What are the four primary aims of overall periodontal therapy (surgical and non-surgical)?
- Arrest the infection (remove etiology). 2. Reduce the overall bacterial load. 3. Restore lost periodontal structures. 4. Ensure the patient maintains a healthy periodontium throughout their life (lifelong maintenance).
What is the main goal of Non-Surgical Periodontal Therapy (NSPT), and when is it performed?
The main goal is infection control to reduce the bacterial load so the patient can heal well. NSPT is the initial treatment for all periodontitis-susceptible patients.
What are the expected clinical outcomes following successful NSPT?
Expected outcomes include pocket depth reduction of 1–3 mm and clinical attachment level (CAL) gain of 0–2 mm.
What is the crucial bacterial shift desired in the pockets following NSPT?
Eliminate anaerobic Red Complex bacteria (P. gingivalis, T. denticola, T. forsythia) found in deep pockets. Encourage colonization of health-associated bacteria (Actinomyces species or Veillonella species) in shallow pockets.
What is the most significant limitation of NSPT, particularly in deep defects?
Access to deep defects. It is difficult to non-surgically access deep intraosseous defects (e.g., 6 mm or more) and horizontal involvement in Grade 2 or Grade 3 furcations.
When should patients be reviewed and re-evaluated following NSPT?
Patients should be reviewed and re-evaluated (re-charted) at 3 months after NSPT.
What clinical criteria indicate the need to consider surgical periodontal therapy?
Surgery is considered when residual pockets of 6 mm or more are still bleeding on probing. Other indications include Class 2 or Class 3 furcation deep defects and infraosseous (vertical or angular) bone defects.
Why is controlling systemic risk factors mandatory before surgical intervention?
Patients with uncontrolled diabetes (HbA1c > 7.5+) do not respond well to therapy, as their immune cells and fibroblasts do not work properly. Smokers also show a poor response due to compromised healing capacity.
Differentiate between the healing mechanisms of resective and regenerative procedures.
Resective procedures heal by repair, resulting in the formation of a long junctional epithelium. Regenerative procedures aim for true regeneration of lost periodontal supporting structures (cementum, PDL, bone).
What is the difference between a full thickness flap and a split thickness flap?
Full thickness flap includes epithelium, connective tissue, and periosteum, raised using blunt dissection (periosteal elevator). Split thickness flap involves only epithelium and partial connective tissue, leaving the periosteum intact, raised using sharp dissection.
What is the purpose of Guided Tissue Regeneration (GTR)?
GTR uses a membrane to separate the fast-growing soft tissue from the defect site. This prevents the soft tissue from growing down and forming a long junctional epithelium, allowing slower-growing cells (bone, PDL, cementum) to regenerate the lost structures.
In Miller’s Classification for gingival recession, which classes allow for 100% root coverage?
Class I and Class II defects allow for 100% root coverage because the interdental bone and soft tissue are still intact (no loss).
What is the critical difference in the post-operative probing timeline for standard surgery versus regenerative surgery?
For standard surgical procedures (healing by repair), it is safe to probe/chart at 3 months. For regenerative procedures (GTR), probing must be avoided for at least 6 months.
What is the appropriate post-operative oral hygiene protocol regarding Chlorhexidine (CHX) mouthwash?
Patients should use a prescribed mouthwash (e.g., Savacol) around the surgical site for the first week, but CHX use must be limited to a maximum of 2 weeks to avoid significant staining.
Why is periodontal dressing (Copac) contraindicated following a Connective Tissue Graft (CTG) used for recession coverage?
Copac is contraindicated over a coronally advanced flap (such as one used for a CTG) because the pressure can move the flap apically, compromising the desired coronal positioning and the survival of the graft.
What characterizes a gingivectomy procedure, and what is a major clinical disadvantage?
Gingivectomy involves resecting excessive gingival tissue (e.g., drug-induced overgrowth) without raising a flap or touching bone. A major disadvantage is that healing occurs by secondary intention, which can be painful and may result in scarring.
Why is initial post-operative healing critical for success?
The initial couple of weeks are extremely important. If the patient fails to maintain good oral hygiene (plaque control), the surgical site can become infected, leading to inflammation and tissue breakdown.
