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Management of Periodontal Inflammations

 

Historical medical records and studies in paleopathology reveal that gingivitis and periodontitis have long been an affliction in the history of mankind. These diseases remain among the most frequent ailments encountered, and they are often aggravated by host susceptibility, tobacco use, calculus, defective restorations, stress, and malnutrition. Associations between periodontal inflammations and systemic disorders underscore the importance of restoring periodontal health.

The presence of bacteria is essential to the initial development of gingivitis and periodontitis. Tissue destruction and tooth-attachment loss, however, result from factors produced by the host during the inflammatory response to biofilms and their products. Relevant host factors include matrix-metalloproteinases (MMPs)—which break down peri-cellular and basement-membrane components of soft connective tissues—and prostaglandins, particularly prostaglandin E2- activating osteoclasts, which facilitate bone destruction. 

The primary objective of current therapeutic and preventive strategies is to eliminate plaque, calculus, and endotoxins from root surfaces using both nonsurgical and surgical approaches.

 

Nonsurgical Approach

Nonsurgical protocols (eg, oral hygiene instruction, removal of local factors) usually eliminate the symptoms of gingivitis. If the resulting improvements are inadequate, scaling and root planing (SRP) or periodontal debridement(ie, phase-1 therapy) can be introduced to assist in the elimination of plaque and calculus, reducing bacterial populations below the threshold-levels critical for inflammation. Hand and ultrasonic instruments are equally effective in calculus removal.  Combining these two methods provides shorter treatment time (ie, via ultrasonic instrumentation) and superior tactile sensation (ie, via hand instruments). Use of a low-power, CO2 laser after hand instrumentation can significantly improve root-surface debridment,1 while diamond-coated scalers and ultrasonic inserts have shown promising results in calculus removal.2The effectiveness of SRP decreases as pocket depth increases; nevertheless, the procedure significantly ameliorates deeper pockets, especially when residual subgingival calculus can be visualized with a fiber-optic periodontal endoscope (Figure 1).3  

           

Surgical Approach

Surgical therapy treats the deep periodontal pockets that remain inflamed after SRP. Advantages of flap debridement (Figure 2) include superior access in the removal of etiologic factors, and possibilities for remodeling bone contours and/or regenerating intrabony defects. Longitudinal evaluations indicate that surgery is more effective than SRP alone in reducing the probing depths of deeper pockets and furcations.

(Continued from page 1 )

            

Pharmacological Approach

Pharmacological therapy advocates the use of oral medications as an adjunct to SRP and/or surgery. Local antibiotics (eg, tetracycline, doxycycline, monocycline, metronidazole, chlorhexidine) are placed directly in periodontal pockets, either via syringe or synthetic fibers (Figure 3). The natural flushing of crevicular fluid and difficulty in reaching the deepest parts of pockets endanger the efficacy of this method. Prior to initiating this treatment, a periodontist’s evaluation is recommended to determine its efficacy in a given case.4 Systemic antibiotics (eg, amoxicillin, azithromycin, ciprofloxacin, clindamycin, gentamycin, metronidazole) are commonly used drugs in the treatment of aggressive periodontitis.

Determining the appropriate drug for a given patient should be assessed only after bacterial tests and clinical evaluation have taken place. Clinical improvements are reported when drugs are administered orally.The possibility of creating bacterial resistance, the risk of gastric, hematological, neurological, and allergic side effects, and the lack of consensus on long-term planning, however, limit their routine use.5 Treatment with a submicrobial dose of doxycycline hyclate (ie, 20-mg tablets) inhibits the endogenous collagenases MMP-8 and MMP-9. Thus, in conjunction with SRP, this therapy can improve significantly the clinical outcome. Antibiotics are commonly used in dental practices also as a prophylaxis for endocarditis. Nonsteroidal anti-inflammatory drugs show promise in their ability to slow periodontitis, although further evaluations are needed for their application because of possible side effects including gastro-intestinal injury and cardiovascular disorders.6

 

Conclusion   

The combined use of patient education, SRP, antibacterial treatment, and surgery has great therapeutic potential. The onset of possible complications with recent protocols, however, emphasizes the need to unravel further the complex microbiological and immunological etiology of periodontal inflammations before novel clinical approaches can be successfully and routinely applied.

 

*Department of Periodontics,  University of Washington, Seattle, Washington; Department of Prosthodontics, School of Dentistry, Universitá  La Sapienza, Rome, Italy.

†Department of Periodontics, University of Washington, Seattle, Washington.

References

  1. Crespi R, Barone A, Covani U. Histologic evaluation of three methods of periodontal root surface treatment in humans. J Periodontol 2005;76(3):476-481.
  2. Yukna RA, Vastardis S, Mayer ET. Calculus removal with diamond-coated ultrasonic inserts in vitro. J Periodontol 2007;78(1):122-126.
  3. Geisinger ML, Mealey BL, Schoolfield J, Mellonig JT. The effectiveness of subgingival scaling and root planing: An evaluation of therapy with and without the use of the periodontal endoscope. J Periodontol 2007;78(1):22-28.
  4. Hanes PJ, Purvis JP. Local anti-infective therapy: Pharmacological agents. A systematic review. Ann Periodontol 2003;8(1):79-98.
  5. Hafajee AD, Socransky SS, Gunsolley JC. Systemic anti-infective periodontal therapy. A systematic review. Ann Periodontol 8(1):115-181.
  6. Sims PJ, Sims KM. Drug interactions important for periodontal therapy. Periodont 2000 2007;44(1):15-28.
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