Nonsurgical periodontal therapy.

Regular home care by the patient in addition to professional removal of subgingival plaque is generally very effective in controlling most inflammatory periodontal diseases. When disease does recur, despite frequent recall, it can usually be attributed to lack of sufficient supragingival and subgingival plaque control or to other risk factors that influence host response, such as diabetes or smoking. Causative factors contributing to recurrent disease include deep inaccessible pockets, overhangs, poor crown margins and plaque-retentive calculus. In most cases, simply performing a thorough periodontal debridement under local anesthesia will stop disease progression and result in improvement in the clinical signs and symptoms of active disease. If however, clinical signs of disease activity persist following thorough mechanical therapy, such as increased pocket depths, loss of attachment and bleeding on probing, other pharmacotherapeutic therapies should be considered. Augmenting scaling and root planing or maintenance visits with adjunctive chemotherapeutic agents for controlling plaque and gingivitis could be as simple as placing the patient on an antimicrobial mouthrinse and/or toothpaste with agents such as fluorides, chlorhexidine or triclosan, to name a few. Since supragingival plaque reappears within hours or days after its removal, it is important that patients have access to effective alternative chemotherapeutic products that could help them achieve adequate supragingival plaque control. Recent studies, for example, have documented the positive effect of triclosan toothpaste on the long-term maintenance of both gingivitis and periodontitis patients. Daily irrigation with a powered irrigation device, with or without an antimicrobial agent, is also useful for decreasing the inflammation associated with gingivitis and periodontitis. Clinically significant changes in probing depths and attachment levels are not usually expected with irrigation alone. Recent reports, however, would indicate that, when daily irrigation with water was added to a regular oral hygiene home regimen, a significant reduction in probing depth, bleeding on probing and Gingival Index was observed. A significant reduction in cytokine levels (interleukin-1beta and prostaglandin E2, which are associated with destructive changes in inflamed tissues and bone resorption also occurs. If patient-applied antimicrobial therapy is insufficient in preventing, arresting, or reversing the disease progression, then professionally applied antimicrobial agents should be considered including sustained local drug delivery products. Other, more broadly based pharmacotherapeutic agents may be indicated for multiple failing sites. Such agents would include systemic antibiotics or host modulating drugs used in conjunction with periodontal debridement. More aggressive types of juvenile periodontitis or severe rapidly advancing adult periodontitis usually require a combination of surgical intervention in conjunction with systemic antibiotics and generally are not controlled with nonsurgical anti-infective therapy alone. It should be noted, however, that, to date, no home care products or devices currently available can completely control or eliminate the pathogenic plaques associated with periodontal diseases for extended periods of time. Daily home care and frequent recall are still paramount for long-term success. Nonsurgical therapy remains the cornerstone of periodontal treatment. Attention to detail, patient compliance and proper selection of adjunctive antimicrobial agents for sustained plaque control are important elements in achieving successful long-term results. Frequent re-evaluation and careful monitoring allows the practitioner the opportunity to intervene early in the disease state, to reverse or arrest the progression of periodontal disease with meticulous nonsurgical anti-infective therapy.

Treatment of periodontitis by local administration of minocycline microspheres: a controlled trial.

BACKGROUND: Periodontitis is an inflammatory condition of tooth-supporting tissues that is usually treated by mechanical removal of plaque and microorganisms that adhere to teeth. This treatment, known as scaling and root planing, is not optimally effective. Adjunctive therapy with locally delivered antimicrobials has resulted in improved clinical outcomes such as probing depth reduction. This article reports on the efficacy and safety of locally administered microencapsulated minocycline. METHODS: Seven hundred forty-eight (748) patients with moderate to advanced periodontitis were enrolled in a multi-center trial and randomized to 1 of 3 treatment arms: 1) scaling and root planing (SRP) alone; 2) SRP plus vehicle; or 3) SRP plus minocycline microspheres. The primary outcome measure was probing depth reduction at 9 months. Clinical assessments were performed at baseline and 1, 3, 6, and 9 months. RESULTS: Minocycline microspheres plus scaling and root planing provided substantially more probing depth reduction than either SRP alone or SRP plus vehicle. The difference reached statistical significance after the first month and was maintained throughout the trial. The improved outcome was observed to be independent of patients' smoking status, age, gender, or baseline disease level. There was no difference in the incidence of adverse effects among treatment groups. CONCLUSIONS: Scaling and root planing plus minocycline microspheres is more effective than scaling and root planing alone in reducing probing depths in periodontitis patients.

Trends in surgical and nonsurgical periodontal treatment.

BACKGROUND: New research is demonstrating that a person's total health is indeed related to his or her oral health. Elimination of all oral infections, including gingivitis and periodontis, is important to overall health. CLINICAL IMPLICATIONS: This article reviews recent evidence on the systemic and oral connection and discusses these findings as they relate to patient care. The article examines trends in nonsurgical and surgical therapy that will successfully arrest periodontal infections. Opportunities for early diagnosis and prevention will play an increasing role in dental practice in the future as patients understand the importance of oral health to overall health.

The effect of locally delivered controlled-release doxycycline or scaling and root planing on periodontal maintenance patients over 9 months.

BACKGROUND: This research report evaluates clinical changes resulting from local delivery of doxycycline hyclate (DH) or traditional scaling and root planing (SRP) in a group of patients undergoing supportive periodontal therapy (SPT). METHODS: In all, 141 patients received either DH (67) or SRP (74) treatment in sites > or =5 mm on one-half of their dentition at baseline and month 4. RESULTS: Clinical results were determined at month 9. Baseline mean probing depth recordings were similar between the two groups (DH = 5.9 mm; SRP = 5.9 mm). Mean month 9 results showed similar clinical results for attachment level gain (DH 0.7 mm; SRP 0.8 mm) and probing depth reduction (DH 1.3 mm; SRP 1.1 mm). Percentage of sites showing > or =2 mm attachment level gain at month 9 was 24.7% in the DH group and 21.2% in the SRP group. Thirty-nine percent (39%) of DH sites and 38% of SRP sites showed > or =2 mm probing depth reduction. When treated sides of the dentition were compared to untreated sides, DH showed a difference in disease activity (> or =2 mm attachment loss) from 19.3% (untreated) to 7.2% (treated); and SRP from 14.3% (untreated) to 8.1% (treated). CONCLUSIONS: Results show that both DH without concomitant mechanical instrumentation and SRP were equally effective as SPT in this patient group over the 9-month study period.

Initial preparation: anti-infective therapy.

The primary aim of anti-infective therapy is to eliminate or reduce the subgingival plaque and to arrest tissue breakdown associated with chronic or progressive periodontitis. Four to six weeks following anti-infective therapy, initial healing is usually complete, and the clinical status should be re-evaluated. After assessing the reduction in probing depths, bleeding on probing and clinical attachment levels, the clinician must decide whether the anti-infective therapy has arrested the disease. If it is determined that maximum healing has occurred, the initial phase of therapy is complete, and the patient is placed into the maintenance program. In sites that remain > or = 6 mm following anti-infective therapy, surgical debridement may be indicated to increase visualization of the roots for deposit removal because the evidence points to better calculus removal in an open versus closed environment. During surgical root preparation, fine diamonds or finishing burs produce the smoothest root surface followed by manual and power-driven scalers. Endoscopic cameras that enable the clinician to see subgingival calculus without benefit of surgical access may prove to be a valuable diagnostic tool for sites that do not respond to therapy. Diamond-coated ultrasonic inserts are available from some manufacturers and have been shown to be efficient and effective in surgical root preparation. New designs and finer grits may enable clinicians to use these instruments in nonsurgical applications in the future. Finally, new evidence from one group in Belgium has shown that significantly more attachment gain and probing depth reduction is achieved when scaling and root planing is done in one or two visits within 24 hours compared with the traditional method of scaling quadrant by quadrant over four visits. These preliminary results need to be confirmed by others but hold a great deal of promise for improving the outcomes from nonsurgical root preparation in the future.

Two multi-center studies evaluating locally delivered doxycycline hyclate, placebo control, oral hygiene, and scaling and root planing in the treatment of periodontitis.

BACKGROUND: The clinical efficacy and safety of doxycycline hyclate (8.5% w/w) delivered subgingivally in a biodegradable polymer (DH) was compared to placebo control (VC), oral hygiene (OH), and scaling and root planing (SRP) in 2 multi-center studies. METHODS: Each study entered 411 patients who demonstrated moderate to severe periodontitis. Patients had 2 or more quadrants each with a minimum of 4 qualifying pockets > or =5 mm that bled on probing. At least 2 of the pockets were > or =7 mm. Treatment with DH, VC, OH, or SRP was provided at baseline and again at month 4. Clinical parameters were recorded monthly. RESULTS: DH and SRP resulted in nearly identical clinical changes over time in both studies. Mean 9 month clinical attachment level gain (ALG) was 0.8 mm for the DH group and 0.7 mm for the SRP group in Study 1, and 0.8 mm (DH) and 0.9 mm (SRP) in Study 2. Mean probing depth (PD) reduction was 1.1 mm for the DH group and 0.9 mm for the SRP group in Study 1 and 1.3 mm for both groups in Study 2. Frequency distributions showed an ALG > or =2 mm in 29% of DH sites versus 27% of SRP sites in Study 1 and 31% of DH sites versus 34% of SRP sites in Study 2. PD reductions > or =2 mm were seen in 32% of DH sites versus 31% of SRP sites in Study 1 and 41% of DH sites versus 43% of SRP sites in Study 2. Comparisons between DH, VC, and OH treatment groups showed DH treatment to be statistically superior to VC and OH. Safety data demonstrated a benign safety profile with use of the DH product. CONCLUSIONS: Results of this trial demonstrate that treatment of periodontitis with subgingivally delivered doxycycline in a biodegradable polymer is equally effective as scaling and root planing and superior in effect to placebo control and oral hygiene in reducing the clinical signs of adult periodontitis over a 9-month period. This represents positive changes resulting from the use of subgingivally applied doxycycline as scaling and root planing was not limited regarding time of the procedure or use of local anesthesia.

Root coverage using Alloderm acellular dermal graft material.

This report describes a surgical technique for root coverage using an acellular dermal graft material and a coronally positioned flap. Video clips of a root coverage surgery are included using the graft material to cover multiple teeth in the same quadrant. Three additional completed cases are presented in which a mean root coverage of 97% was achieved, resulting in 100% coverage on 9 of 11 teeth. The results from this case series conform with the available evidence on the use of acellular dermal graft material in root coverage procedures.

The use of locally delivered doxycycline in the treatment of periodontitis. Clinical results.

The clinical safety and effectiveness of a subgingivally delivered biodegradable drug delivery system containing doxycycline hyclate (DH) has been evaluated in 3 large 9-month multicenter randomized parallel-design controlled clinical trials. A total of 1002 patients having at least 2 quadrants with a minimum of 4 qualifying pockets > or = 5 mm that bled on probing were enrolled. Each subject had > or = 7 mm probing depths in 2 of the qualifying pockets. Study 1 (n=180) compared DH to sanguinarine chloride (SC) and vehicle control (VC). Study 2 (n=411) and study 3 (n=411) compared DH to VC, scaling and root planing (SRP), and oral hygiene (OH). Clinical measurements included probing depth reduction (PDR), attachment level gain (ALG), bleeding on probing reduction (BOP) and plaque index (PI). Analysis of efficacy data from these 3 trials show all treatments gave significant positive clinical changes from baseline at most time points. Study 1 results indicate that DH was superior to SC and VC in PDR at all time points. Similar results were obtained for ALG when DH was compared to SC and VC. For BOP reductions, DH was superior to VC at all time points and to SC at months 5 through 9. For DH, mean ALG in deep (> or = 7 mm) pockets was 1.4 mm; mean PDR for DH was 2.6 mm. For moderate (5 to 6 mm) pockets, ALG was 0.8 mm and PDR 1.5 mm. Studies 2 and 3 reported mean month 9 ALG for SRP as 0.7 mm and 0.8 mm, respectively. For DH, ALG was 0.8 mm in both studies 2 and 3. At month 9 in studies 2 and 3, 29% and 31% of DH sites and 27% and 34% of SRP sites showed ALG > or = 2 mm. Probing depth reductions followed the same pattern, with 32% of DH sites and 32% of SRP sites showing > or = 2 mm PD reductions in study 2, and 41% of DH and 43% of SRP sites showing PDR of > or = 2 mm in study 3. Comparisons between DH, VC, and OH treatment groups in studies 2 and 3 showed DH treatment was statistically superior to VC and OH at most time points. Results of these 3 large clinical trials demonstrate that treatment of periodontitis with 10% doxycyline hyclate in a bioabsorbable delivery system is equally as effective as SRP and superior in effect to VC and OH in reducing the clinical signs of adult periodontitis.

Root instrumentation. Power-driven versus manual scalers, which one?

The literature is clear that periodontal therapies aimed at altering the progression of inflammatory periodontal diseases must include meticulous subgingival mechanical débridement during both the nonsurgical and the surgical phases of treatment as the basis of most anti-infective therapy. In the past, infection control was achieved by the mechanical removal of subgingival deposits of plaque, calculus, and endotoxin with curets, files, and hoes. Historically, it was also generally agreed that aggressive scaling and root planing with hand instruments was necessary to remove tenacious calculus deposits to produce roots as smooth as possible for removal of the endotoxins previously thought to be deeply embedded into the root surfaces. Based on current evidence in the literature, it is now known that endotoxin is a weakly adherent surface phenomenon and that sonic and ultrasonic (power-driven) instruments can be used to accomplish definitive root detoxification and maximal wound healing without overinstrumentation of root and without extensive cementum removal. Power-driven scalers may have unique advantages because of the cavitational activity associated with ultrasonics thought to supplement removal of root surface plaques. In addition, the constant flushing activity of the lavage used to cool the tips results in disruption of the unattached and weakly attached subgingival plaques. The ability to flush the pocket during subgingival instrumentation with water or other chemical irrigating solutions is unique to ultrasonic and sonic scalers and has been shown to enhance pocket depth reduction and gain in clinical attachment beyond that achieved with hand scaling. The added benefit of chemical lavage during ultrasonic instrumentation shows great promise and may enhance the overall effect of nonsurgical anti-infective periodontal therapy. Other major advantages of power-driven scalers may include better access to difficult areas, such as deep narrow defects, root grooves, and furcations, using newly designed microultrasonic tips, which are smaller in diameter and able to penetrate the pocket approximately 1 mm farther than hand instruments. Taken together, it appears that use of ultrasonic or sonic scalers for periodontal débridement will result in improvements in clinical and microbial parameters at a level equal to or superior to hand scalers.

Multi-center comparative evaluation of subgingivally delivered sanguinarine and doxycycline in the treatment of periodontitis. II. Clinical results.

The clinical safety and effectiveness of a subgingivally delivered biodegradable drug delivery system containing either 10% doxycycline hyclate (DH), 5% sanguinarium chloride (SC) or no agent (VC) was evaluated in a 9-month multi-center trial. The study was a randomized parallel design with 180 patients who demonstrated moderate to severe periodontitis. All patients had at least two quadrants with a minimum of four qualifying pockets > or = 5 mm that bled on probing. Two of the qualifying pockets were required to be > or = 7 mm. At baseline and at 4 months all qualified sites were treated with the test article administered via syringe. Probing depth reduction (PDR), attachment level gain (ALG), bleeding on probing reduction (BOP), and plaque index were determined monthly. Analysis of efficacy data from the 173 efficacy-evaluable patients indicated that all treatments gave significant positive clinical changes from baseline at all subsequent timepoints. DH was superior to SC and VC in PDR at all timepoints (P < or = 0.01 to 0.001) with a maximum reduction of 2.0 mm at 5 months. For ALG, DH was superior to VC at months 2, 3, 4, 5, 6, 8, and 9 (P < or = 0.04 to 0.002) and superior to SC at months 5, 6, 7, 8, and 9 (P < or = 0.01 to 0.001) with a maximum ALG of 1.2 mm at 6 months. For BOP reduction, DH was superior to VC at all time points (P < or = 0.05) and to SC at months 3, 5, 6, 8, and 9 (P < or = 0.03). For DH, the maximum ALG in deep (> or = 7 mm) pockets was 1.7 mm and PDR 2.9 mm compared to 0.8 mm and 1.6 mm, respectively for moderate (5 to 6 mm) pockets. Test articles were applied without anesthesia and no serious adverse events occurred in the trial. The results of this study indicate that 10% doxycycline hyclate delivered in a biodegradable delivery system is an effective means of reducing the clinical signs of adult periodontitis and exhibits a benign safety profile.