Initial preparation: anti-infective therapy

The primary aim of anti-infective therapy is to eliminate or reduce the subgingival plaque and to arrest tissue breakdown associated with chronic or progressive periodontitis. Four to six weeks following anti-infective therapy, initial healing is usually complete, and the clinical status should be re-evaluated. After assessing the reduction in probing depths, bleeding on probing and clinical attachment levels, the clinician must decide whether the anti-infective therapy has arrested the disease. If it is determined that maximum healing has occurred, the initial phase of therapy is complete, and the patient is placed into the maintenance program. In sites that remain > or = 6 mm following anti-infective therapy, surgical debridement may be indicated to increase visualization of the roots for deposit removal because the evidence points to better calculus removal in an open versus closed environment. During surgical root preparation, fine diamonds or finishing burs produce the smoothest root surface followed by manual and power-driven scalers. Endoscopic cameras that enable the clinician to see subgingival calculus without benefit of surgical access may prove to be a valuable diagnostic tool for sites that do not respond to therapy. Diamond-coated ultrasonic inserts are available from some manufacturers and have been shown to be efficient and effective in surgical root preparation. New designs and finer grits may enable clinicians to use these instruments in nonsurgical applications in the future. Finally, new evidence from one group in Belgium has shown that significantly more attachment gain and probing depth reduction is achieved when scaling and root planing is done in one or two visits within 24 hours compared with the traditional method of scaling quadrant by quadrant over four visits. These preliminary results need to be confirmed by others but hold a great deal of promise for improving the outcomes from nonsurgical root preparation in the future.