PHASE 1 PERIODONTAL

THERAPHY
Periodontal Therapy

Re- Phase Phase

Phase I Phase II
assess III IV
Phase I Periodontal Therapy

elimination and prevention of reccurence of

supra/subgingivally located bacterial deposit

Achieved by:
complete removal of calculus
Correction of defective restoration
Treatment of carious lesion
Comprehensive daily plaque control regimen

May be the only one procedure OR

constitute the preparatory phase for surgical
therapy
 SEQUENCE OF
Step 1: Limited Plaque
Step
Step
of
3: Comprehensive
5:
Defective
Plaque
Step 2:5:
Step
Step
Recountouring
Step 4: Obturation
control
1: Instruction
Limited Plaque
Control
restorations
supragingival
3:Instruction
Recountouring
Comprehensive
4: Obturation
control
Carious
Removal
and
Instruction
Crowns
Defective
Plaque
Step
Lesion
of restorations
Calculus
Control
2: supragingival
of Carious Lesion
and
Instruction
Crowns
Removal of Calculus
PROCEDURES
St
ep
6:
Su
bg
in
gi
va
l
Ro
ot
Tr
eat
m
en
t
St
ep
7:
Ti
ss
ue
re
ev
al
ua
tio
n
●
● Plaque Control
●
● Caries Control
●
● Scaling n Root Planning, probing depth reduction

RESULT
RESULT
PLAQUE CONTROL - OHE
Indication
- Low oral health knowledge, awareness, motivation
- Poor self performed plaque control,smoking &
other psychosocial behaviors.
- High risk individuals to plaque – induced diseases
 OHE – Patient Motivation

Change in Change in
knowledge understandin

Change in
attitude

Use simple
Change in
everyday
habit language
 Tooth brushing method:
Bass Technique
Vibratory – Circular – Fones
Technique

Roll – Modified
Stillman
Technique

Scrub Technique
Horizontal –
Technique
Leonard
Vertical –
Modified Stillman’s method
Bass Method
Charters method
Recommendation of toothbrush design:

Soft

Nylon bristle

Need to be replaced
Powered toothbrush
– also can remove plaque effectively (properly used)
- Patients need to be instructed in the proper use of
powered devices.
- Patients who are poor brushers, children and
caregivers may particularly benefit from using
powered toothbrushes.
* Dentifrices : Fluoride and anti microbial
Interdental Cleaning Aids
Cleans the interdental region (most common site for
plaque retention)
Most inaccessible site to toothbrushing

• Dental Floss - technique

• Interdental Space Brush
Plaque Control
Gingival Massage – oral rinse containing CHX
Oral irrigation – supragingival and subgingival
irrigation
Caries control
Disclosing agent
Prophylaxis
Removal of supragingival plaque &calculus
(scaling & polishing)

Removal of plaque retentive factors:

Smooth roughness of restoration

Removal of overhangs
Ill-fitting / rough prosthesis
Removal of staining
Nontoooonnnn...
 Scaling and Root planing
.

should not be ●
Scaling
thought of as ●
Root planing, detoksifikasi akar:
mekanis/kimiawi, tujuan?
separate procedure

Detecting ●
Visual examination
Tactile exploration
Calculus
●
Supragingival Scaling Technique

The blade
Sickles, curettes, The cutting edge
Hoes and isadapted with an
and ultrasonic should engage
angulation of
and sonic chisels are the apical margin
slightly less than
instruments are less frequently of the
90 degrees to the
most commonly used supragingival
surface being
used calculus scaled.
Subgingival scaling technique and Root
Planing
rely heavily on tactile sensitivity
The curette (universal, gracey ) is preferred by most
clinicians for subgingival scaling and root planing
because of the advantages afforded by its design
The correct cutting edge is slightly adapted to the tooth,
with the lower shank kept parallel to the tooth surface.
 The lower shank is moved toward the tooth so that the
face of the blade is nearly flush with the tooth surface.
The blade is then inserted under the gingiva and
advanced to the base of the pocket by a light explorator
stroke.
Gerakan dasar

Gerakan Eksplorasi

●
Mencari letak deposit subgingiva, mata pisau dilewatkan sepanjang
permukaan kar atau deposit kalkulus, ke arah apikal hingga dasar poket

Gerakan menarik

●
Setelah kalkulus ditemukan, sudut instrumen dibuat 80derajat, dg hati-hati
instrumen digerakkan ke arah oklusal.
Maxillary right posterior sextant :
facial aspect
 Operator position: Side position.
 Illumination: Direct.
 Visibility: Direct (indirect for distal surfaces of molars).
 Retraction: Mirror or index finger of the nonoperating
hand.
 Finger rest: Extraoral, palm up. Backs of the middle and
fourth fingers on the lateral aspect of the mandible on the
right side of the face.
Maxillary right posterior sextant,
premolar region only : facial aspect
 Operator position: Side or back position.
 Illumination: Direct.
 Visibility: Direct.
 Retraction: Mirror or index finger of the nonoperating
hand.
 Finger rest: Intraoral, palm up, Fourth finger on the
occlusal surfaces of the adjacent maxillary posterior teeth.
Maxillary right posterior sextant: palatal
aspect 14,15
 Operator position: Side or front position.
 Illumination: Direct and indirect.
 Visibility: Direct or indirect.
 Retraction: None.
 Finger rest: Extraoral, palm up. Backs of the middle and
fourth fingers on the lateral aspect of the mandible on the
right side of the face
Maxillary right posterior sextant: palatal
aspect
Operator position: Front position.
Illumination: Direct.
Visibility: Direct.
Retraction: None.

Finger rest: Intraoral, palm up, finger-on-finger. Index

finger of the nonoperating hand on the occlusal
surfaces of the maxillary right posterior teeth; fourth
finger of the operating hand or the index finger of non-
operating hand.
Maxillary anterior sextant: facial aspect, surfaces away
from the operator
Operator position: Back position.
Illumination: Direct.
Visibility: Direct.

Retraction: Index finger of the nonoperating hand.

Finger rest. Intraoral, palm up. Fourth finger on the
incisal edges or occlusal surfaces of adjacent maxillary
teeth.
Maxillary anterior sextant: facial aspect,
surfaces toward the operator
Operator position: Front position.
Illumination: Direct.
Visibility: Direct.

Retraction: Index finger of the nonoperating hand.

Finger rest. Intraoral, palm down. Fourth finger on
the incisal edges or the occlusal or facial surfaces of
adjacent maxillary teeth.
Maxillary anterior sextant: palatal aspect,
surfaces away from the operator
surfaces toward the operator are scaled from a front
position
Operator position: Back position.
Illumination: Indirect.
Visibility: Indirect.
Retraction: None.

Finger rest. Intraoral, palm up. Fourth finger on the incisal

edges or occlusal surfaces of adjacent maxillary teeth.
Maxillary left posterior sextant:
facial aspect

Operator position: Side or back position.

Illumination: Direct or indirect.
Visibility: Direct or indirect.
Retraction: Mirror.
Finger rest : Extraoral, palm down. Front surfaces of
the middle and fourth fingers on the lateral aspect of
the mandible on the left side of the face
Maxillary left posterior sextant:
facial aspect
Operator position: Back or side position.
Illumination: Direct or indirect.
Visibility: Direct or indirect.
Retraction: Mirror.

Finger rest. Intraoral, palm up. Fourth finger on the

incisal edges or occlusal surfaces of adjacent maxillary
teeth.
Maxillary left posterior sextant:
palatal aspect
Operator position: Front position.
Illumination: Direct.
Visibility: Direct.
Retraction: None,

Finger rest: Intraoral, palm down, opposite arch,

reinforced. Fourth finger on the incisal edges of the
mandibular anterior teeth or the facial surfaces of the
mandibular premolars, reinforced with the index finger
of the nonoperating hand.
Nonton dulu..
Mandibular left posterior sextant: facial aspect
 Operator position: Side or back position.
 Illumination: Direct.
 Visibility: Direct or indirect.
 Retraction: Index finger or mirror of the nonoperating
hand.
 Finger rest. Intraoral, palm down. Fourth finger on the
incisal edges or the occlusal or facial surfaces of adjacent
mandibular teeth.
Mandibular left posterior sextant: lingual aspect
Operator position: Front or side position.
Illumination: Direct and indirect.
Visibility: Direct.
Retraction: Mirror retracts tongue.umination.
Finger rest. Intraoral, palm down. Fourth finger on
the incisal edges or the occlusal surfaces of adjacent
mandibular teeth.
Mandibular anterior sextant: facial aspect, surfaces
toward the operator
 Operator position: Front position.
 Illumination: Direct.
 Visibility: Direct.
 Retraction: Index finger of the nonoperating hand.
 Finger rest: Intraoral, palm down. Fourth finger on the
incisal edges or the occlusal surfaces of adjacent
mandibular teeth.
Mandibular anterior sextant: facial aspect, surfaces away
from the operator
 Operator position: Back position.
 Illumination: Direct.
 Visibility: Direct.
 Retraction: Index finger or thumb of the nonoperating
hand.
 Finger rest. Intraoral, palm down. Fourth finger on the
incisal edges or the occlusal surfaces of adjacent
mandibular teeth.
Mandibular anterior sextant: lingual aspect, surfaces
away from the operator
 Operator position: Back position.
 Illumination: Direct and indirect.
 Visibility: Direct and indirect.
 Retraction: Mirror retracts tongue.
 Finger rest. Intraoral, palm down. Fourth finger on the incisal edges or
the occlusal surfaces of adjacent mandibular teeth.
Mandibular anterior sextant: lingual aspect, surfaces
toward the operator
 Operator position: Front position.
 Illumination: Direct and indirect.
 Visibility: Direct and indirect.
 Retraction: Mirror retracts tongue.
 Finger rest: Intraoral, palm down. Fourth finger on the incisal edges
or the occlusal surfaces of adjacent mandibular teeth.
Mandibular right posterior sextant: facial
aspect
Operator position: Side or front position.
Illumination: Direct.
Visibility: Direct.

Retraction: Mirror or index finger of the nonoperating

hand.
Finger rest. Intraoral, palm down. Fourth finger on
the incisal edges or the occlusal surfaces of adjacent
mandibular teeth
Mandibular right posterior sextant:
lingual aspect
Operator position: Front position.
Illumination: Direct and indirect.
Visibility: Direct and indirect.
Retraction: Mirror retracts tongue.

Finger rest: Intraoral, palm down. Fourth finger on

the incisal edges or the occlusal surfaces of adjacent
mandibular teeth.
Nonton lagi deh..
Ultrasonic Scaling
De
bri
de
K
o
m
Jar
ing
an
lun
me ak
nt bi ker
me na as
nj si tid
ak
adi da aka
leb ri n
ih me
ka
m nga
ud vit lam
ah asi i
ker
da ya usa
n ng kan
ce dit bila
pa alat
t,
im dig
ke bu una
kan
ny lk dg
am an tek
an ai ana
an n
r rin
pa
sie
da gan
,
n n kon
me ge sta
ni ta n,
ng air
ra cuk
ka
n up
t
Magnetostriktif:

Types of Power Instruments

Bekerja dengan lempengan logam, diletakkan pada medan magnet, 25ribu-35ribu putaran perdetik, bagus untuk kalkulus subgingiva, ujung sperti probe Cth: Titan S7, putaran2000- 6500 putaran per detik

Piezoelektik
Cth: Odontoson, didesain untuk mengeluarkan obat-obatan antimikroba sambil melakukan skaling subgingiva, ujung tip sama dengan skalerv manual

Ultrasonik Sonik
 USS Vs Manual scaling

Both methods of instrumentation are able to provide

satisfactory clinical results as measured by removal of
plaque and calculus, reduction of bacteria, reduction of
inflammation and pocket depth, and gain in clinical
attachment
Gracey curets were more effective than slim ultrasonic
inserts in debriding root trunks, furcation entrances,
and furcation areas of mandibular first molars
 Some Notes for USS
Use a sterile, Rinse for 1 minute
autoclave ultrasonic with antimicrobial oral
handpiece, or wipe rinse to reduce the
with disinfectant contaminated aerosol

The instrument is
Clinical and assistan
grasped with a light
wear protective
pen or modified pen
eyewear and masks grasp
Some Notes for USS
The working end should be kept in constant motion and the
tip should be kept parallel to the tooth surface

The instrument should be switch off periodically to allow for

aspiration water, and the tooth should be examined with explorer

Any remaining irregularities of the root surface may be removed

with sharp standard or mini bladed curettes if necessary
Nonton lagi yuuuuk... 
 Non surgical Instrumentation

Chemot
Topi
herapeu
tic
cal

Scaling
appli
catio
n of
Root Debridement
antis
eptic

approac
s
to
prev
ent
plaq
ue

hes
accu
mula
tion
&
todis
infec
t the
root
surfa
Chemotheraupetic
Agents

Systemic and
Local
antiinfective
Periodontal theraphy
Pocket

Bacterial
Infection
GOA
L
 Chemical Periodontal Therapy
Terminology
Plaque inhibitory effect : reducing plaque to a level
insufficient to prevent the development of gingivitis.
Anti-plaque effect: produces a prolonged & profound
reduction in plaque sufficient to prevent the development of
gingivitis.
Anti-gingivitis: anti-inflammatory effect on the gingival health
not necessarily mediated through an effect on plaque
Antibiotic
Local application
* Gel --  for topical application onto surface or
sub-gingival application
 atridox, arestin, Elyzol

Doxycycline

Minocycline
Antibiotic (cont’d)
Systemic administration
Antibiotic for Aggressive Periodontitis
Amoxicillin in combination with Metronidazole (if
allergic to penicillin give clindamycin)
250 mg amoxicillin & 200 mg Metronidazole for 4 to
7 days.
 Tetracycline 250 mg  for 14 days
 Doxycycline 100 mg once a day for 14 days(double
dose for first day because half of it will bind to plasma
& another half will be in blood)
Antibiotic for ANUG/P
200 mg Metronidazole tds for 3 – 4 days
Analgesic may be prescribed to patient diagnosedwith
ANUG/P due to pain
Since the ANUG/P lesions being very painful to
mechanical plaque control,chlorhexidine may be given
*For post-surgical Metronidazole may be
needed for 1 – 7 days, anagetic and
moutwash (CHX)
 Caution !!!
Antibiotic prophylactic agents in which the risks of bacterimia
& infective endocarditis is high.

Systemic antibiotics prescribed are directed against specific

microorganisms as an adjunct to mechanical instrumentation in
aggressive periodontitis & ANUG/P.

 The used of systemic antibiotic without cautions can lead to

development of bacterial resistance.

Certain individual may suffered from immediate

hypersensitivity which can be fatal
 Monocycline Doxycycline

Effective against broadspectrum

 Same spectrum of activity
of microorganisms. as minocycline& may be
equallyeffective
Suppresses spirochetes &motile

rods as effectivelyscaling &
rootdebridement.

Less phototoxicity &


renaltoxicity than
tetracyclinebut may cause
reversedvertigo.
 Metronidazole
Bactericidal to anaerobic organisms
& is believed to disrupt bacterial
DNA synthesis in conditions with a
low reduction potential.
Effective against Porphyromonas
gingivalis & provetella intermedia.
Used in ANUG, chronic
periodontitis & aggressive
periodontitis
Clindamycin
Effective againstanaerobic
bacteria.
Effective in situationsin
patient is allergic
topenicillin.
Shown efficacy inpatient
withrefractoryperiodontitis
 Ciprofloxacin Amoxicillin

Semisynthetic penicillin with

Quinolone active against gram-
negative rods, including all
facultative & some anaerobic
putative periodontal pathogens.
Minimal effect on Streptococcus
Used in management
species.
 To fight AA.
extended anti infective
spectrum that includes gram-
positive & gram-negative
bacteria.
of aggressive periodontitis in
both localized &
generalized forms.

Susceptible to penicillinase
Antiseptic
Directed against supra-gingival plaque
development
Directed against sub-gingival bacteria
 Topically (mouthwash) Locally applied
Typically act supra- Slow release devices
gingivally (biodegradable polymer,
gel,fibers, collagen)
Applied into periodontal
pockets
Typically act sub-
gingivally
 Topically acting : Requirement
Effective in reducing plaque & gingivitis
Effective & remains for a sufficient amount of time to
accomplish the desired results (substantivity)
Without development of resistant bacterial strains
ordamage to the oral tissues
Cost-effective
Pleasant to use
Low toxicity – without adverse effects
High potency
Good permeability & intrinsic efficacy
 Chlorhexidine (CHX)
Broad spectrum antiseptic which possess anti-plaque activity.

Mostly available in digluconate salts formulations.

Strong base & dicationic at pH levels above 3.5 with 2

positive charges on either side of hexamethylene bridge.

At low concentration – cause increase in cell membrane

permeability & leakage of intracellular components.

At high concentration – precipitation of bacterial cytoplasm

& cell death
CHX m/w indicated to post perio-surgical patient to
reduce the bacterial load / to prevent plaque formation at
time when mechanical cleaning may be difficult due
discomfort.

Patient with mental & physically disabilities lack

of manual dexterity in : Parkinson disease-Adjunct to
immunocompromised such as HIV/AIDS-Cerebral palsy

In this situation, advisable agent would be CHX m/w

CHX m/w can be prescribed to patient wearing
orthodontic appliance & also for patient with
intermaxillary fixation following trauma /orthognathic
surgery.

As an adjunct to mechanical instrumentation in case

such as refractory periodontitis & locally applied
antimicrobial agents can be used
CHX - Limitation
CHX particular inhibit plaque formation in a clean
mouth but not significantly reduce bacterial load in
untreated mouth.

CHX m/w cannot penetrate into gingival crevice,

therefore have no place in control of chronic
periodontitis – presence of deep pocket of >5 mm
 CHX – Limitation (cont’d)
CHX have local side effects such as :  Tooth & tongue
staining; Staining tooth ; colored restorations(composite &
porcelain)

Reversible parotid swelling

Numbness of tongue – taste disturbance

Bitter taste

Mucosal erosion are also reported

REFERENCES
Newman M.G., Takei H.H., Carranza F.A., 2006,
Carranza’s Clinical Periodontology, Elseveier
Science, New York
Redy.P.F., Vernino., A.R., Silabus Periodonti, 2004,
EGC