EVALUATION OF RESULTS FOLLOWING PHASE I PERIODONTAL THERAPY

Chapter 43: Phase I Periodontal Therapy - Sequence of Procedures

Step 1: Plaque Control Instruction
Plaque control is the essential component to successful periodontal therapy, and
instruction should begin in the first treatment appointment. The patient must learn to
correctly brush the teeth, focusing on applying the bristles at the gingival third of the
clinical crowns of the teeth, and begin using floss or other aids for interdental cleaning.
This is sometimes referred to as targeted oral hygiene[18] and emphasizes thorough
plaque removal around the periodontal tissues. The multiple appointment approach to
phase I therapy permits the dentist to evaluate, reinforce, and improve the patient's oral
hygiene skills. ( Chapter 44 details plaque control options.)
Step 2. Removal of Supragingival and Subgingival Calculus
Removal of calculus is accomplished using scalers, curettes, ultrasonic instrumentation,
or combinations of these devices during one or more appointments. Evidence suggests
that the treatment results for chronic periodontitis are similar for all instruments,[6] and
some dentists now incorporate laser technology into periodontal therapy, including phase
I therapy.[3,15]
Step 3. Recontouring Defective Restorations and Crowns
Corrections for restorative defects, which are plaque traps, may be made by smoothing
surfaces and overhangs with burs or hand instruments or by replacing restorations. These
procedures can be completed concurrently with other phase I procedures.
Step 4. Management of Carious Lesions
Removal of the carious tissue and placement with either temporary or permanent
restorations is indicated in phase I therapy because of the infectious nature of the caries
process. Healing of the periodontal tissues will be maximized by removing the reservoir
of bacteria in these lesions so that they cannot repopulate the microbial plaque.
Step 5. Tissue Reevaluation
After scaling, root planing, and other phase I procedures, the periodontal tissues require
approximately 4 weeks to heal sufficiently to be probed accurately. Patients also need the
opportunity to improve their plaque control skills to both reduce inflammation and adopt
new habits. At the reevaluation appointment, periodontal tissues are probed, and all
related anatomic conditions are carefully evaluated to determine if further treatment,
including periodontal surgery, is indicated. Additional improvement from periodontal
surgical procedures can be expected only if phase I therapy resulted in the gingiva being
free of overt inflammation and the patient has learned effective daily plaque control.

RESULTS
Scaling and root planing therapy has been studied extensively to evaluate its effects on
periodontal disease. Countless studies indicated that this treatment is both effective and
reliable. Studies ranging from 1 month to 2 years in length demonstrated up to 80%
reduction in bleeding on probing and mean probing depth reductions of 2 to 3 mm.
Others demonstrated that the percentage of periodontal pockets of 4-mm or greater depth
was reduced more than 50% and up to 80%.[4] Figures 43-1 and 43-2 show examples of
the effectiveness of phase I therapy.
The control of infectious organisms during phase I treatment is of critical importance.
Recently, there has been considerable interest in providing phase I therapy in one long
appointment or two appointments on consecutive days while the patient is receiving an
aggressive prescribed regimen of antimicrobial agents rather than staged appointments to
treat one quadrant or sextant at a time, usually with 1 week separating appointments. This
single-stage treatment sequence has been referred to as antiinfective or disinfection
treatment.[11,14] Recent studies suggested both the one appointment and staged or multiple
appointment treatment strategies work well. The modest differences in clinical
parameters in comparing healing after one session or multiple sessions were not clinically
significant.[7,17] In addition, microbial parameters were not significantly different after 8
months, regardless of treatment modality[17] and the risk of recurrence of periodontal
pockets was no greater for either modality.[20] Until evidence indicates otherwise, the
sequence and duration of phase I therapy appointments should be determined based on
amount of disease present and patient comfort.[5] Staged therapy permits the advantage of
evaluating and reinforcing oral hygiene care, and the one or two appointment therapies
can be more efficient in reducing the number of office visits the patient is required to
attend.
Additional individual treatments, such as caries control and correction of poorly fitting
restorations, clearly augment the healing gained through good plaque control and scaling
and root planing by making tooth surfaces accessible to cleaning procedures. Figure 43-3
demonstrates the effects of an overhanging amalgam restoration on gingival
inflammation in an otherwise healthy periodontium. Maximal healing from phase I
treatment is not possible when local conditions retain plaque and provide reservoirs for
repopulation of periodontal pathogens.
Healing
Healing of the gingival epithelium consists of the formation of a long junctional
epithelium rather than new connective tissue attachment to the root surfaces. The
attachment epithelium reappears 1 to 2 weeks after therapy. Gradual reductions in
inflammatory cell population, crevicular fluid flow, and repair of connective tissue result
in decreased clinical signs of inflammation, including less redness and swelling. One or
two millimeters of recession is often apparent as the result of tissue shrinkage.[4]

Transient root sensitivity frequently accompanies the healing process. Although evidence
suggests that relatively few teeth in a few patients become highly sensitive, this
development is common and can be disconcerting to patients. The extent of the
sensitivity can be diminished through good plaque removal.[19] Warning patients about
these potential outcomes, the teeth appearing longer because of shrinkage of periodontal
tissues and tooth root sensitivity, at the beginning of the treatment sequence will avoid
surprise if these changes occur. Unexpected and possibly uncomfortable consequences to
treatment may result in distrust and loss of motivation to continue therapy.
Decision to Refer for Specialist Treatment
Often, periodontal conditions heal sufficiently well after phase I therapy that no further
treatment is required beyond routine maintenance, making treatment of most periodontal
patients the responsibility of the general dentist. However, advanced or complicated cases
benefit from specialist care. It is critical to be skilled in determining which patients would
benefit from specialist care and should be referred.[12,16]
The 5-mm standard has been commonly used as a guideline for identifying candidates for
referral and relates to the presence of 5 mm or more of clinical attachment loss present at
the reevaluation appointment. The rationale behind the 5-mm standard is that the typical
root length is about 13 mm and the crest of the alveolar bone is at a level approximately
2 mm apical to the bottom of the pocket. When there is 5 mm of clinical attachment loss
the crest of bone is about 7 mm apical to the cementoenamel junction, therefore only
about half the bony support for the tooth remains. Specialist care can help preserve teeth
in these cases by eliminating deep pockets and regenerating support for the tooth. Figure
43-4 depicts the relationship of clinical attachment loss to tooth support. In terms of
probing depths, the treatment of periodontal diseases is generally successful in patients
with 6- to 8-mm probe depths. Success rates diminish when probing depths are 9 mm or
greater, so early referral of advanced cases is likely to provide the best results.
Figure 43-4 The 5-mm standard for referral to a periodontist is based on root
length, probing depth, and clinical attachment loss. The standard serves as a
reasonable guideline to analyze the case for referral for specialist care. CEJ,
Cementoenamel junction.
In addition to the 5-mm standard and evaluation of probe depths, the following factors
must also be considered in the decision to refer:
1
2
3
4

Extent of disease and generalized or localized deep involvement. Extensive bone

loss, even in localized areas suggest the need for specialized reconstructive
techniques.
Root length. Short roots are more seriously jeopardized by 5 mm of clinical
attachment loss than long roots.
Hypermobility. Excessive tooth mobility suggests contributing factors and a more
guarded prognosis.
Difficulty of scaling and root planing. The presence of deep pockets and furcations

5
6
7

makes instrumentation much more difficult and results can often be improved with
surgical access.
Restorability and importance of particular teeth for reconstruction. Long-term
prognosis of each tooth is important when considering extensive restorative work.
Age of the patient. Younger patients with extensive attachment loss are more likely
to have aggressive forms of disease that require extensive therapy.
Lack of resolution of inflammation after scaling and planing. If inflammation
persists, further therapy is often necessary to gain the most positive results.

Every patient is unique, and the decision process for each patient is complex. The
considerations presented in this chapter should provide guidance understanding the
significance of phase I therapy and in making referral decisions.
Science Transfer

The major goal of phase I therapy is to control the factors responsible for the
periodontal inflammation; the removal of subgingival bacterial deposits and the
subsequent control of plaque levels by patients are particularly significant. Phase I
therapy should be comprehensive and include scaling, root planing, and oral hygiene
instruction, as well as other therapies such as caries control, replacement of defective
restorations, occlusal therapy, orthodontic movement, and smoking cessation.
Comprehensive reevaluation after phase I therapy is essential to validate treatment
options and to estimate prognosis. Many patients can have their periodontal disease
controlled with phase I therapy and not require further surgical intervention. In patients
who do need surgical treatment, phase I therapy is advantageous in that it also provides
tissue with reduced inflammatory infiltration, thus improving the surgical management
of the tissue and improving the healing response.
For patients with 5 mm or more of attachment loss and with pockets present after phase
I treatment, surgical treatment should be planned. Advanced cases may be best treated
by periodontal specialists.
Those patients who do not demonstrate the ability to have 20% or less of tooth surfaces
free of plaque are poor candidates for successful surgical outcomes and should be
closely monitored on a recall maintenance program until plaque control is established.
Reevaluation After Phase I Therapy (excerpt from Chapter 52)
Longitudinal studies have noted that all patients should be treated initially with scaling
and root planing and that a final decision on the need for periodontal surgery should be
made only after a thorough evaluation of the effects of Phase I therapy.[5] The assessment
is generally made no less than 1 to 3 months and sometimes as much as 9 months after
the completion of Phase I therapy.[1] This reevaluation of the periodontal condition should
include reprobing the entire mouth. The presence of calculus, root caries, defective
restorations, and signs of persistent inflammation should also be evaluated.