Concepts in Nonsurgical Anti-Infective Periodontal Therapy
Sebastien Dujardin, DDS, MS
of patients with generalized, severe chronic periodontitis has been a
continuous challenge for clinicians. Traditionally, patients with generalized,
moderate-to-severe chronic periodontitis have been treated with resective
periodontal surgical procedures. As a result, some patients have suffered
marked gingival recession and interproximal soft tissue disfigurement that resulted
in root sensitivity, an increased risk of root caries, and, occasionally, compromised
aesthetics. Major demographic shifts to an older patient population, as well as
increased use of selected medications that depress wound healing and immune
mechanisms, have further precluded periodontal surgeries.
Recently, there has been a movement
towards nonsurgical periodontal therapy, employing full-mouth periodontal
instrumentation within a narrow time frame (ie, single-stage periodontal/oral
disinfection) and use of adjunctive chemotherapeutics agents in mouthrinses,
pocket irrigants, and systemically administered drug regimens. Potential
adjunctive antimicrobial approaches to enhance the outcome of conventional,
mechanical, nonsurgical periodontal therapy may include use of chlorhexidine
mouthrinses at various concentrations, homecare procedures with hydrogen
peroxide and baking soda, and professional, in-office pocket irrigation with a
povidone-iodine antiseptic solution.
Concepts Surrounding Therapeutic Treatment
hydrogen peroxide and sodium bicarbonate into patient homecare procedures was
popularized over 25 years ago.1-5 Studies have further shown that a
combined professional and patient home application of a sodium bicarbonate
slurry may result in clinical healing of severe periodontitis lesions following
nonsurgical periodontal instrumentation6,7
disinfection focuses on mechanical removal of all tooth-associated plaque
biofilms and calculus over a 24-hour time period (ie, two patient visits), with
concurrent tongue disinfection with a chlorhexidine gel (brushed on for two
minutes), oral mucosal surface disinfection with a chlorhexidine mouthrinse,
and subgingival disinfection with 0.06% chlorhexidine pocket irrigation.8
In most mouthrinse-related studies,
a 0.2% chlorhexidine concentration was employed. In the United States, however, only a
0.12% chlorhexidine concentration is available in commercial mouthrinses.
Fortunately, similar in vivo plaque inhibitory effects are found with both
periodontal therapy can potentially reduce gingival tissue inflammation,
decrease periodontal probing depths, and improve clinical periodontal
attachment levels. Significantly superior treatment outcomes are found in deep
periodontal pockets when a 0.1% povidone-iodine disinfectant is adjunctively
delivered subgingivally through an ultrasonic scaler.10
Systemic periodontal antibiotic
therapy, particularly joint administration of amoxicillin and metronidazole,
are recognized as significantly beneficial in periodontitis therapy11 and can be used in the
absence of any mechanical subgingival instrumentation.12 Key periodontal
pathogens at the apical aspect of periodontitis lesions may be potentially suppressed
or eliminated—leading to reduced gingival tissue inflammation—with
administration of certain types of systemic antibiotic drug regimens alone.12
As a result, it may be possible to better sequence periodontitis therapy by
initiating short-term systemic periodontal antibiotics prior to subgingival,
mechanical, periodontal root instrumentation is carried out (Table A). This may
better protect and preserve the most coronal intact periodontal connective
tissues from iatrogenic trauma induced by mechanical periodontal
instrumentation performed in inflamed periodontal pockets.
A 50-year-old female
patient presented for periodontal treatment. Although the patient reported a
history of smoking a pack of cigarettes per day for many years, smoking had
ceased over 10 years prior to presentation. The patient’s dental history was
sporadic and her chief complaint was regarding tooth #8(11), which exhibited
suppuration for over six months and for which she had been given antibiotics.
Clinical photographs and a complete
periodontal examination (eg, pocket depths, mobility, recession, furcation
involvement, masticatory mucosa) were performed (Figure 1; Table B).12-14
A complete series of radiographs, including bitewings, was taken (Figure 2).
Diagnostic study models were fabricated in order to formulate an optimum
treatment plan. A comprehensive review of the medical history ruled out any
systemic involvement. Phase-contrast microscopic examination revealed high
numbers of motile rods and spirochetes.4,5,15,16
The patient was diagnosed with
generalized severe periodontitis, with 18 (ie, 69.2%) teeth exhibiting one or
more periodontal sites with ≥ 7-mm probing depths and all teeth displaying one
or more periodontal sites with ≥ 5-mm probing depths at baseline prior to
plaque removal was performed by the patient using a soft toothbrush and interdental
cleaner with the aid of disclosing solution to demonstrate areas of plaque. Chemical
plaque-control was then initiated using 3% hydrogen peroxide and sodium
bicarbonate applied on a soft toothbrush and proxabrush followed by
chlorhexidine 0.12% rinse. Systemic antibiotics were then administered.
debridement was performed using an ultrasonic scaler.17 At each
visit, whole-mouth scaling was performed at all sites, working from the pocket
orifice towards the subgingival depth of the periodontal pockets. Removal of
visible supra- and subgingival calculus was performed at six appointments, over
a total of four hours. Subgingival irrigation was also performed with 0.5%
povidone-iodine at each visit.18,19 The tissue response was
subsequently reevaluated at six to eight weeks (Figure 3).
The patient was
seen for supportive periodontal therapy on a three-month interval for the first
18 months.20 New clinical photographs, radiographs, and probing
pocket depths were taken to document the changes that had occurred over time
with improved care (Figures 4 and 5; Table C). At nine months
post-treatment, no ≥ 7-mm probing depths were detected, and only 3 (ie, 11.5%)
of the patient’s 26 teeth exhibited a ≥ 5-mm probing depth. Among the 44 sites
exhibiting ≥ 7-mm probing depths at the baseline, all revealed a ≥ 3-mm
clinical attachment level-gain nine months postoperatively.
The patient agreed to be seen on a
six-month recall schedule. She also expressed interested in orthodontic treatment
to retract and consolidate the anterior segment. When active tooth movement is
initiated, she will need to present every three months for supportive
periodontal therapy, to ensure that periodontal health is maintained.
several potential caveats for clinicians when treating severe chronic
periodontitis. It is important to focus on the disease as a bacterial infection
conducive to anti-infective treatment strategies. Reducing gingival tissue
inflammation prior to mechanical root instrumentation, by resequencing
periodontal treatment procedures may enhance preservation of intact periodontal
connective tissues and may better promote postoperative periodontal
regeneration. Administration of systemic antibiotics may be better positioned
earlier in periodontal treatment plans than is generally practiced. Severe
forms of human periodontitis may respond successfully, with potential retention
of near-hopelessly involved teeth, to nonsurgical periodontal therapies
augmented by antimicrobial agents delivered both professionally and by the
*Department of Periodontology and
Oral Implantology, Temple University, Philadelphia,
†Associate Professor, Department
of Periodontology and Oral Implantology, Predoctoral Clinic Director; Temple
University Kornberg School of Dentistry, Assistant Professor, Drexel University
School of Medecine, Department of Pediatrics, St Christopher’s Hospital for
Children, Department of dental Medecine. Philadelphia,
‡Professor of Microbiology and Immunology, School of Medicine; Professor
of Periodontology and Oral Implantology, School of Dentistry; Associate Dean
for Graduate Education and International Affairs and Program Director of
Graduate Periodontics, Temple University Kornberg School of Dentistry,
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