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Concepts in Nonsurgical Anti-Infective Periodontal Therapy

The management 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

Incorporation of 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

Single-stage periodontal/oral 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 formulations.9

Conventional, nonsurgical 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.

 

Case Presentation

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 treatment.

Plaque Control

Mechanical 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.

In-Office Therapy

Full-mouth 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).

Follow-Up Therapy

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.

Conclusion

There are 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 patient.

 

*Department of Periodontology and Oral Implantology, Temple University, Philadelphia, Pennsylvania.

†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, Pennsylvania.

‡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, Philadelphia, Pennsylvania.

 

References

 

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