JADA Continuing Education
NONSURGICAL PERIODONTAL THERAPY IN 2000: A LITERATURE REVIEW
GARY GREENSTEIN, D.D.S., M.S.
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ABSTRACT
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Background. This article addresses the advantages and limitations of nonsurgical periodontal therapies to treat patients with mild-to-moderate chronic periodontitis.
Types of Studies Reviewed. Controlled clinical trials were selected that assessed the efficacy of the following treatment methods: mechanical instrumentation, ultrasonic débridement, supragingival irrigation, subgingival irrigation, local drug delivery, administration of systemic antibiotics and host-response modulation. Evidentiary data with regard to alterations of probing depth, clinical attachment levels and inflammatory status were evaluated.
Results. Comparison of the data from test and control groups revealed the following results. Manual and ultrasonic débridement can be used to treat most patients with mild-to-moderate chronic periodontitis. Patients who do not practice optimal plaque control can enhance their personal hygiene procedures by using supragingival irrigation. Subgingival irrigation usually does not provide any benefit beyond that achieved with root planing. Systemic and locally delivered antimicrobial agents appear to be most beneficial among patients who do not respond to conventional treatment. Host modulation may enhance root planing modestly.
Clinical Implications. The data indicate that most patients with mild-to-moderate periodontitis can be treated with nonsurgical therapies. However, clinicians need to be aware of the limitations of each technique with regard to the magnitude of improvement that it can induce at specific sites.
In this new millennium, an increasing percentage of the population will seek periodontal care. This will occur because of several reasons: patients are becoming more aware of the benefits of periodontal therapy, clinicians have received increased training in the diagnosis and management of periodontal conditions, and the U.S. population is aging. The majority of patients with periodontitis will be treated by general practitioners using a variety of therapies. In this regard, numerous studies have addressed the utility of nonsurgical procedures to provide definitive treatment for patients with mild-to-moderate periodontitis.
The intent of this article is to review results achieved with various treatment methods: mechanical instrumentation, ultrasonic débridement, supragingival irrigation, subgingival irrigation, local drug delivery, systemic antibiotics and host-response modulation. The benefits and limitations of each technique will be addressed. This discussion will be preceded by a description of the new classification of periodontal diseases and alteration of the paradigm concerning periodontal disease pathogenesis, since they may affect the selection of treatment methods.
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PREVALENCE AND CLASSIFICATION OF PERIODONTAL DISEASES
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Approximately 50 percent of the U.S. population manifests gingivitis that includes inflammation on at least six teeth.1 Researchers recognize that gingivitis usually does not proceed to periodontitis; however, gingivitis frequently precedes periodontitis and usually is associated with periodontitis.2 Therefore, elimination of all inflammation remains a critical objective of periodontal therapy.3 This fact is underscored by the finding that the absence of inflammation is a negative predictor of clinical attachment loss.4
In 1999, the International Workshop for a Classification of Periodontal Diseases and Conditions reclassified periodontal diseases, and this reclassification has been adopted by the American Academy of Periodontology.5 The workshop participants noted that gingivitis could be associated with dental plaque and be modified by systemic factors and medications, and that there are non–plaque-induced gingival lesions (Table 1
).5 According to the new classification system, adult periodontitis is now referred to as chronic periodontitis (Table 1),5 and it affects about 30 percent of the population.1 If a 5-millimeter or greater loss of clinical attachment at one or more sites is used to define a patient as having severe chronic periodontitis, then about 10 percent of the population has advanced disease.6–10 The workshop participants created another distinct category that delineated periodontitis as a manifestation of systemic diseases (Table 1).5
Before the workshop, the term "early-onset periodontitis" was used to denote either juvenile periodontitis (localized and generalized forms), rapid progressive periodontitis or prepubertal periodontitis. Juvenile periodontitis (localized and generalized forms) is now referred to as aggressive periodontitis (localized and generalized forms) (Table 1
).5 Rapidly progressive periodontitis has been deleted as a separate disease category, since any form of periodontitis can progress at a rapid rate under certain circumstances. Furthermore, the workshop participants recognized that the formerly used disease category of prepubertal periodontitis represented a heterogeneous group. Many patients who once were included in this category actually had a systemic disease with periodontal manifestations. Under the new classification system, such patients would fit into the category of "periodontitis as a manifestation of systemic disease."5 Systemically healthy pre-pubertal children might have chronic or aggressive periodontitis, depending on a variety of factors.5
The classification of refractory periodontitis was eliminated as a separate disease entity. Therefore, a patient with chronic or aggressive periodontitis who does not respond to therapy would be considered to be refractory to treatment, but would be categorized as having either chronic or aggressive periodontitis.5 An additional new category was designated as necrotizing periodontal diseases, which includes necrotizing ulcerative gingivitis and necrotizing ulcerative periodontitis (Table 1).5
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PATHOGENESIS OF PERIODONTITIS
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Historically, the dental community assumed that bacteria were directly responsible for release of enzymes and toxins that destroyed the periodontium. At present, it is believed that if the microbial challenge is not contained by neutrophils and other cells, the host response results in a cascade of events that culminate in connective-tissue and alveolar bone loss (Figure).11 This sequence of events often is initiated when gram-negative bacteria shed vesicles containing lipopolysaccharides that stimulate the release of cytokines. Cytokines are inflammatory mediators, which are secreted by a variety of mononuclear cells (for example, monocytes, macrophages). The cytokines activate normal cells, such as fibroblasts and epithelial cells, that subsequently produce prostaglandins (for example, PGE2) and matrix metalloproteinases (for example, collagenase). Prostaglandins can induce alveolar bone resorption, and matrix metalloproteinases can destroy connective tissue. In addition, other proinflammatory mediators (for example, interleukin-1ß and tumor necrosis factor-
) are involved in degradation of the periodontium.11 Therefore, we can conclude that the host response can be both protective and destructive.
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Figure. Model of disease pathogenesis.11 Adapted with permission of Quintessence Publishing Co. Inc. from Greenstein and Lamster.121
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Although periodontitis consists of a family of diseases, these diseases do share a common histopathology, manifest similar signs of disease and usually respond to conventional therapy. The clinical severity of defects caused by periodontal diseases is influenced by several factors: virulent pathogens must reach a critical threshold and overwhelm the host response, and environmental factors (such as smoking) and acquired factors (such as diabetes) can affect the clinical signs of disease and the magnitude of periodontal destruction.12 In addition, there may be a genetic component associated with susceptibility to periodontitis.13,14
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MECHANICAL HAND INSTRUMENTATION
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Mechanical instrumentation of roots using curets is an effective treatment for patients with mild-to-moderate periodontitis (that is, clinical attachment loss of less than 5 mm).15,16 Numerous studies have supported the contention that root planing can reduce probing depths, gain clinical attachment and inhibit disease progression.15,16 An increase of clinical attachment refers to new connective-tissue attachment (that is, new periodontal fibers inserting into the cementum) or formation of a long junctional epithelium (repair). Usually, the latter occurs.
In a thorough evidence-based review, Cobb16 calculated the mean probing depth reduction and gain of clinical attachment that can be achieved with root planing at sites that initially were 4 to 6 mm in depth and 7 mm or greater in depth. He reported mean pocket depth reductions of 1.29 mm and 2.16 mm, respectively, and mean gains of clinical attachment of 0.55 mm and 1.29 mm, respectively.16 In that review, probing depth reduction usually was greater at sites with larger initial probing depths. The decrease in probing depth consisted of two components: gain of clinical attachment and recession. As a rule of thumb, clinicians can expect the gain of clinical attachment to be about half the probing depth reduction.
In general, clinicians should assess healing four to six weeks after performing root planing.17 Usually, recession of the gingival margin is followed by a gain of clinical attachment.18 After six weeks, most of the healing has occurred, but repair can continue for an additional nine months.19
Before using nonsurgical methods to treat patients with periodontal disease, clinicians must carefully interpret the data from clinical trials, because they may not reflect patient care in diverse practice settings or treatment of patients with severe periodontitis.20 For instance, in university-conducted clinical trials, 10 minutes per tooth was often used for root planing and the procedure was performed by highly proficient clinicians.15,20 Therefore, dentists should not assume that results reported in clinical trials are routine findings, because procedures performed in clinical practice settings may be less thorough than those performed in clinical trials. Furthermore, clinical trials—which often have been cited to show that nonsurgical and surgical therapy achieved equivalent results—usually did not provide a fair comparison with respect to the efficacy of treatment techniques at probing sites that were greater than 6 mm in depth. In this regard, Hujoel and colleagues21 assessed 10 studies to determine if the statistical tests used had the power to evaluate differences between nonsurgical and surgical therapy. They reported that there was only a 14 percent chance of achieving a fair assessment, because too few deep sites were included in the investigations.
Additional data supporting the efficacy of root planing can be found in several large clinical trials that compared the efficacy of local drug delivery with that of root planing. They reported that the mean reduction of probing depth after root planing was around 1 mm (Table 2).22–25 A decrease in the amount of total time used for root planing in these studies probably could account for the diminished results when compared with the classic root planing studies.
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TABLE 2 COMPARISON OF PROBING DEPTH REDUCTION FROM SEVERAL LARGE CLINICAL TRIALS (N > 100) USING LOCAL DRUG DELIVERY.*
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Clinicians need to consider other factors as well when contemplating treating patients with nonsurgical therapy, including the efficacy of subgingival accretion removal, predictability of bone fill in an angular osseous defect and bacterial suppression. Numerous studies have indicated that the predictability of removing sub-gingival deposits decreases with increasing probing depth.26,27 For example, Caffesse and colleagues26 demonstrated that when pockets exceeded 5 mm, clinicians often failed to adequately débride root surfaces and removed deposits completely only 32 percent of the time. With respect to the treatment of angular osseous defects, Cobb16 found that limited bone fill occurred subsequent to root planing. In contrast, Laurell and colleagues28 found that more bone was deposited after open débridement with bone grafting or guided tissue regeneration procedures.
Nonsurgical therapy also is not effective in suppressing Actinobacillus actinomycetemcomitans.29 This is because the bacterium is tissue-invasive. Therefore, for patients suspected of being infected with A. actinomycetemcomitans (for example, patients with aggressive periodontitis or patients who do not respond to conventional therapy), it might be necessary to perform a microbiological test to determine the appropriate antibiotic or antibiotics to be administered.
Mechanical therapy is effective for the majority of patients with mild-to-moderate chronic periodontitis.
Mechanical therapy is effective for the majority of patients with mild-to-moderate chronic periodontitis. However, before selecting a definitive treatment method, clinicians need to consider the severity of the periodontal condition, as defined in the new classification system (Table 1), as well as the magnitude of the probing depths, which may preclude meticulous débridement of the root surfaces. Dentists also need to determine the desired outcomes for each patient and evaluate the potential of mechanical instrumentation to achieve these results. In general, mechanical instrumentation has been successful in stabilizing clinical attachment levels for most patients with mild-to-moderate periodontitis. However, if bone fill or major probing depth reductions are desired outcomes, then surgical procedures may be needed. Most important, after patients are successfully treated, either nonsurgically or surgically, they need to be monitored and reevaluated periodically to determine if disease progression has occurred.
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ULTRASONIC DÉBRIDEMENT
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The term "ultrasonic débridement" refers to the removal of root-surface accretions with a vibrating mechanical device. Its purpose is to resolve inflammation in the adjacent soft tissues.30 This procedure differs from root planing, which involves removal of root accretions and cementum down to a smooth hard surface. Numerous studies have shown that ultrasonic periodontal débridement has achieved similar results to those achieved with scaling and root planing with respect to probing depth reduction, gain of clinical attachment and decreased clinical inflammation.31–34 For example, at sites initially manifesting probing depths greater than 4 mm, the mean probing depth reduction ranged from 1.20 to 2.3 mm after root planing, and from 1.70 to 1.9 mm after ultrasonic débridement.31–34 Ultrasonic débridement accomplished this without overinstrumentation of the roots, which can cause dentinal hypersensitivity. Furthermore, ultrasonic débridement may result in less chair time and operator fatigue than does manual instrumentation.35,36 On the other hand, root planing attains a smoother root surface at the microscopic level than does ultrasonic débridement, but the difference does not appear to have any clinical significance.37,38
Investigations assessing the use of medicaments delivered via ultrasonic instruments have had mixed results.39–42 Most studies have reported no benefit from using chlorhexidine as an irrigant.39,40 However, other studies have noted an improved result when povidone iodine, or PVP-I (for example, Betadine, Purdue Frederick) is used at deep sites (
7 mm).41,42 PVP-I is sold commercially as a 10 percent concentration, and one-tenth of that is iodine.43 To reduce the staining and bad taste of this antiseptic, clinicians can dilute it by using three parts water to one part PVP-I. This will result in a 0.25 percent iodine concentration, which is the minimal bactericidal concentration needed to kill Porphyromonas gingivalis in five minutes.44
One problem associated with ultrasonic instrumentation is the development of aerosols that contain blood and bacteria.45,46 Aerosols develop within several feet of the operator and remain in the air for approximately 30 minutes. Consequently, clinicians should wear a mask,47,48 use high-speed suction49,50 and ask patients to use a preprocedural rinse to reduce the amount of bacteria in their saliva.51,52 Overall, the use of ultrasonic devices or microultrasonic tips (
0.5 mm wide) is as effective as scaling and root planing. The addition of medicaments as irrigants in deep probing depths may provide some benefit.
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SUPRAGINGIVAL IRRIGATION
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During the early 1980s, there was doubt in the dental community as to whether supragingival irrigation provided any benefit beyond that of toothbrushing in the control of plaque and gingivitis. Since then, six well-designed studies have indicated that supragingival irrigation enhanced the effects of toothbrushing and reduced gingival inflammation in patients who did not perform good oral hygiene.53–58 The additional reduction in gingival inflammation ranged from 6.5 to 54.0 percent (Table 3).53–58 This occurred because of a decreased amount of supragingival plaque and secondary subgingival penetration of irrigants, which flushed bacteria out of pockets.59 Studies that evaluated the ability of supragingival irrigation to project water or medicaments subgingivally determined that supragingival irrigation with a standard irrigating tip was capable of delivering water or a medicament 3 mm subgingivally, or to approximately half the probing depth in a 6-mm pocket.60,61 Another device, the Pik Pocket (Teledyne), which was placed 1 mm subgingivally, facilitated subgingival penetration of irrigants to 90 percent of the depth of 6-mm pockets.62
Chemotherapeutic agents added to the irrigator may55,56,58,63 or may not53,64–66 provide a benefit beyond that of irrigation with water. However, several studies have shown that irrigation with a medicament consistently achieved a better result than did rinsing with an antimicrobial agent.55,67,68 Lang and Raber68 attributed this to the ability of the irrigators to better distribute drugs in the mouth. To decrease staining caused by irrigation with chlorhexidine rinses (for example, 0.12 percent concentrations, Peridex [Zila Inc.] and PerioGard [Colgate Oral Pharmaceuticals]), clinicians can dilute the rinses to 0.02 percent. The selection of a 0.02 percent chlorhexidine concentration is based on a study that determined that a reduced amount of chlorhexidine (0.02 percent) delivered with an irrigator achieved a clinical result similar to that achieved with a 0.2 percent concentration, and reduced staining.69 This concentration can be formulated by diluting 0.12 percent chlorhexidine mouthrinses with five parts water to one part chlorhexidine.
Several reports in the early 1990s also indicated that good supragingival plaque control could reduce bacterial populations within pockets of up to about 5 mm in depth.70–72 The finding that supragingival irrigation can contribute to supragingival and subgingival plaque control and reduce gingival inflammation supports its use as an adjunctive aid for personal hygiene.59 However, dentists should keep in mind that irrigation is not the best method for disrupting or removing biofilms (that is, bacterial aggregates that adhere to each other and to surfaces); therefore, it cannot be used as a substitute for toothbrushing or professional periodic maintenance therapy.
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SUBGINGIVAL IRRIGATION
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Several studies have found that subgingival irrigation with a variety of medicaments reduced the amount of subgingival pathogens.73–76 These investigations established the biological rationale of using irrigation therapy. However, single episodes of subgingival irrigation usually did not enhance the results achieved with scaling and root planing; therefore, it is usually unnecessary to perform it.59
Eight studies indicated that irrigation did not enhance the therapeutic effect attained with root planing alone.77–84 Six other studies noted an additional effect, but the improvement was minimal.85–90 One investigation indicated that prolonged irrigation (five minutes per tooth) with a high concentration of tetracycline (10 percent), used in conjunction with root planing, enhanced the gain of clinical attachment compared with root planing alone (1.8 mm vs. 1 mm, respectively).90 However, after six months, Christersson and colleagues90 found no significant difference between the treatment methods with regard to probing depths or inflammatory status. Other clinical trials that noted an additional benefit after root planing involved multiple professional irrigation visits85,88 or frequent irrigation by patients themselves.86,87,89
Subgingival irrigation usually does not provide any reduction of inflammation, probing depth reduction or gain of clinical attachment beyond that achieved with root planing.
Overall, negligible risk is associated with subgingival irrigation. However, it usually does not provide any reduction of inflammation, probing depth reduction or gain of clinical attachment beyond that achieved with root planing. Therefore, when considering the cost-benefit ratio, clinicians should question whether irrigation is a worthwhile in-office procedure.59,91,92
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LOCAL DRUG DELIVERY
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Several local drug delivery devices have become commercially available.93,94 Studies addressing the efficacy of 10 percent doxycycline hyclate (Atridox, Block Drug Corp.), 25 percent metronidazole gel (Elyzol, Dumex Ltd. [available in Europe]) and tetracycline-impregnated fibers (Actisite, ALZA Corp.) have shown that treatment with these drugs achieved similar results to those achieved with root planing with regard to probing depth reduction (about 1 mm) and gain of clinical attachment (Table 2).22–25 Other investigations demonstrated that locally delivered drugs (for example, chlorhexidine gluconate [PerioChip, AstraZeneca LP] and tetracycline-impregnated fibers) enhanced the results achieved with root planing alone.25,95 Nevertheless, these improvements usually were less than 1 mm. When root planing alone was compared with root planing plus placement of the PerioChip with respect to the percentage of sites that experienced a 2-mm probing depth reduction, Jeffcoat and colleages25 noted that this outcome occurred more often with the combined therapy (19 percent vs. 9 percent of the treated sites). However, to achieve this result, researchers placed the chip two or three times in 60 percent of the sites during the nine-month evaluation period; by contrast, subjects in the control group underwent root planing only once.
The benefits of local drug delivery include its ability to deliver drugs deep within pockets at a bactericidal or bacteriostatic concentration, and at an elevated concentration that can be maintained for a long period.93,94 At present, only Atridox has been approved by the U.S. Food and Drug Administration, or FDA, as a monotherapy for the treatment of periodontitis, but there are no data available regarding its ability to enhance the effects of root planing. The other devices have been approved as adjuncts to conventional treatment (that is, root planing). Dentists should keep in mind that FDA labeling of indications for a device is based on data submitted by companies regarding their products’ efficacy in controlled clinical trials. Frequently, drugs have unlabeled applications.
Currently, insufficient data exist to conclude that any one device is superior to the other delivery systems.94 In this regard, only PerioChip and Atridox have two device characteristics that are highly desirable: resorbability and controlled release of the drug. Controlled release refers to the ability of the device to maintain a high drug concentration for a prolonged period, whereas sustained-release devices, such as Elyzol, deplete their drug reservoirs in about 24 hours.94 All of the devices are resorbable except Actisite, which needs to be removed after 10 days.
At present, no studies have confirmed that local drug delivery induces bacterial-resistant strains,96–99 but it is prudent to administer drugs, especially antibiotics, in a judicious manner. Also, insufficient data exist to suggest that local drug delivery results in less disease progression, and there are no data to indicate that if used, these systems facilitate a longer interval between maintenance visits.93,94
Local drug delivery is not effective against tissue-invasive organisms (for example, A. actinomycetemcomitans).100 Therefore, clinicians should consider microbiological testing in patients who do not respond to local drug delivery to determine the proper systemic drug to administer.93,94
Use of local drug delivery devices as a monotherapy remains controversial, since root planing alone usually achieves a similar result.93,94 Furthermore, since equivalent results can be attained without using medications, administration of these drugs as adjuncts to conventional therapy usually is unnecessary. In general, use of local drug delivery devices should be reserved for sites in patients who fail to respond to mechanical instrumentation.93,94 Furthermore, before using local drug delivery, it is prudent to use mechanical instrumentation on the root surfaces of teeth to disrupt the subgingival biofilms and remove calculus.93,94
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SYSTEMIC ANTIBIOTIC THERAPY
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The biological rationale for using antibiotics in the treatment of periodontal diseases is that bacteria are the major etiologic factor.101 However, antibiotic therapy usually is not needed and should be avoided in the routine treatment of chronic periodontitis (formerly called adult periodontitis).102 For patients who manifest any of the following conditions, however, antibiotics may be indicated: ongoing disease progression despite meticulous mechanical instrumentation, refractory chronic or aggressive periodontitis related to persistent sub-gingival pathogens or perhaps impaired host resistance, and acute infections. Antibiotics also may be appropriate for certain medically compromised patients.102,103–107
More than 500 species of bacteria have been identified within periodontal pockets, but only a limited number have been associated with periodontal diseases.102 Since there is variation in the antimicrobial sensitivity of putative pathogens, a simplistic antimicrobial approach is problematic, and often antibiotic sensitivity testing is needed to ensure optimal clinical results.102 Table 4 lists commonly used antibiotics in the treatment of periodontitis.
Systemic drug therapy offers several benefits compared with local drug delivery.93,108 Systemic drugs can be delivered via serum to the base of the pocket and can affect tissue-invasive organisms (for example, A. actinomycetemcomitans). They also can affect reservoirs of bacterial reinfection—the saliva, tonsils and mucosa. Furthermore, systemic drugs are often less costly and require less time to treat patients than do locally delivered drugs.93,108
Currently, when a microbiological assessment (such as culturing) is used to diagnose an A. actinomycetemcomitans–associated periodontitis, researchers recommend that clinicians use a combination of drugs (that is, amoxicillin with clavulanic acid [Augmentin, Smith-Kline Beecham] and metronidazole, an antibiotic that is specific for obligate anaerobes).109–111 If the patient is allergic to penicillin, ciprofloxacin could be substituted for amoxicillin with clavulanic acid.109 Ciprofloxacin is effective against enteric rods, pseudomonads and staphylococci. Another antibiotic that is effective and specific for anaerobes is clindamycin.107,109 Clinicians should adhere to judicious pharmacological principles when prescribing antibiotics to avoid inducing bacteria-resistant strains. This is underscored by recent reports that have shown that the percentage of organisms developing resistance to commonly used drugs has increased dramatically during the past decade.112
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HOST MODULATION
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A new approach to enhancing conventional treatment of periodontitis involves the administration of host-response–modulating drugs to block the destructive aspects of the immune response. The FDA recently approved a new systemic drug that is to be used in conjunction with scaling and root planing. The drug, Periostat (CollaGenex Pharmaceuticals Inc.), is a collagenase inhibitor that consists of a 20-milligram capsule of doxycycline hyclate for oral administration.113–115 Although Periostat is an antibiotic, it is administered at such a low level that it has no bacteriostatic activity. Its purpose is to reduce collagenase activity in patients with periodontitis.
Adjunctive use of subantibacterial dosing with doxycycline, or SDD (nine months’ duration), plus root planing has resulted in a small, but statistically significant, clinical improvement over root planing alone.114 The mean clinical attachment gain at sites with an initial probing depth of 4 to 6 mm was 1.03 mm after root planing plus SDD and 0.86 mm after root planing alone, for a difference of 0.17 mm. For sites with an initial probing depth of 7 mm or greater, the mean clinical attachment gain was 1.55 mm following root planing plus SDD and 1.17 mm following root planing alone, for a difference of 0.38 mm.
Systemic drug therapy offers several benefits compared with local drug delivery.
At sites with an initial probing depth of 4 to 6 mm, the mean probing depth reduction was 0.95 mm after root planing plus SDD and 0.69 mm after root planing alone, for a difference of 0.26 mm. For sites with an initial probing depth of 7 mm or greater, the mean amount of probing depth reduction was 1.68 mm following root planing plus SDD and 1.20 mm following root planing alone, for a difference of 0.48 mm.
Furthermore, more sites with initial probing depths of 4 mm or greater exhibited a 2-mm reduction in probing depth when SDD was used as an adjunct to mechanical instrumentation than when root planing alone was performed (29.9 percent vs. 22.0 percent of the sites).114
In general, clinicians should try to eliminate the bacterial challenge using conventional therapy before administering systemic drugs whose objective is to alter the host response to pathogens.116 It is important to keep in mind that drug administration is not a substitute for professional root planing and appropriate treatment designed to minimize bacterial load and facilitate proper personal hygiene.
Subantimicrobial dosing with doxycycline probably will prove most advantageous in the treatment of patients with refractory or recurrent disease; however, this concept needs to be verified in controlled clinical trials. Clinicians also should be aware that repeated root planing may achieve a larger probing depth reduction than one episode of root planing plus SDD, which needs to be used for several months.31,117,118 In addition, when the efficacy of locally delivered drugs (such as Actisite)22 or systemic antibiotics (such as metronidazole)119,120 used as adjuncts to root planing at deep sites ( 7 mm) is compared with the benefits produced by SDD, it appears that the antibiotics achieved a numerically greater result with regard to probing depth reduction. These findings are consistent with the concept that containment of the bacterial challenge should remain the primary focus of clinicians.
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CONCLUSION
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Most patients with mild-to-moderate chronic periodontitis respond to nonsurgical therapy; however, some require surgical therapy. Therefore, treatment plans need to be customized for patients with different types and stages of periodontitis. Adjunctive use of local drug delivery devices may enhance treatment results, but antibiotics should be reserved for patients who do not respond to conventional treatment. Similarly, host-modulating agents may be beneficial for some patients. However, before using them, it would be prudent to try to reduce the bacterial challenge.
To ensure optimal results, clinicians should select treatment techniques that are capable of attaining desired clinical outcomes (for example, pocket-depth reduction, inhibition of disease progression, bone fill). Clinicians need to consider the magnitude of improvement that a treatment usually can induce in light of the severity of the defect. Accordingly, when treating patients with advanced periodontal defects, clinicians may need to select a surgical approach.121 Table 5 summarizes the results that can be achieved with different treatment methods.16,22,24,25,28,114,122 Ultimately, integration of several factors will guide therapy: the results of clinical trials and their reasonable interpretation and application to clinical practice, selection of techniques that can produce desired outcomes and good clinical judgment.
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FOOTNOTES
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Dr. Greenstein is a clinical professor, Department of Periodontology, University of Medicine and Dentistry, Newark, N.J. He also is in private practice, specializing in periodontics. Address reprint requests to Dr. Greenstein, 900 W. Main St., Freehold, N.J. 07728.
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ABSTRACT
PREVALENCE AND CLASSIFICATION OF...