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Adjunctive Therapy to Periodontal Debridement

Adjunctive therapy to periodontal debridement may include the use of systemic or local delivery antimicrobials. The intent of local delivery antimicrobials is to allow for the controlled delivery of the agent at the site of infection over a prolonged period of time. In a review on the impact of locally applied antimicrobials, researchers have found that the greatest results occurred in conjunction with the use of tetracycline, minocycline, metronidazole, and chlorhexidine.1 Key advancements in local delivery antimicrobials have been made in both the method of delivery and in the use of bioresorbable/biodegradable materials that do not require post-treatment removal. Several products have been introduced for use in the US over the past two decades; those products in the US showcasing these advancements include minocycline, doxycycline, and chlorhexidine.

The initial phase of periodontal therapy includes the thorough debridement of the tooth surface by means of ultrasonic power and hand instrumentation. The outcome, or endpoint, of debridement scaling and root planing should be evaluated two to four weeks after completion to allow sufficient time for tissue healing, with reassessment at continuing care appointments. Evidence of effective treatment will be demonstrated by positive tissue changes, the elimination of bleeding upon probing, reductions in probe depth, and clinical attachment gain. Following this initial phase of treatment, patients should be assessed to determine if local delivery antimicrobials are indicated.

In general, site selection will include areas with inflammation and probe depths of 5 mm or greater. The selection of sites and the application of local delivery two to four weeks following ultrasonic debridement provide sufficient time for tissue healing and afford dental professionals the opportunity to identify areas that exhibit limited response to treatment. This approach is the most cost effective, since the number of sites indicated for placement should be reduced following debridement. It is recommended that therapies other than local delivery antimicrobials be considered when there are multiple sites in the same quadrant with probing depths greater than 5 mm. The previous use of local delivery antimicrobials in depths under 5 mm has been unsuccessful and anatomical defects (ie, intrabony defects) were present.2

Prior to the placement of any local delivery antimicrobials, the patient’s health history should be reviewed to identify any conditions, such as allergies or pregnancy, which would preclude their use. Even with the use of local delivery antimicrobials, there is the potential for some systemic absorption; therefore, agents from the tetracycline class should be avoided during pregnancy due to the discoloration that may result in the developing teeth. Patient instructions for oral self care vary depending on the manufacturer; however, as a general guideline, patients should be instructed to brush gently in the area of treatment and to avoid the use of floss or interproximal cleaning aids for 7 to 10 days.

Research has shown that improvements in probing depths can be observed when local delivery antimicrobials are incorporated into a treatment of periodontal debridement scaling and root planing. The degree to which locally applied antimicrobials impact the endpoint of treatment is still unclear and further research is indicated to determine the full benefits of their use in the treatment of chronic periodontitis.1,2

*Assistant Professor and Sophomore Clinic Coordinator, Department of Dental Hygiene, University of New Haven, West Haven, Connecticut.

 

References

  1. Bonito AJ, Lux L, Lohr KN. Impact of local adjuncts to scaling and root planing in periodontal disease therapy: A systematic review. J Periodontol 2005;76(8):1227-1236.
  2. Task force on local delivery of antimicrobials as adjunct therapy. American Academy of Periodontology statement on local delivery of sustained of controlled release antimicrobials as adjunctive therapy in the treatment of periodontitis. J Periodontol 2006;77:1458.
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