Carissa Crook & Tina Reitz

Non-Surgical Periodontal Therapy, Evaluation of NonSurgical Supportive Periodontal Maintenance

Bob Smiley hasnt been seen in the dental office for several years. He
has filled out a new medical history and there are no significant findings.
According to his assessments he has presented with active chronic
periodontal disease. Films have been taken and evaluated by the RDH and
DDS.
RDH: Good morning Bob, it is nice to see you in again. I see that you filled
out a new medical history for us, thank you for doing that.
Bob: Yeah, that took me awhile to fill that out. I dont know why you guys
couldnt just use my other one from before. Its not that big of a deal anyway.
RDH: It is very important that we have everything up to date on here so we
can treat you accordingly. Something may have changed that you might not
think is a big deal, like a medication and you might not know all of the side
effects it could be causing you. We want to make sure that you get the best
treatment possible that is specific to your needs.
RDH: So, I know it has been several years since your last cleaning. I just
want you to know that sometimes after I do my initial assessment we might
need to schedule you back for a cleaning.
Bob: Why is that? I had to take off of work to come in here this morning. I
cant just keep taking off for just a cleaning.
RDH: I know that your time is very valuable and I want to be as proficient as
I can to only have you come here as little as possible. Since it has been
several years since you have been in, a lot could have changed and I want to
make sure that you are getting the best possible care. As you know, your oral
health and your overall health are directly related. We do multiple
assessments because we now have information that infections in your mouth
may affect and can contribute to many other diseases such as heart disease,
diabetes and even arthritis. Our immune system responds to bacteria in our
mouths just like it does to a cut on our finger. It sends many types of
messengers to the site and wants to begin to repair the damaged area. In

our mouths these messengers in large numbers can be very destructive.

They begin to attack the bone and skin around our teeth in an effort to get
rid of the bad bacteria.
Bob: Oh wow, I never knew that my mouth could have such an effect on my
body and vice versa. I have noticed that my gums have been bleeding more
since my last cleaning. I am curious to see what you find.
** Assessments are completed and you share your information with the
Dentist
DDS: Upon examination of your mouth it is apparent that you have active
chronic periodontal disease. It is crucial that we treat you accordingly in
order to return your mouth to a stable healthy state. Your hygienist will be
working alongside of you to do so. She will go over with you the
recommended treatment.
RDH: After the Doctor and I reviewed your x-rays we found some areas of
bone loss. Here is what we are looking for.

These images in conjunction with our other assessments help us to

determine what is going on in your mouth. They also help us to find an
individualized treatment plan for you.
Bob: What other assessments for?
RDH: Well I can start by explaining what a healthy mouth should look like.
The first assessment we did was called the periodontal assessment. In this
assessment we measure the collar of gum tissue that hugs your tooth all the
way around. We do this using a probe. These measurements indicate if the
bone around your tooth has begun to shrink and if the tissue around the
tooth is swollen and irritated. The second half of your assessment was
reviewing your x-rays as we talked about earlier.

** Using a chart similar to this I would continue to explain the measurements

and what they mean.

What we see in a healthy mouth is pink, healthy, tight tissue. This tissue will
not bleed when we use our probe. The collar of tissue will measure 1-3 mm.
There is no bone loss present.
The first image we see here is what the early signs of periodontitis look like.
Sometimes gingivitis appears this way and is 100% reversible. You will have
some build up below your gums that are causing redness, irritation and
swelling. Often the tissue will bleed when we use our instruments. Here we
see measurements at about 4mm. The higher probe reading is mostly due to
the top of your bone disappearing. Once bone is lost it will not be regained.
In the following two pictures we see deeper probe depths similar to what we
are seeing in your mouth. These readings are 5+mm. This is the response of
your body trying to get rid of the bacterial build up. Because there is so
much bone destruction it is important that we take action and treat your
mouth accordingly. Our goal is to slow and eventually stop the progression of
this disease. If treatment isnt started it is possible that the teeth will become
mobile and have to be removed.
RDH: As the Dentist said before you have active chronic periodontitis.
Bob: That doesnt sound good, what is that?

RDH: Active chronic periodontitis is a common disease of the oral cavity

consisting of chronic inflammation of the periodontal tissues that is caused
by accumulation of dental plaque and calculus. The good news here is the
Dentist feels that we can try to effectively treat your disease here in the
office. As your dental hygienist, I will perform what is called Non-Surgical
Periodontal Therapy.
Bob: What is that, I have never heard of that before.
RDH: It is where I go in with specialized instruments and remove the hard
and soft deposits in your mouth. I am going to be going below your gumline
to make sure I break up any biofilm that may have formed.
Bob: Biofilm, that sounds disgusting. That could be in my mouth?
RDH: Biofilm is a living film that contains a well-organized community of
bacteria. It consists of many species of bacteria that rapidly grown on almost
any wet surface. Have you ever had that slimy feeling on your teeth when
you wake up in the morning? There is a good chance that it was biofilm on
your teeth. That is another good reason we need good homecare. Here is a
picture of some examples of where you can find biofilm.
** show picture of biofilm

Bob: Wow that is disgusting. I never thought that could be on my teeth.

RDH: Remember when you said that your gums have started to bleed more
since your last cleaning. Any time bleeding is present, pathological change is
occurring in your mouth that needs to be evaluated and appropriately
treated sooner rather than later. When periodontal disease is present, the
potential for bone loss has already begun. It can occur quickly and become
aggressive very easily. This is why it is so important to keep up on your
homecare as well.

Bob: Well I usually brush my teeth before I go to work is that enough to keep
that film off my teeth?
RDH: What youre doing is great! But in order to maintain the therapy that I
need to perform I need you to be more involved in cleaning your mouth.
Biofilm is always forming. The bad bacteria dont begin to adhere in our
mouths until later in the formation cycle. By brushing thoroughly two times
per day we will stop the bad bacteria from adhering thus improving the
health of our gum tissue and bone. We also need to remember to clean in
between our teeth, this is where the disease progresses most rapidly
because it is often forgotten. By cleaning between our teeth we will disrupt
that biofilm weve been talking about. There are many different ways that we
can clean our mouths, throughout the therapy process I will teach and
introduce new things so we can find a method that is effective and suits your
liking.
The initial phase of your care will take 2-4 appointments. Depending on our
findings we will work on either half of your mouth or a quarter of it in each
appointment. By breaking it down we are able to provide you with our best
abilities in the area of treatment. Is there anything that I can clarify for you?
Bob: No, this is all new information to me, but it makes sense! What will my
dental care schedule look like upon completion?
RDH: Before the first phase is completed we will see you four weeks after
your final appointment to re-evaluate your mouth and how it has responded.
We will be taking another assessment and comparing it to the one we took
today. Ideally we would like to see a decrease in probe measurements and
bleeding. It is possible that some areas of your mouth may fail to respond
positively. If that is the case I will use the appropriate instruments to go back
and check and remove any possible deposits that were left behind. We also
will evaluate how your care at home is doing. If the area seems clean but is
still unresponsive we may have to send you to a specialist who will perform
the proper procedure to clean the area and bring it back to a state of health.
The areas that typically require surgery are the areas with more bone loss
and deeper pocket depth readings. Our instruments are unable to reach
these areas adequately.
The goal at the end of treatment is to see a reduction in the pocket depth,
and the readapting of tissues to the root surface forming what is called a
long junctional epithelium.

Bob: That sounds great! So my gums will be back to normal?

RDH: Not exactly, the new epithelium tissue is more fragile than the tissue
you had there before and it is more susceptible to bacterial pathogens
causing it to breaks down faster. This leaves you more susceptible to
infections if there is a break in your oral tissue and bacteria can enter your
bloodstream. That is why it is important that you understand that you are
now at a state in your oral health that will require you to visit me more
frequently. Because of the bone loss present, your toothbrush will not clean
the deep pockets adequately. Once your therapy has been completed and we
reach a stable state I will need you to visit me every 3 months. Maintaining
your oral health will take teamwork from here on out and your hard work and
commitment is what will make this work.
** show a picture of long junctional epithelium

Bob: Well, can I eventually go back to 6 mo visits?

RDH: Probably not, remember that biofilm we talked about? If you extend
the time between your visits you are allowing the biofilm to build up longer in
areas that you cant clean. These areas will continue to progress in the
disease process and could potentially spread to other areas of your mouth. In
return this will destroy the newly formed, fragile long junctional epithelium
that we talked about before. After all the time and money you will have put
into restoring the health of your mouth you will want to continue to maintain
it to prevent a relapse into the diseased state from occurring.
Bob: Yeah, once you explain it like that it does makes sense. I dont want to
have to do this all over again. I have never had this explained to me like this

before. I wish my last hygienist told me as much as you as did today and
maybe I wouldnt be in this situation. Thank you again. I look forward to
coming and getting my mouth healthy again!
RDH: Thats great Bob! Im glad I can help. Lets get you scheduled right
away so we can start.