Riassunto esame Parodontologia 2, Prof. Discepoli Nicola, libro consigliato Clinical Periodontology and Implant Dentistry, Lindhe

Protocol to Perform Subgingival Instrumentation

Four grasps are used with hand instruments: modi ed pen, inverted pen, palm-and-thumb, and modi ed palm-and-thumb. (Source: https://pocketdentistry.com/6-instruments-and-equipment-for-tooth-preparation/)

1. Grasp the curette with the modi ed pen position (grasp) in which the pads of the thumb, fore nger, and middle nger contact the instrument, while the tip of the ring nger is placed on a nearby tooth surface of the same arch as a rest. This position allows to rotate the curette more easily. Movement must only come from the shoulder and arm, if we move the wrist, we can have physical problems in the future.
2. Curette should enter in the pocket with the blade parallel to the tooth (at angle) as deep as we can, until we feel an elastic resistance, represented by the lamina propria and the supracrestal connective tissue attachment. If we go deeper when we feel an elastic resistance we will touch the bone and the patient will hurt. terminal shank parallel to the tooth.

When we reach the deepest point, we will turn the tooth 80 degree angle to have the blade at to the root.

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Small clock winding movements rst mm4. are done with ngers to work only with the of the blade. Then we make strokes usually as long as the depth of the pocket.

Then you can make shorter strokes just to define a little bit better the calculus.

TIPS:

1. Always remain within the pocket because every time we come out and insert the curette again we cause trauma to the pocket.
2. Performing the treatment on the anterior teeth is more advantageous because we can observe more easily and we can put the support finger very close on the adjacent teeth. On posteriors instead we have to adapt according to the length of our fingers and arm. adjusting physical position
3. The most difficult part of using curette is (body, back, elbow, fingers) to properly activate the blade on the bottom of the pocket.
4. Every time you apply properly the angulation of

The blade and you make a stroke younails on a wall. will hear a very speci c sound likeNibali et al 2015 , “Minimally invasive non-surgical approachfor the treatment of periodontal intrabony defects: aretrospective analysis” Nowadays we follow the minimally invasive guidelinesproduce less recession. suggested by Luigi Nibali to This author suggests to approach the interproximal area notinserting the tip of the instrument on the tip of the papilla butapproximal areafrom the (in blu). Therefore to minimise soft tissue trauma, never insert thedevice from the papilla (1). […] When we approach the patient for the rst time we should be very delicate then after theroutine has come to you, you can be more aggressive. You must balance aggressivenesswith the e cacy.

4. Outcome It should be stressed that outcome can only bemeasured by clinical variables. Sherman et al. 1990 “The e ectiveness of subgingival scaling and root planing: Clinical responsesrelated to residual

calculus” - PART 2

Aim was to evaluate the efficacy of clinician to identify the presence of calculus before/after instrumentation, compared to the microscope.

On the graphs we see the true values of calculus by microscope and how clinicians were able to detect it: there is no correspondence between the presence of 13 di 18 fi ffi ffi fi ffi ff fi fi fi fi fi fi Periodontology 26th November 2021 calculus and how the clinician was able to detect it.

70% 11% of sites microscopically positive for calculus are not identified clinically, instead of sites clinically positives for calculus have no calculus.

So we cannot trust the presence of calculus detected by the probe.[…]

The main target is a closed pocket which indicates that the progression of the disease is stopped or reduced.

How many open pockets should we assume to be risky for the progression of the disease at the patient level (at the science level we cannot establish it)?

Last year a group of researchers tried to evaluate which was the

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Considering all the sites treated there were no differences between the two approaches in terms of percentage of the closed pockets and even in the PPD between 5-6mm the difference was negligible and non statistically significant.

At a more severe probing pocket depth this difference is still not statistically significant although is a bit more accentuated.

So, these differences probably deserve a more accurate evaluation from a clinical standpoint.

This is the reason why prof is not fully convinced to treat the severe pockets only with the ultrasonic debridement.

They calculated in how many minutes, according to the whole treatment plan, they need to close a pocket with the two different approaches.

They found out that they require 3 times more time to obtain the pocket closure for the quadrant wise in comparison to the full-mouth ultrasonic Debridement.

The percentage according to the severity of the probing pocket depth. And how do they change from

Baseline to six months. And that the fact that 2/3 of the entire pockets were successfully closed. but if you if you see, Severe pockets on quadrant wise approach require a little bit more attention. This result was maintained even until 18 months and even some severe pockets continue to shrink.

Tomasi et al 2007 “Factors influencing the outcome of non-surgical periodontal treatment: a multilevel approach”

The aim was to identify the parameters that modify or predict clinically the pocket closure, pocket no more than 4mm. initial PPD, smoking, plaque at the site level, monoThe parameters considered were: rooted vs multi-rooted, age, gender, intrabony defects and type of treatment (quadrant/full mouth).

If my main outcome measure must be considered the pocket closure according to the initial PPD (on the x axis), according to multi-rooted teeth, plaque and smoking I can have different types of healing and chances to close the pocket.

For example let’s look at two different profiles.

with an initialPPD of 8 mm:- Red pro le: a smoking patient, 8 mm of PPD on a multirooted tooth, and plaque positive at the re-evaluation.Considering all these factors together, an 8 mm pocket atthe re-evaluation can be only shrinked. So after therapy,even if considered well performed, we can only achieve a1mm reduction. So with these characteristics we are notable to close the pocket.

- Green pro le: a non-smoking patient, with 8mm of PPD on a single rooted tooth,negative to plaque, the chances to achieve a reduction of almost 4 mm are quite high.The capability to obtain the pocket closure depends on speci c clinical characteristics.

According to the data what they found was that mainly 4 factors:presence of plaque at the site multi rooted tooth,and are mandatory to evaluate thepotential PPD reduction, after step 1 and step 2 therapy.

Cobb 1996 "Non surgical periodontal

therapy: Mechanical”In this narrative review, several papers addressing non-surgical periodontal therapieswere evaluated.initial PPD PPD reduction CAL gain:The was related to and• PPD 1-3mm (physiological sulcus)After therapy, PPD reduction is almost null and instead of a CAL gain there is loss ofattachment of 0,34mm. Here periodontal therapy was performed by standard curettes(not used anymore) so loss of attachment occurredmechanical trauma.as a result ofIn fact if PPD doesn’t change, it means that loss ofattachment is produced by apical shift of gingivalrecession.margin i.e.• PPD 4-6 mm (intermediate pocket)PPD reduction of about 1.3After therapy we have amm slight gain of attachmentand a (0.55 mm).• PPD ≥ 7mm (severe periodontal pocket)2.16 mm 1.2 mm.After therapy PPD reduction is of and CAL gain is[…]Van der HeijdenFew years later, and coworkers, published another systematic review onthe same issue, with results quite similar to those of

Cobb: Physiological loss of attachment on physiological sulcus, reduction of about 1 mm of PPD in PPD between 4-6mm and of about 2 mm in PPD ≥ 7. While CAL gain was of 0.5 mm for 4-6 mm PPD and about 1 mm in PPD > 6. If we want to have a global picture we have to add smoking habits of patient, the presence of plaque and the difference between multi rooted and anterior tooth. […]

Suvan et al, 2019 "Subgingival instrumentation for treatment of periodontitis. A systematic review?" J. Suvan published a systematic review about this issue, evaluating the PPD reduction after 6-8 months from severe pocket (>6 mm), giving the same results: a PPD reduction of almost 2.5. 75% of initial pathological pocket be closed after This systematic review states that 6-8 months re-evaluation. […]

Step 1 and step 2 can successfully close 75% of pathological pockets. So the quantity of patients that will undergo to adjunctive treatment of non responding sites is very small. 16 di

1. Healing clinical attachment gain

Healing from a clinical standpoint can be considered as the instead from an histological standpoint we can observe:

1. Reduction of cell infiltrates, since we clean the tooth surface so we create a biostability with immune system.
2. A long junctional epithelium with hemidesmosomes and basal layer cells.

Physiologically, in the supra-crestal tissue attachment (biological width), the junctional epithelium was about 1 mm. If we take a probe, we will have a new consistency of tissue that allows us to say that we do