Non Surgical Control of Periodontal Diseases A

Comprehensive Handbook

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This book is dedicated to the memory of Dr. Irving Glickman

“…It is only in the past quarter century that the dental

curriculum has undergone a major change insofar as
periodontics is concerned. Only recently has the status of
periodontics been changed from that of a peripheral subject
tacked on somewhere in the third and fourth year, a position in
which it could not impress the student attitude regarding the
importance of periodontal health in the total dental care which
should be provided by general practitioners. It gradually has
become a major clinical discipline stressing the philosophy that
the periodontal care of the American public is primarily the
responsibility of the general practitioner and that restorative
dentistry without necessary periodontal care is not an oral
health service…

The concept of what constitutes the practice of dentistry must

change. Dentistry’s mission under its franchise must be clearly
defined as primarily the preservation of the health of the
natural structures through the prevention of disease and
deformities, and secondarily the repair of destroyed tissue the
replacement of lost parts and the correction of developmental
anomalies.”

Irving Glickman. Preventive periodontics: a blueprint for the

periodontal health of the American public. J Periodontol.
1967;(38):361.
Purpose

The purpose of this book is to share information that is of great value and
practical use to general dentists, dental students, dental hygiene students,
dental assistants, dental assisting students and postgraduate periodontal resi-
dents. Two of the authors have had the very good fortune, early in their pro-
fessional careers, of coming under the pedagogical influence of Dr. Irving
Glickman. The other two authors, graduates of Tufts University School of
Dental Medicine, were influenced by the Glickman philosophy of dental edu-
cation, which today still strives to remain a strong component of the curricu-
lum at Tufts.
Dr. Glickman was Research Professor of Oral Pathology and Professor
and Chairman of the Department of Periodontology at Tufts University
School of Dental Medicine in Boston, Massachusetts. During four decades of
active teaching and research (1940s–1970s), Dr. Glickman pioneered the
teaching of a rigorous curriculum in periodontics, for all pre- and postdoc-
toral students. The rigorous nature of the program was necessary, he felt, to
ensure that future general dentists were thoroughly prepared and motivated to
serve the periodontal needs of all patients regardless of whether they prac-
ticed in a private office setting, a hospital or military setting, or a community
health center. As Dr. Glickman so often said, “There is no such thing as a
‘periodontal patient,’ as all patients with natural teeth have a periodontium.”
Many of the ideas presented in this book can find their source in the numerous
original writings of Dr. Glickman.
Dr. Glickman was particularly concerned with fostering among his stu-
dents a deep appreciation for the following ideas:

(a) The importance of preventative dentistry measures in the daily practice

of general dentistry
(b) The importance of diagnosing periodontal diseases in the incipient
stages, by examining the periodontal tissues with an uncompromising
attention to detail
(c) The importance of being capable of treating periodontal disease by
providing nonsurgical therapy in the daily practice of general
dentistry

vii
viii Purpose

(d) The importance of supportive therapy in the long-term maintenance of

periodontal health once disease is eliminated
(e) The importance of understanding clinical phenomena in terms of under-
lying microscopic tissue changes
(f) The importance of working intelligently and with confidence as a
co-therapist, when the nature of the case suggests referral to the
periodontal specialist

Dr. Glickman’s teaching legacy endures to this day because, at its core, it
addresses the most crucial dental needs of the public—namely, the attainment
and preservation of oral and dental health. The authors are grateful for his
public health vision and for all the arduous work he shouldered in bringing
his vision to reality. The intent of this book is to continue the Glickman phi-
losophy—a philosophy that at its heart embraces the idea that family dentists
are responsible for the early diagnosis and appropriate treatment of the com-
mon periodontal diseases that afflict the public at large.
Only through comprehensive training and familiarity with the detailed
information presented in this handbook will dental clinicians and hygienists
be prepared to meet their responsibility in providing an excellent standard of
dental care to their patients. The hard-won achievement of oral health can
also be counted upon to foster improved general health—certainly another of
the crucial needs that must be addressed and to which the public is entitled.
Other students of Dr. Glickman have undertaken the challenging task of
authoring textbooks in the fields of periodontology and oral pathology; taken
together, the works of Drs. Jerome B. Smulow, Gerald Skhlar, Fali S. Mehta,
Esther M. Wilkins, Edward Cohen, and Noshir Mehta, along with the present
publication, represent a rich legacy to one of the truly great dental educators
of the twentieth century—Dr. Irving Glickman.
Acknowledgments

We gratefully thank the following individuals for their major contributions to

this book. Their efforts and expertise have greatly assisted the authors in cre-
ating a handbook, which can be utilized by the readers to provide valuable
information in a concise and yet comprehensive manner.

Stephen P. Comstock – Fourth-year dental student at Tufts University

School of Dental Medicine, medical and dental textbook illustrator – All text-
book illustrations
Nevin Zablotsky, D.M.D. – Periodontist and authority in smoking cessa-
tion, speaker for the American Dental Association, and teacher of smoking
cessation for medical and dental students at Nova Southeastern University –
Wrote Section 7.2 on smoking cessation
Lorenzo Mordini, D.D.S. – Periodontist, fellow at Tufts University
School of Dental Medicine, clinical photographer – Contribution of clinical
photographs
Julia Zhogina, R.D.H. – Practicing dental hygienist, professional
photographer – Dental product pictures

Additionally we thank our spouses, Patty Levi and Shannon Coleman and
our friends and relatives who supported us and provided us with excellent
feedback throughout the process of writing this book.

ix
About the Authors

Dr. Robert J. Rudy earned his D.M.D.

from Tufts University in 1970. After
serving as a captain in the USAF, from
1970 to 1972, he earned a Certificate in
Periodontology from the University of
Washington, in Seattle, in 1975.
Returning to Boston and the Tufts
School of Dental Medicine, Dr. Rudy
became a Clinical Instructor in the
Department of Periodontology. Ten
years later he became an Associate
Clinical Professor. From 1995-2014,
Dr. Rudy served as Director of Pre-
doctoral Periodontology. Additionally,
he maintained a private practice, in
Brookline and Newton Centre,
Massachusetts, from 1975-2015.

Dr. Y. Natalie Jeong is an Assistant

Professor in the Department of
Periodontology at Tufts University
School of Dental Medicine. She earned
her D.M.D. and her Certificate in
Periodontology from Tufts University.
She is a Diplomate and a Board
Examiner of the American Board of
Periodontology. She is a Director of
Lincoln Dental Study Club and main-
tains a private practice limited to
Periodontics and Implant surgery in
Lincoln, Massachusetts.
About the Authors xi

Dr. Paul A. Levi, Jr. is an Associate

Clinical Professor in the Department of
Periodontology at Tufts University
School of Dental Medicine, Visiting
Professor at Universitat Internacional de
Catalunya in Barcelona, Spain, and a
Clinical Instructor at the Harvard
University School of Dental Medicine.
He earned a B.S. at St. Lawrence
University in Canton, NY, and his
D.M.D. and Certificate in Periodontology
from Tufts University. He is a Diplomate
and a Director of the American Board of
Periodontology. Additionally, he main-
tains a private practice limited to
Periodontics and Implant surgery in
Burlington, VT.

Dr. Daniel K. Coleman is a Diplomate

of the American Board of Periodontology.
He is a Clinical Instructor in the
Department of Periodontology at Harvard
University School of Dental Medicine.
Dr. Coleman earned his B.S. at Trinity
College in Hartford, CT, and his D.M.D.,
M.S., and Certificate in Periodontology
from Tufts University School of Dental
Medicine Boston, MA. Additionally, he
maintains a private practice limited to
Periodontics and Implant Surgery in
Rhode Island.
Contents

1 Fundamentals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2.1 Gingival Anatomy with Respect
to Periodontal Diseases or Deformation . . . . . . . . . . 1
1.2.2 Gingival and Tooth Anatomy with Respect
to Professional Hygiene Therapy . . . . . . . . . . . . . . . . 5
1.2.3 Gingival and Tooth Anatomy with Respect
to Patient Hygiene Therapy . . . . . . . . . . . . . . . . . . . . 9
1.2.4 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.3 Periodontal Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.4 Diagnosis of Periodontal Diseases and Caries . . . . . . . . . . . . 13
1.4.1 Gingivitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.4.2 Periodontitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
1.4.3 Peri-implant Mucositis . . . . . . . . . . . . . . . . . . . . . . . . 15
1.4.4 Peri-implantitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1.4.5 Dental Caries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1.4.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1.5 Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1.6 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1.7 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2 Empowering Your Patients: From Compliance
to Concordance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.2 Motivation of the Dental Patient to Remove
Biofilm (Dental Plaque) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.3 Assurance That the Techniques Patients Are Using
Are Effective and Correct . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.4 Access: The Patient Must Be Able to Access
the Root for Plaque Removal . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.4.1 Probing Depth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2.4.2 Supra- and Subgingival Calculus, Rough Roots . . . . 29
2.4.3 Tooth Anatomic Irregularities . . . . . . . . . . . . . . . . . . 29
2.4.4 Gingival Morphologic Alterations . . . . . . . . . . . . . . . 29
2.4.5 Malposed Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

xiii
xiv Contents

2.4.6Orthodontic Appliances . . . . . . . . . . . . . . . . . . . . . . . 31
2.4.7Defective Restorative Margins . . . . . . . . . . . . . . . . . . 31
2.4.8Provisional Fixed Restorations. . . . . . . . . . . . . . . . . . 31
2.4.9Tactile Root Sensitivity . . . . . . . . . . . . . . . . . . . . . . . 32
2.4.10
Improper Plaque Removal Techniques. . . . . . . . . . . . 32
2.4.11
Improper Toothbrush Due to Bristle Stiffness,
Type of Bristle, or Design of Brush Head . . . . . . . . . 32
2.4.12 Defective Toothbrush Due to Wear . . . . . . . . . . . . . . 33
2.4.13 Ineffectual Dental Floss Technique
or Floss Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
2.4.14 Dental Implant Design . . . . . . . . . . . . . . . . . . . . . . . . 34
2.4.15 Dental Implant-Supported Prostheses . . . . . . . . . . . . 34
2.5 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
3 Methods of Plaque Removal by the Patient . . . . . . . . . . . . . . . . 37
3.1 Detection of Dental Plaque with the Use
of Disclosing Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
3.2 Bleeding on Probing (BOP) . . . . . . . . . . . . . . . . . . . . . . . . . . 40
3.3 Using BOP for Motivation . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
3.4 Supra- and Subgingival Calculus . . . . . . . . . . . . . . . . . . . . . . 43
3.4.1 Calculus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
3.4.2 Attachment of Calculus to the Tooth Surface . . . . . . 43
3.5 Detection of Supragingival Calculus
Including Instruments, Materials, and Techniques . . . . . . . . 45
3.5.1 Supragingival Calculus Detection . . . . . . . . . . . . . . . 45
3.5.2 Subgingival Calculus Detection . . . . . . . . . . . . . . . . . 45
3.6 Toothbrushes: Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
3.7 Toothbrushes: Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
3.8 Tooth Brushing Techniques: Hand Brush . . . . . . . . . . . . . . . 49
3.8.1 The Bass Technique (BT). . . . . . . . . . . . . . . . . . . . . . 51
3.8.2 The Modified Bass Technique (MBT) . . . . . . . . . . . . 52
3.8.3 The Stationary Bristle Technique (SBT) . . . . . . . . . . 52
3.8.4 The Stillman’s Technique (ST) . . . . . . . . . . . . . . . . . 55
3.9 Tooth Brushing Techniques: Power Brush . . . . . . . . . . . . . . . 56
3.10 Hand and Power Tooth Brushing
with Fixed Orthodontic Appliances . . . . . . . . . . . . . . . . . . . . 56
3.11 Conclusion: Tooth Brushing . . . . . . . . . . . . . . . . . . . . . . . . . 57
3.12 Interproximal Plaque Removal . . . . . . . . . . . . . . . . . . . . . . . 57
3.12.1 Dental Floss/Tape . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
3.13 An Effective Technique for Flossing . . . . . . . . . . . . . . . . . . . 59
3.14 Interproximal Brushes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
3.15 Other Interproximal Cleaning Devices . . . . . . . . . . . . . . . . . 62
3.15.1 Rubber Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
3.15.2 Floss Threaders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
3.15.3 Toothpick-Type Devices. . . . . . . . . . . . . . . . . . . . . . . 63
3.15.4 Other Means of Reducing Oral Bacteria . . . . . . . . . . 64
3.16 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Contents xv

4 Patient Examination and Assessment . . . . . . . . . . . . . . . . . . . . . 71

4.1 Preparation for Patient Encounter: Operatory,
Instrument, and Materials Arrangement . . . . . . . . . . . . . . . . 71
4.1.1 Patient/Provider Positioning
and Operator Visibility . . . . . . . . . . . . . . . . . . . . . . . . 71
4.2 Patient Interview and Initial Examination . . . . . . . . . . . . . . . 77
4.2.1 The Patient’s Chief Complaint . . . . . . . . . . . . . . . . . . 77
4.2.2 Patient’s Expectations . . . . . . . . . . . . . . . . . . . . . . . . 77
4.2.3 Baseline Vitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
4.2.4 Medical/Social History. . . . . . . . . . . . . . . . . . . . . . . . 78
4.2.5 Dental History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
4.2.6 Daily Oral Hygiene Habits . . . . . . . . . . . . . . . . . . . . . 79
4.2.7 Oral Habits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
4.2.8 Extraoral Exam. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
4.2.9 Intraoral Soft Tissue Examination . . . . . . . . . . . . . . . 80
4.2.10 Gingival Tissue Evaluation . . . . . . . . . . . . . . . . . . . . 81
4.3 Periodontal Charting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
4.3.1 Probing Depth Measurements . . . . . . . . . . . . . . . . . . 82
4.3.2 Bleeding on Probing. . . . . . . . . . . . . . . . . . . . . . . . . . 86
4.3.3 Recession Measurement . . . . . . . . . . . . . . . . . . . . . . . 87
4.3.4 Amount of Attached Gingiva . . . . . . . . . . . . . . . . . . . 90
4.3.5 Mucogingival Deformities . . . . . . . . . . . . . . . . . . . . . 92
4.3.6 Tooth Mobility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
4.3.7 Fremitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
4.3.8 Furcation Involvement . . . . . . . . . . . . . . . . . . . . . . . . 94
4.3.9 Calculus Detection . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
4.3.10 Plaque . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
4.3.11 Gingival Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
4.4 Radiographic Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . 99
4.4.1 Intraoral Radiographs . . . . . . . . . . . . . . . . . . . . . . . . . 99
4.4.2 Extraoral Radiographs . . . . . . . . . . . . . . . . . . . . . . . . 100
4.4.3 Characteristics of an Acceptable Radiograph . . . . . . 102
4.4.4 Analysis and Interpretation
of Completed Radiographs. . . . . . . . . . . . . . . . . . . . . 102
4.4.5 Radiographic Changes in Periodontal Disease . . . . . 103
4.4.6 Additional Periodontal Documentation . . . . . . . . . . . 104
4.5 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
5 Instrumentation for Diagnosis and Basic
Treatment of Gingivitis/Periodontitis . . . . . . . . . . . . . . . . . . . . . 107
5.1 Principles for Proper Use of Periodontal
Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
5.1.1 Grasp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
5.1.2 Wrist Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
5.1.3 Fulcrum (Finger Rest Position) . . . . . . . . . . . . . . . . . 107
5.1.4 Adaptation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
5.1.5 Angulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
xvi Contents

5.1.6 Lateral Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

5.1.7 Strokes (Activation of the Instrument) . . . . . . . . . . . . 110
5.2 Periodontal Instrumentation: Armamentarium . . . . . . . . . . . 110
5.2.1 Classification of Periodontal Instruments . . . . . . . . . 110
5.2.2 Introduction to Periodontal Instruments. . . . . . . . . . . 110
5.3 Diagnostic Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
5.3.1 Dental Mirror or Mouth Mirror . . . . . . . . . . . . . . . . . 111
5.3.2 Air/Water Syringe . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
5.3.3 Periodontal Probes . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
5.3.4 Periodontal Probing: What Is Its Value? . . . . . . . . . . 113
5.3.5 The Ten Critical Applications
of the Periodontal Probe . . . . . . . . . . . . . . . . . . . . . . . 113
5.3.6 Functions of the Periodontal Probe . . . . . . . . . . . . . . 113
5.3.7 Automated Periodontal Probes. . . . . . . . . . . . . . . . . . 113
5.3.8 Explorers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
5.4 Periodontal Hand Instrumentation . . . . . . . . . . . . . . . . . . . . . 114
5.4.1 Scalers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
5.4.2 Curettes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
5.4.3 Comparison of the Working Edges of: Universal
Scalers, Universal Curettes, and Gracey Curettes . . . 119
5.5 Adjunctive Hand Instruments . . . . . . . . . . . . . . . . . . . . . . . . 119
5.6 Power Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
5.6.1 Sonic, Magnetostrictive Ultrasonic,
and Piezoelectric Instruments . . . . . . . . . . . . . . . . . . 120
5.6.2 Advantages and Disadvantages
of Power Instruments . . . . . . . . . . . . . . . . . . . . . . . . . 122
5.7 Polishing Instruments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
5.7.1 Rubber Cup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
5.7.2 Air-Powder Polishing . . . . . . . . . . . . . . . . . . . . . . . . . 124
5.8 Instrument Sharpening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
5.8.1 Instrument Sharpening Theory. . . . . . . . . . . . . . . . . . 125
5.8.2 Sharpening Techniques for Hand Instruments . . . . . . 127
5.9 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
6 Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
6.1 Phasing of Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
6.1.1 Advantages of Phasing Treatment Plans . . . . . . . . . . 133
6.1.2 Phase I Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
6.1.3 Phase II Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
6.1.4 Phase III Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
6.1.5 Phase IV Therapy (see Chap. 8) . . . . . . . . . . . . . . . . . 140
6.2 Clinical Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
6.2.1 The Rationale for Dental Prophylaxis
and Scaling and Root Planing Procedures . . . . . . . . . 140
6.2.2 Scaling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
6.2.3 Root Planing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
6.2.4 Gingival Curettage: Coincidental vs. Closed . . . . . . . 142
Contents xvii

6.3 Patient Management Protocol for the Dental

Prophylaxis Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
6.3.1 Patient Management Protocol for the Scaling
and Root Planing Procedure . . . . . . . . . . . . . . . . . . . . 147
6.3.2 Therapy Choices for Specific Clinical Situations . . . 150
6.3.3 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
6.4 Local Anesthesia Necessary for Scaling
and Root Planing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
6.4.1 Anatomy for Periodontal Local Anesthesia . . . . . . . . 151
6.4.2 Non-injectable Topical Anesthesia. . . . . . . . . . . . . . . 152
6.4.3 Injectable Local Anesthesia . . . . . . . . . . . . . . . . . . . . 152
6.4.4 Injection Techniques . . . . . . . . . . . . . . . . . . . . . . . . . 154
6.4.5 Used for Both Maxillary and Mandibular
Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
6.4.6 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
6.5 Treatment of Dentinal Hypersensitivity Associated
with Periodontal Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
6.5.1 Etiology and Treatment Options . . . . . . . . . . . . . . . . 160
6.6 Treatment Modalities for Dentinal Hypersensitivity . . . . . . . 160
6.6.1 Treatment Recommendations . . . . . . . . . . . . . . . . . . . 161
6.6.2 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
7 Adjunctive Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
7.1 Pharmacotherapeutics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
7.1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
7.1.2 Systemic Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . 163
7.1.3 Local Delivery Antibiotic Therapy . . . . . . . . . . . . . . 164
7.1.4 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
7.2 The Importance of Smoking Cessation . . . . . . . . . . . . . . . . . 166
7.2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
7.2.2 The Systemic Impact of Tobacco Use . . . . . . . . . . . . 166
7.2.3 The Dental Implications of Tobacco Use . . . . . . . . . . 167
7.2.4 The Role of the Dental Practitioner
in Smoking Cessation. . . . . . . . . . . . . . . . . . . . . . . . . 167
7.2.5 Pharmacological Therapies
for Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . . . 168
7.2.6 E-Cigarettes and Electronic Nicotine
Delivery Systems (ENDS) . . . . . . . . . . . . . . . . . . . . . 168
7.2.7 Smoking Cessation Counseling and Referrals . . . . . . 168
7.2.8 Five Major Steps to Intervention (The “5 As”) . . . . . 168
7.2.9 Stages of Readiness . . . . . . . . . . . . . . . . . . . . . . . . . . 169
7.3 Laser Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
7.4 Oral Bacterial Culturing and Sensitivity Testing . . . . . . . . . . 170
7.5 DNA Probe Sampling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
7.6 Periodontal Endoscope. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
xviii Contents

8 Maintenance Therapy/Necessary for Long-Term Success . . . . 175

8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
8.1.1 The Maintenance Therapy Program . . . . . . . . . . . . . . 175
8.2 Getting Started . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
8.2.1 High-Risk Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
8.3 Treatment Principles Regarding the Prevention
of Gingivitis and Periodontitis . . . . . . . . . . . . . . . . . . . . . . . . 176
8.4 Basic Features of a Structured Maintenance
Therapy Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
8.4.1 Guidelines for Evaluation: What Are
the Key Signs to Look for in Early Disease? . . . . . . . 177
8.5 The Maintenance Therapy Appointment:
The Basic Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
8.6 Implant Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
8.6.1 Anatomy of a Dental Implant
and its Supporting Prosthesis . . . . . . . . . . . . . . . . . . . 179
8.6.2 Evaluation of Implant Health . . . . . . . . . . . . . . . . . . . 179
8.6.3 Instrumentation of Dental Implants . . . . . . . . . . . . . . 181
8.6.4 Protocol for Home Care for Patients . . . . . . . . . . . . . 183
8.7 Knowing Your Diagnostic Goals . . . . . . . . . . . . . . . . . . . . . . 185
8.8 Knowing the Treatment Goal of Periodontal Therapy . . . . . . 186
8.9 Knowing the Psychological Difficulties
Associated with the Maintenance Therapy Program . . . . . . . 187
8.10 Understanding Anatomic Realities: The Degree
of Attachment Loss and the Presence of Pockets . . . . . . . . . 188
8.11 Extending the Vision of Success: Does Maintenance
Therapy Work? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
8.12 The Challenge of Compliance . . . . . . . . . . . . . . . . . . . . . . . . 191
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
9 Concluding Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Appendix A: American Academy of Periodontology Classification
of Periodontal Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Appendix B: Antibiotic Prophylaxis Guidelines . . . . . . . . . . . . . . . . . . 201
Appendix C: Treating Tobacco Use: Pharmacological Therapy . . . . . . 203
Appendix D: Fagerstrom Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Appendix E: Sample Patient Brochure Describing the Maintenance
Therapy Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
 Fundamentals
1

1.1 Introduction to the protective interactions between the tooth

surface and subjacent bacteria, which resist the
A healthy periodontium is essential for the long- effects of antimicrobial agents, such as mouth-
term survival of the dentition and for success- washes. Without mechanical removal the bacte-
ful restorative dentistry. To maintain periodontal ria’s secretions or toxins remain on the tooth and
health requires a recognition and understand- are responsible for the development of gingival
ing of the multiple factors that contribute to inflammation and the acidic demineralization of
the etiology of periodontal disease progression. teeth. For susceptible individuals, these toxins
Most dental and dental implant diseases are must be removed daily. For less susceptible indi-
plaque induced and, therefore, are infections. viduals who are periodontally healthy, it has been
Plaque, or microbial biofilm, is a sticky secre- shown that the removal of dental plaque every
tion comprised of bacterial cells in a polysac- 24–48 h can successfully prevent clinical signs of
charide media, which is attached to the teeth gingivitis. From daily mechanical removal to
and other non-shedding surfaces by a glycoca- more in-depth preventative care, the maintenance
lyx (Fig. 1.1). This biofilm can be toxic to the of periodontal health is the shared responsibility
teeth and the surrounding soft and hard tissues. between the patient and the clinician.
Intraorally, it is responsible for dental caries,
gingivitis, periodontitis, peri-implant mucositis,
and peri-implantitis (Fig. 1.1a–c). Additionally, 1.2 Anatomy (Fig. 1.2a, b)
host susceptibility (host response) to the toxins
in dental plaque plays a significant role in the 1.2.1 Gingival Anatomy
degree of periodontal inflammation and its pro- with Respect to Periodontal
gression. The body’s immune response medi- Diseases or Deformation
ates the inflammation and always must be taken
into consideration when diagnosing and treating (a) The gingiva, which along with the soft tissue
periodontal inflammation. covering the hard palate is known as mastica-
Plaque/biofilm accumulates on teeth daily in tory mucosa and is comprised of the mar-
quantities that have the potential for creating gin- ginal gingiva and the attached gingiva. The
gival inflammation. Dental plaque must be epithelial surface of the gingiva is keratin-
removed to ensure freedom from periodontal dis- ized on the facial or buccal surfaces from the
eases, peri-implant diseases, and dental caries. crest of the marginal gingiva to the
Mechanical removal is especially necessary due mucogingival junction. The sulcular surface

© Springer-Verlag Berlin Heidelberg 2016 1

P.A. Levi, Jr. et al., Non-Surgical Control of Periodontal Diseases: A Comprehensive Handbook,
DOI 10.1007/978-3-662-46623-0_1