Non surgical periodontal therapy.
Periodontal disease is the number one chronic infectious disease in the world. It is the leading cause of tooth loss, and begins as painless infection in the gums that is caused by buildup of bacterial plaque. Loe et al. in their classic study in 1965 established the relationship between plaque accumulation and development of gingivitis. (1) If left untreated the inflammation spreads to underlying tissues leading to periodontitis.
Numerous treatment modalities exist for the treatment of gingivitis and periodontitis depending on the extent and severity, but the primary objective is to restore the gingival health by removing the elements that provoke inflammation. Non-surgical periodontal therapy (NSPT) is the management of gingival infection with scaling, root planning, antibiotics and other non surgical means. These modalities can be implemented by a general dentist or periodontist. Many studies have shown high success rates with NSPT in successful treatment of mild to moderate periodontitis. (2)
Regular home care by the patient in addition to professional removal of plaque and calculus is generally very effective mode of NSPT, 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. (3)
Analysis of Egyptian hieroglyphics and medical papyri indicate that non-surgical periodontal treatment was common 3000-4000 years ago. The presence of bacterial deposits on teeth has been observed since the birth of microbiology but it has taken over 300 years to understand which elements of the various hard and soft dental deposits must be removed in order to arrest the destructive processes caused by the periodontal diseases. (4) Albucasis of Arabia in 10th century emphasized on the etiological role of calculus and designed several sets of instruments for performing scaling.
Anton van Leeuwenhoek first published drawings of oral bacteria and performed some anti plaque experiments. The 19th and 20th centuries saw major developments in diagnosis, patho-physiology and surgical and non-surgical treatment procedures for periodontal diseases. In the early 20th century Isadore Hirschfield strongly supported non surgical treatment modalities and published many papers in support. Now the recent trends in research and treatment outcomes are re emphasizing on the importance of NSPT.
DIFFERENT APPROACHES OF NSPT:
The various treatment modalities available in NSPT are:
Scaling and root planing have been shown to decrease gingival inflammation and bleeding on probing. (5) In areas with mild to moderate periodontitis, scaling and root planing resulted in reduced probing depth and improved clinical attachment levels when compared to supragingival plaque removal alone. (6,7,8)
Mechanical instrumentation has shown a shift in gingival microbial populations, with decrease in gram negative organisms and increase in gram positive rods and cocci associated with periodontal health. (9) But mechanical instrumentation was not effective in reducing levels of tissue penetrating bacteria, especially Actinobacillus actinomycetem comitans (10). But mechanical debridement has shown limited ability in areas with deeper pockets, underlying bony defects and in aggressive periodontitis.
The entry of ultrasonic instrumentation in periodontics have improved the patient compliance and decreased the time taken for thorough debridement. Several studies have shown similar results with both manual and ultrasonic instrumentation in terms of plaque, calculus and endotoxin removal. (7) However ultrasonic instrumentation when used on medium power settings has shown comparatively lesser root surface alteration and found to be more effective in furcation areas. (11)
SUPRA & SUB GINGIVAL IRRIGATION:
Supra and sub gingival irrigation are more effective in flushing out the bacteria and reducing gingivitis scores when compared to mouth rinses.
Subgingival irrigation penetrates much deeper in to the pocket and significant improvements in gingival health, when compared to supra gingival irrigation. (12)
Several irrigant solutions are tried viz. 0. 2% chlorhexidine digluconate, 0. 5% tetracycline, 0. 5% metronidazole, 0. 02% stannous fluoride and several other agents.
Scaling followed by gingival irrigation has shown better results when compared to either of the procedure alone.
The success of the gingival irrigation depends on the patient compliance and dexterity, irrigant used, and the design of the tip.
Nonsurgical scaling and root planing may remove or decrease the bacterial loads, but is frequently ineffective against Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Bacteroides forsythus, staphylococci and enteric rods. (13)
Mechanical debridement as ineffective against tissue penetrating organisms and other those inhabiting inaccessible areas. Though systemic antibiotics are not prescribed routinely in treatment of periodontitis, they are considered when the mechanical debridement fails to arrest the disease progression and tissue destruction, and in refractory and aggressive periodontitis cases. Commonly used antibiotics are Pencillin/amoxicillin, metronidazole, Tetracycline/doxycycline, Clindamycin, erythromycin etc.
The combination of 250 mg Amoxicillin and 200 mg metronidazole taken thrice daily for 8 days has shown to be highly effective in reducing Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis counts. (14)
Systemic antibiotics are not substitutes for proper mechanical debridement. (15) Currently no ideal antibiotic for the treatment of periodontal disease exists. Therefore, if indicated, microbial specificity, spectrum of the drug, possible interactions and adverse reactions of the drug are to be considered before prescribing.
LOCAL DRUG DELIVERY:
Systemic antibiotics when used for treating periodontal diseases have many negative effects like failure to reach the site, development of bacterial resistance, systemic side effects etc. So local delivery of the drug directly into the diseased site might eliminate these effects and allow higher dosages of the drug to be used at the specific sites and improve patient compliance. (16) Several of the systems using different drugs delivered in the form of gels, intments, fibres, impregnated chips, microspheres etc.
Some of the local drug delivery systems available commercially are
Drug Available Commercial form Name Tetracycline Non resorbable fibers Actisite [R] Metronidazole Gel Elyzol [R] Doxycycline hyclate Gel Atridox [R] Minocycline Microspheres Arestin [R] Minocycline Ointment Dentamycin [R] Chlorhexidine Resorbable Chip PerioChip [R]
Use of Local drug delivery alone has shown similar results to that of mechanical debridement.
But Local drug delivery when used as an adjunct to scaling and root planing showed better clinical results in terms of probing depth reduction and clinical attachment gain especially in non-responding sites or patients with recurrent disease who need an alternate treatment approach.
Loesche et al. concluded that systemic and local drug delivery used in conjunction with scaling and root planing was able to reduce the need for periodontal surgery. (17)
HOST MODULATION THERAPY:
Current research and clinical data available has shown that the periodontal tissue destruction is brought about by the plaque bacteria and their toxins, and the host's inflammation-immunity response to them. The host response which is genetically determined varies accordingly in different patients and determines the response to the periodontal infection. Susceptible patients show severe response to periodontal pathogens and deep pocketing inspite of proper plaque control. Host modulatory therapy (HMT) aims at modulation of host response to bring down the destruction levels. Various host modulatory agents which are available are subantimicrobial dose Doxycycline, Bisphosphonates, Anti-inflammatory drugs, Enamel matrix derivatives and growth factors.
Non surgical periodontal therapy is as effective as the surgical therapy if correctly performed in indicated patients. 18 Carefully choosing the patient and employing the correct form of therapy helps in high success levels of NSPT. The importance of NSPT lies in the fact that it can be performed successfully by a regular dentist who is well educated. This helps in reducing and treating the periodontal disease in areas where a periodontist is not available.
(1.) Loe H, Theilade E, Jensen SB. Experimental gingivitis in man. J Periodontal 1965; 36:177-187.
(2.) Greenstein G. Non surgical periodontal therapy in 2000: a literature review. J Am Dent Assoc 2000; 131:1580-1592.
(3.) Drisko C. Nonsurgical periodontal therapy: Periodontol 2000 2001;37:77-88.
(4.) Greene PR. Non-surgical periodontal therapy: Essential and adjunctive methods. Br Dent J 1995 Jul 8; 179(1):28-34.
(5.) Caton J, Bouwsma O, Polson A, Epseland M. Effect of personal oral hygiene and subgingival scaling on bleeding interdental gingiva. J Periodontol 1989; 60:84-90.
(6.) Badersten A, Nilveus R, Egelberg J. Effect of non-surgical periodontal therapy. I. Moderately advanced periodontitis. J Clin Periodontol 1981; 8:57-72.
(7.) Cobb Cm, non surgical pocket therapy: Mechanical. Ann Periodontol 1996;1:443-490.
(8.) Cercek JF, Kiger RD, Garret S, Egelberg J. Relative effects of plaque control and instrumentation on the clinical parameters of human periodontal disease. J Clin Periodontol 1983; 10:46-56.
(9.) Greenstein G. Periodontal Response to Mechanical NonSurgical Therapy: A Review. J periodontal 1992; 2: 118-130.
(10.) Renvert S, Wikstrom M, Dahlen G, Slots J, Egelberg J. Effect of root debridement on the elimination of Actinobacillus actinomycetemcomitans and Bacteroides gingivalis from periodontal pockets. J Clin Periodontol 1990; 17:345-350.
(11.) Leon L, Vogel R. A comparison of the effectiveness of hand scaling and ultrasonic debridement in furcations as evaluated by differential darkfield microscopy. J Periodontol 1987; 58:86-94.
(12.) Braun RE, Ciancio SG. Subgingival delivery by an oral irrigation device. J Periodontol 1992; 63:469.
(13.) Mombelli A, Schmid B, Rutar A, Lang NP. Persistence patte rns of Porphyromonas gingivalis, Prevotella intermedia/nigrescens, and Actinobacillus actinomycetemcomitans after mechanical therapy of periodontal disease. J Periodontol2000: 71: 14-21.
(14.) Haffajee AD et al. Systemic anti infective periodontal therapy: a systemic review. Ann Periodontol 2003; 8:115.
(15.) Slots J, Ting M. Systemic antiobiotics in periodontal therapy. Periodontol 2000 2002; 28:106-176.
(16.) Greenstein G, Polson A. The role of local drug delivery in the management of periodontal diseases. A comprehensive review. J Periodontal 1998; 69:507-520.
(17.) Loesche W, Giordano J, Soehren S, Hutchinson R, Rau CF, et al. Nonsurgical treatment of patients with periodontal disease. Oral Surg Oral Med Oral Pathol 1996; 81:533-543.
(18.) Greene PR. Non-surgical periodontal therapy: Essential and adjunctive methods. Br Dent J 1995; 179(1):28-33.
Rajababu P , Harinath Reddy S , Satyanarayana D , Sunil Kumar P 
Dept of Periodontics Kamineni Institute of Dental Sciences, Narketpally, Andhra Pradesh, India
Professor & HOD 
Senior Lecturer 
Received: 8th July, 2009
Review Completed: 14th August, 2009
Accepted: 14th September, 2009
Available Online: 18th January, 2010
Email for correspondence: firstname.lastname@example.org
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|Author:||Rajababu, P.; Harinath, Reddy S.; Satyanarayana, D.; Sunil, Kumar P.|
|Publication:||Indian Journal of Dental Advancements|
|Date:||Oct 1, 2009|
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