Non-surgical Periodontal Treatment
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The primary goal of the periodontal treatment plan is to:
- Eliminate gingival inflammation.
- Correct the conditions that led to gingival inflammation.
- Eliminate pain if present.
- Arrest soft and hard-tissue deterioration.
- Re-establish occlusal form and function.
- Prevent further disease recurrence and tooth loss.
Treatment can be broken into “phases” according to priority:
- Preliminary/emergency phase – involves the removal of hopeless, severely compromised teeth.
- Phase I (nonsurgical) – therapy consists of caries control, removal of calculus and plaque, restoration repair, and the re-establishment of proper oral hygiene practices. Phase I therapy may also include local or systemic antimicrobial therapy or provisional splinting and stabilization. This is usually followed by a 4 week evaluation phase.
- Phase II (surgical) – therapy encompasses all surgical treatments, including implant placement and endodontic therapy.
- Phase III (restorative) – therapy includes placement of final prostheses and restorations.
- Phase IV (maintenance) – therapy includes periodic review of periodontal health.
Scaling and root planing describes the instrumentation of the coronal and root surfaces to remove plaque, calcified deposits, and rough cementum. Root planing involves the removal of irregularities on the root surface, leaving behind a clean, hard, smooth surface. The end result is a smooth and clean root surface. Scaling and root planing is the primary treatment for periodontal inflammation and is often the only treatment necessary. Instrumentation reduces the quantity of subgingival microorganisms and causes a shift in the microflora, from disease-causing gram-negative anaerobes to the more favorable gram-positive, facultative microorganisms. A reduction in the pathognomic bacteria like P. gingivalis, T. forsythia, and T. denticola would be indicative of success periodontal treatment. One week after proper treatment a reduction in pocket depths and a reduction in gingival inflammation should be evident.
Sickle scalers are used to remove supragingival calculus. They have a triangular cross-sectional shape, with two cutting edges and a pointed tip. Hoes, chisels, and file scalers can be used for removal of tenacious calculus. A periodontal curette is designed for atraumatic entry into the subgingival space in order to detect and remove calculus. They have a spoon-shaped blade with a semicircle cross-section, one or two cutting edges/working surfaces, and a rounded end. Universal curettes have two cutting edges and are designed to be used in any area of the mouth. Gracey curettes are site-specific and are designed to adapt to targeted tooth surfaces. Gracey curettes are mini-bladed curettes with a shorter, curvier blade designed to adapt more closely to the root surface.
- Gracey 1-2 and 3-4 – anterior teeth.
- Gracey 5-6 – anterior teeth and premolars.
- Gracey 7-8 and 9-10 – posterior teeth, both facial and lingual.
- Gracey 11-12 – posterior teeth, mesial surfaces only.
- Gracey 13-14 – posterior teeth, distal surfaces only.
Ultrasonic instruments are hand-held devices that convert electrical current into high-frequency mechanical vibrations (20,000-50,000 Hz). They are used for calculus, plaque and stain removal. Ultrasonic instruments should be used with caution when treating older patients with pacemakers since older-style cardiac pacemakers may not include adequate shielding. Sonic instruments vibrate at around 2000 to 8000 Hz.
Magnetostrictive ultrasonic scalers cause the scaler tip to vibrate in an elliptical pattern by converting energy to vibrations from the elliptical stroke patterns of the unit’s metal rod or stack of metal sheets. All sides of the magnetostrictive tip may be used for removing debris. Piezoelectric ultrasonic scalers cause the scaler tip to vibrate in a linear pattern via crystals activated by the ceramic handpiece. Piezo units require less water to control heat and will not interfere with cardiac pacemakers. Only the lateral sides are effective for removing debris.
Furcation treatment depends on the severity of the defects and may include:
- Localized antibiotics.
- Scaling and root planing.
- Surgical intervention to facilitate direct access.
- Bone grafting and/or guided tissue regeneration.
- Root resection/hemisection.
- Tooth extraction.
ACUTE NECROTIZING ULCERATIVE GINGIVITIS (ANUG)
Acute Necrotizing Ulcerative Gingivitis/Periodontitis (aka trench mouth or Vincent’s disease) is a distinct form of periodontal disease that has an acute clinical presentation characterized by the rapid onset of interdental gingival necrosis. There is often visible pseudomembrane formation on marginal tissues and the patient may present with gingival pain, bleeding, low grade fever, lymphadenopathy, generalized malaise, and halitosis (fetor oris). Necrotizing ulcerative gingivitis (NUG) does not exhibit attachment loss. Necrotizing ulcerative periodontitis (NUP) presents with attachment and bone loss. ANUG is primarily seen in adults between 18 and 30 and is more common in patients with a history of smoking, gingivitis, poor hygiene, stress, poor nutrition, or immunological deficiencies (e.g. HIV infection). It is not common to see ANUG in healthy adults.
Treatment of ANUG may start with the application of topical anesthetic, followed by the cleaning of necrotic gingiva to remove the pseudomembrane, the removal of plaque and calculus with ultrasonics (unless contraindicated), and hydrogen peroxide rinses. Systemic antibiotics (often Metronidazole) should only be prescribed if there is evidence of systemic disease (lymphadenopathy, fever etc). The patient is instructed to avoid alcohol and tobacco and to improve oral hygiene, which includes a daily rinse with chlorhexidine. Analgesics may be prescribed for pain.
ANTIBIOTICS
Since the primary cause of periodontal disease is bacteria and their byproducts, it makes sense that antibiotics can be part of the armamentarium for treatment. A variety of antibiotics have been utilized in combination with mechanical debridement, including metronidazole, tetracycline, doxycycline, and clindamycin. Combination therapies that show promise include amoxicillin-clavulanate (Augmentin), metronidazole-amoxicillin, and metronidazole-ciprofloxacin. However, antibiotics should not be used as a monotherapy or as a replacement for mechanical debridement. It is not good practice to prescribe bacteriostatic and bactericidal drugs simultaneously.
Tetracyclines are a class of antibiotics used to treat various infections. They are bacteriostatic, inhibiting protein synthesis by binding to the 30S ribosomal subunit in the susceptible organisms. Tetracyclines are often used for treating localized, aggressive (molar-incisor distribution) periodontitis, and are most effective against gram-positive bacteria. Tetracyclines inhibit Actinobacillus actinomycetemcomitans, and exert an anti-collagenolytic effect (inhibits collagen breakdown). Minocycline and doxycycline are semisynthetic tetracycline derivatives that can be used with localized delivery systems.
Metronidazole is a bactericidal antibiotic often used in conjunction with amoxicillin. It disrupts bacterial DNA and is most effective against anaerobic organisms. Patients taking metronidazole should avoid alcohol due to a possible disulfiram-like reaction, which may lead to severe cramps, nausea, and vomiting.
Penicillins are a bactericidal class of antibiotics. The extended spectrum penicillins like Amoxicillin are effective against both gram-positive and gram-negative microorganisms. They work by interfering with the synthesis of the bacterial cell wall by inhibiting transpeptidases. Penicillins are susceptible to penicillinase (β-lactamase), an enzyme that specifically breaks the β-lactam ring structure and inactivates the antibiotic. Amoxicillin is often combined with clavulanate potassium (Augmentin) to resist penicillinases. Amoxicillin is a semisynthetic penicillin.
Clindamycin is both bacteriostatic and bactericidal, inhibiting protein synthesis by binding to 50S ribosomal subunit. It is a broad-spectrum antibiotic that is effective against aerobic, anaerobic, and beta-lactamase-producing bacteria. Clindamycin exhibits high oral absorption, significant tissue and bone penetration, and stimulates the host’s immune system. It is most often used in patients who cannot tolerate penicillin. Clindamycin use has been associated with pseudomembranous colitis.
Macrolides are bacteriostatic or bactericidal depending on the concentration of the drug and the type of microorganism. They inhibit protein synthesis by binding to the 50 S ribosomal subunits of sensitive microorganisms. The macrolide antibiotics used for periodontal treatment include erythromycin, spiramycin, and azithromycin. Erythromycin is commonly used in patients who have a sensitivity to penicillin. Macrolides do not exhibit great tissue penetration and are not very effective against most periodontal bacteria, but azithromycin can be effective against anaerobic, gram-negative bacilli.
Chlorhexidine can be utilized in a resorbable gelatin matrix delivery system (PerioChip) placed subgingivally.
