Nonsurgical Periodontal Therapy
Nonsurgical treatment of periodontal disease is the management of gum disease with cleanings and antibiotics. Both of these modalities can be implemented by a general dentist or a periodontist (a dentist specially trained in the periodontal field), who also prescribe any necessary antibiotics.
The primary goals of periodontal treatment are the eradication of the disease process from the gums, ligaments, and bones that surround the teeth, and restoration of health that can be maintained on a daily basis. This nonsurgical approach is the conservative method of treating periodontal disease; it is for the patient who is fearful of surgery or wants the most conservative, noninvasive treatment. This approach is also used for the patient who presents a case of mild-to-medium severity of periodontal disease.
The patient medical history is vital information that should be known by the entire dental staff. For example, it is crucial for them to know if the patient has allergies to certain medications—especially antibiotics—which cannot be tolerated, or will not mix well with prescriptions the patient is already taking. A nonsurgical treatment will be chosen by some patients, even after surgery has been recommended by the dentist or periodontist because it is the optimal treatment.
Periodontal disease is the number one chronic infectious disease in the world. Surveys and studies show that over 50% of the American adult population have gingivitis and that 36% have periodontal disease. Periodontal disease increases with age. Most children and teenagers show some forms of gingivitis, but the harmful bacteria linked to gum disease is not present in young children. Periodontitis affects 1% of American teenagers and 3.6% of young adults aged 18–34. Among people aged 70 years or older, the rate of periodontitis increases to 86% due to the bacteria linked to this disease. It is the leading cause of tooth loss, and begins as a painless infection in the gums that is caused by buildup of bacteria. The bacteria buildup becomes dental plaque. If left untreated, pockets of plaque form around the gum
Treatment for periodontal disease differs depending on the severity of the case the patient presents to the office. Nonsurgical therapy for periodontal disease needs to be taken in steps and cannot be treated in a one visit trip to the dentist. The periodontist will divide the mouth into four quadrants—upper left; lower left; upper right; and lower right. Each quadrant is treated during a single visit. Different nonsurgical approaches to treating this disease are:
- oral hygiene instruction
- scaling and tooth planing
- systemic antibiotic therapy (medication taken by mouth)
- topical and local antibiotic therapy
Oral hygiene instruction is a procedure designed to educate the patient on its importance, and to train the patient, via a hands-on approach, how to properly clean and brush the teeth.
Scaling and root planing, also known as deep cleaning, is the conservative approach to the removal of plaque from and the prevention of infection beneath the gum line. During the scaling, a vibrating ultrasonic unit is used to clean tartar and visible particles from the teeth. Scaling removes deposits of bacterial plaque, food debris, and any pus that has accumulated in the infected pocket as a result of periodontitis. For areas that are more difficult to reach, a curet is used. This probes and cleans the pockets that the receding gums form around the teeth. Root planing smooths and cleans the root of the tooth so that the gum tissue may heal next to the tooth. The curette is used to plane the tooth root to make the surface smooth.
This procedure also removes the source of bacteria from the pockets around the tooth. It is helpful in reducing the opportunity for more bacteria to invade as a result of an inherent characteristic of plaque: it does not adhere well to smooth surfaces.
Scaling and root planing are done one quadrant at a time, and thus require several visits to the dental office to have the other quadrants treated. A local anesthetic can be used if there is any discomfort or pain. Scaling and root planing treatment are often effective in allowing the healing of early stages of periodontitis, and can help to reduce time spent in subsequent surgical treatment.
Systemic antibiotics (antibiotics taken by mouth) may be used in conjunction with other treatments to help rid the mouth of the bacteria causing periodontitis. Systemic antibiotics, however, are used conservatively because of the danger of a patient developing antimicrobial resistance. In fact, topical antibiotics are used more frequently than systemic antibiotics. Studies by the AAP reveal that taking antibiotics after undergoing scaling and root planing reduce the need for surgery by stopping the progression of the disease.
Systemic antibiotic administration may include the use of:
- Augmentin 500 mg: taken twice daily for at least eight days.
- Metronidazole (Flagyl), 500 mg: taken twice daily for at least eight days.
- Clindamycin (for penicillin-allergic patients), 300 mg: twice daily for at least eight days.
- Tetracycline 500 mg: taken for at least 14 days.
- Doxycycline 100 mg: taken twice daily for at least 14 days.
As mentioned previously, topical, or local antibiotic therapy, is another method of delivering antibiotics to the infected space in the gum tissue of the affected teeth. Here, the medication is applied directly to the affected area(s). This nonsurgical treatment approach is used mainly when scaling and root planing are considered insufficient to treat the infected tissue. The drugs that may be used include:
Atridox was approved by the U.S. Food and Drug Administration (FDA) in late 1998 as the first and only locally delivered antibiotic treatment for periodontal disease. It contains the antibiotic "doxycycline," a proven antibiotic that kills bacteria associated with periodontal disease. The American Dental Association (ADA) awarded Atridox their Seal of Approval in 2000. Atridox gives dental professionals a practical, highly effective, and pain-free therapeutic option for treating moderate-to-severe periodontal disease before costly and invasive treatments become necessary. This type of treatment is used in conjunction with scaling and root planing. Anesthetics are not needed.
PerioChip treatment releases chlorhexidine as the antibiotic to fight against the disease. The entire chip must be used to insure adequate concentration of chlorhexidine for the seven to ten day treatment period. The PerioChip has three considerations during usage.
Adjunct—One connected to the other in a dependent or subordinate nature.
Calculus—Calcium deposits on teeth from the buildup of plaque that has not been removed.
Conjunction—In combination or association with.
Local or topical antibiotics—Method of therapy that delivers medications to local area of the body.
Periodontal—Tissue and structures that surround and support the teeth.
Periodontist—A dentist with specialized training for periodontal treatment and care.
RDA—Registered dental assistant. Individual trained to assist the dentist in dental procedures.
RDH—Registered dental hygienist. An individual trained for the specific purpose of oral hygiene, which includes the performance of teeth cleanings and home care instruction.
Root planing—Making the tooth smooth by removing built up calculus and tartar from below the gum tissue.
Scaling—The removal of food and debris from the portion of the tooth above the gum line.
Systemic antibiotics—Antibiotic medications that affect the whole body.
First, it is designed to be placed in a periodontal pocket of 5 mm or more. It is 5 mm long and 4 mm wide, with a curved end. This end is inserted into the pocket, into which it completely disappears. A patient who might be a candidate for this treatment approach might be one who is medically compromised in some way; someone in for whom surgery is contraindicated. Lastly, the PerioChip can be used where probing produces bleeding—where other forms of care have been unsuccessful, but root planing has been achieved. Initially, the area to be treated should be scaled and root planed; any subgingival plaque must be removed.
Published studies by the AAP have indicated the subgingival administration of this drug in a controlled release device reduces the bacteria and improves gingival health. Controlled clinical trials compared the benefits of scaling and root planing (SRP) alone to that of scaling, root planing and the use of the PerioChip, and revealed statistically significant benefits of adjunctive chip use with regard to reducing probing pocket depths (0.65 mm versus 0.95 mm) and a gain of clinical attachment (0.58 mm versus 0.78 mm). The changes were small, but change did occur. Currently in studies performed by the AAP, two-chip applications have produced a result if any result is going to be seen. If no clinical result is seen after the two-chip application, additional chip therapy may be limited, but not produce any results at all. No data to date have been found by the AAP regarding further need of surgical or non-surgical treatment of sites after PerioChip treatment.
Periostat therapy, available in a 20 mg capsule as doxycycline hyclate (tetracycline) for oral administration, is indicated as an adjunct to scaling and root planing. It has been available in pharmacies since November 1998. It is listed under local and topical antibiotic treatment rather than systemic antibiotic treatment because its use is only for the treatment of periodontal disease and no other. Periostat works by attacking the enzymes that are produced by the cells within the pockets and inside the gum tissue itself. These enzymes are produced in response to a bacterial invasion of the gum and pockets with adult periodontitis. Periostat is the only treatment that suppresses the pathologically elevated levels of tissue-destroying enzymes that may lead to tooth loss in adult periodontitis. Periostat treats all periodontal pockets throughout the mouth simultaneously and therefore may be called a systemic type of therapy. Periostat administered for nine months revealed statistically significant benefits of adjunctive Periostat use with regard to reducing probing pocket depths from 1.48 mm to a gain of 1.17 mm pocket attachment and depth of 1.36 mm to a gain of 0.86 mm pocket depth. The magnitude of these changes is quite small (0.17 mm to 0.48 mm) and patients were required to use Periostat for the duration of the study. Periostat can be taken for a period of three to nine months. The length of duration depends upon the treating periodontist and the severity of the periodontal disease being treated. The AAP found no data regarding further need of surgical or non-surgical treatment of sites after using Periostat.
Preparation for nonsurgical treatment of periodontal disease is limited to reading the medical history of the patient if any allergies to antibiotics exist and if the patient has any sensitivity to the medication prescribed. It is vital to know all existing medical conditions of the patient and what other medications being taken, especially in older patients with advanced periodontal disease. A need to know what type of medications might interact
Since periodontal treatment is done in quadrants, root planing and scaling can leave the gums and teeth tender to the touch. Chewing soft foods and rinsing with salt-water rinses will help heal the tissue. If treatment is accomplished using systemic antibiotics, aftercare is limited to following the prescription directions prescribed by the periodontist. If topical or local antibiotic treatment has been performed in quadrants, eating soft foods and light use of the quadrants will be advised. Brushing is recommended, but using a soft bristle toothbrush will be advised. If Atridox or the PerioChip have been used during treatment, flossing will not be advised until the treatment is completed.
Maintenance of periodontal disease is ongoing to prevent recurrence of the disease. Visits to the dental office for evaluations and checkups should occur on a regular basis. The examination should include observation of the gums, checking the bite, and removing any new plaque and tartar. How often the appointments are made depends upon the patients' willingness to control the disease. Most maintenance is practicing good daily hygiene habits at home. All patients should go back to the basics with regard to toothbrushing, flossing, and rinsing.
There are some concerns by the ADA that use of systemic therapy should be reserved for patients with continuing periodontal breakdown. The concern stems from the frequent use of antibiotics, because bacteria are increasing developing strains that are resistant to systemic therapy. This will make treating the disease harder, and is a growing health concern around the world. Incorporating this type of therapy into a routine management for adult periodontitis is not justified at this time. Periostat offers some solution because the antibiotic dosage level is very low, but it still poses some concern.
Periodontal disease can be eradicated with the help and cooperation of the patient.
Health care team roles
A recent poll done by the AAP of 165 periodontists found that half of the patients seen in the offices reported feeling fearful of pain before they were treated, but only 10% reported feeling extreme discomfort or pain during treatment. Most patients making appointments with a periodontist are being referred by their general dentist and are aware of the periodontal disease they present. It is vital that periodontal office have a good rapport with local general dental offices to keep a specialty office running.
As a health care team, all areas of the office are helpful to the treating and healing of a patient. A registered dental hygienist (RDH) is most often seen by patients for root planing and scaling. Pocket depth charting is accomplished by the RDH and then relayed to the periodontist, who then plans the treatment with the patient. The registered dental assistant (RDA) assists the periodontist in organizing and sterilizing the instruments. The RDA keeps the patient flow running smoothly. A patient is greeted by the receptionist, who is also the last to see the patient. A warm and courteous front office staff is vital to the operation of any dental office at which the patient's disease is managed and his or her healing is accomplished.
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Cindy F. Ovard, R.D.A.