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I agree with the conclusion of Dr. Walter Loesche and colleagues that patients now have a choice in treatment options: surgery or extraction, or treatment based on an antimicrobial approach ("The Nonsurgical Treatment of Patients With Periodontal Disease: Results After Five Years," March JADA).

I have been treating patients with moderate to advanced periodontal disease since 1979 with an antimicrobial approach, and I know that teeth can be saved without surgery. While metronidazole and doxycycline are extremely useful toward this end, a successful reduction of periodontal pathogens can be accomplished without the use of systemic or local antibiotics. This is especially important when private-practice patients refuse antibiotics or cannot take them.

Metronidazole, for example, is contraindicated if a patient uses alcohol or is taking lithium or coumadin. Doxycycline is contraindicated if a patient takes digoxin, while antacids and gastroesophageal reflux disease medications may impair doxycycline absorption. And antibiotics, as we know, can decrease the efficacy of oral contraceptives.

Periodontal microorganisms can be reduced effectively with preliminary pocket irrigation using PVP-iodine,¹ followed by full-mouth (not quadrant) scaling and root planing, or SRP,^2,3 utilizing ultrasonics^4,5 with an antiseptic irrigant such as chlorhexidine.⁶ The use of non-steroidal anti-inflammatory drugs, both topical and systemic, also has been shown to reduce the alveolar bone loss of periodontal disease.⁷ As Dr. Loesche indicated, during the active periodontal treatment phase, SRP should take place several times over a period of several months. I typically see patients every two to three weeks over a three-to four-month period.⁸

Then, to maintain low levels of bacteria commensurate with periodontal health, supportive periodontal treatments should be scheduled every three months. A rigorous but realistic home care program including pulsed oral irrigation^9,10 is essential. This nonsurgical protocol is extremely effective in eliminating periodontal infection and inflammation and arresting moderate to advanced periodontitis without the use of antibiotics.

During both the treatment and the maintenance phase, Dr. Loesche makes no mention of any home care regimen or patient compliance. It has been my observation that nonsurgical periodontal treatment, either with or without antibiotics, will not be successful without a structured, detailed and compliant home care schedule that includes dietary recommendations or supplements.^11,12

	REFERENCES

TOP REFERENCES

1. Rosling B, Hellstrom MK, Ramberg P, Socransky SS, Lindhe J. The use of PVP-iodine as an adjunct to non-surgical treatment of chronic periodontitis. J Clin Periodontol 2001;28(11):1023–31.[Medline]
   
   
2. Quirynen M, Bollen CM, Vandekerckhove BN, Dekeyser C, Papaioannou W, Eyssen H. Full- vs. partial-mouth disinfection in the treatment of periodontal infections: short-term clinical and microbiological observations. J Dent Res 1995;74(8):1459–67.[Abstract/Free Full Text]
   
   
3. Mongardini C, van Steenberghe D, Dekeyser C, Quirynen M. One stage full- versus partial-mouth disinfection in the treatment of chronic adult or generalized early-onset periodontitis, I: long-term clinical observations. J Periodontol 1999;70(6):632–45.[Medline]
   
   
4. Walsh TF, Waite IM. A comparison of postsurgical healing following debridement by ultrasonic or hand instruments. J Periodontol 1978;49(4):201–5.[Medline]
   
   
5. Drisko CL, Cochran DL, Blieden T, et al. Position paper: sonic and ultrasonic scalers in periodontics. Research, Science and Therapy Committee of the American Academy of Periodontology. J Periodontol 2000;71(11):1792–801.[Medline]
   
   
6. Reynolds MA, Lavigne CK, Minah GE, Suzuki JB. Clinical effects of simultaneous ultrasonic scaling and subgingival irrigation with chlorhexidine: mediating influence of periodontal probing depth. J Clin Periodontol 1992;19(8):595–600.[Medline]
   
   
7. Jeffcoat MK, Reddy MS, Haigh S, et al. A comparison of topical ketorolac, systemic flur-biprofen, and placebo for the inhibition of bone loss in adult periodontitis. J Periodontol 1995; 66(5):329–38.[Medline]
   
   
8. Sbordone L, Ramaglia L, Gulletta E, Iacono V. Recolonization of the subgingival microflora after scaling and root planing in human periodontitis. J Periodontol 1990; 61(9):579–84.[Medline]
   
   
9. Walsh TF. Pulsed oral irrigation in the management of inflammatory periodontal diseases. Dent Update 1993;20(2):65, 67–8, 70–1.[Medline]
   
   
10. Frascella JA, Fernandez P, Gilbert RD, Cugini M. A randomized, clinical evaluation of the safety and efficacy of a novel oral irrigator. Am J Dent 2000;13(2):55–8.[Medline]
    
    
11. Krall EA, Wehler C, Garcia RI, Harris SS, Dawson-Hughes B. Calcium and vitamin D supplements reduce tooth loss in the elderly. Am J Med 2001;111(6):452–6.[Medline]
    
    
12. Nishida M, Grossi SG, Dunford RG, Ho AW, Trevisan M, Genco RJ. Calcium and the risk for periodontal disease. J Periodontol 2000;71(7):1057–66.[Medline]
    
    

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