical plaque control

  Quantitative (reduction of the number of microorganisms) and/or qualitative (altering the vitality of the biofilm)
• Ideal features of agents and formulations for chemical plaque control

  • Specificity
  • Efficacy
  • Substantivity
  • Safety
  • Stability
• Categories of chemical plaque control action

  • Anti-adhesive agents
  • Antimicrobial agents
  • Plaque removal agents
  • Anti-pathogenic agents
• Vehicles for delivery of chemical agents


  Toothpaste, mouth rinses, spray, irrigators, chewing gum, varnishes, gel, chips
• Substantivity

  Persistent action measured in hours, depends on adsorption, antimicrobial activity, and slow release
• Chlorhexidine (CHX) is the best chemical supra-gingival plaque control agent
• Chlorhexidine digluconate (CHX)


  Bisquanide antiseptic frequently used as a mouth rinse (0.2% or 0.12% w/v)
• Characteristics of CHX


  • Nontoxic, broad antimicrobial action, no bacterial resistance
• Antimicrobial effect of CHX

  At low concentrations - bacteriostatic, at higher concentrations - bactericidal, can penetrate and act inside biofilms
• Rinsing with CHX reduces the number of bacteria in saliva by 50-90%, with a maximum reduction of 95% around 5 days