Effectiveness of supragingival plaque control on the development of subgingival plaque and gingival inflammation in patients with moderate pocket depth

Laser Assisted Non-surgical Periodontal Therapy: A Double Blind, Randomized Clinical Trial

The objective of this study was to examine potential benefits of using laser therapy for secular decontamination in conjunction with scaling and root planing in the treatment of chronic periodontitis. The study was performed on 173 teeth in 14 patients in a split-mouth design, one side received scaling and root planing followed by laser therapy using a carbon dioxide (CO2) laser with an ablative handpiece (test group); the contralateral side received scaling and root planing without laser (control group). Clinical and laboratory parameters were evaluated prior to treatment and at 3 and 6 months following therapy; clinical measurements were performed by two blinded examiners. The clinical parameters included measurement of gingival recession (REC), bleeding on probing (BOP), clinical attachment level (CAL), pocket depth (PD), furcation involvement (FUR), and tooth mobility (MOB). Laboratory testing to determine the levels of periodontal pathogens was performed using PCR techniques. The results of the study revealed statistically significant differences in clinical and laboratory parameters at 3 and 6 months after therapy for both test and control groups, but no significant difference was observed between the two groups. However, sites receiving laser therapy tended to show a greater decrease in probing depths, gain in clinical attachment level, and reduced bacterial levels. In conclusion, the overall results of the study suggest a potential benefit of using laser therapy in conjunction with scaling and root planing for the treatment of chronic periodontitis.

Multidisciplinary Treatment of a Fenestration-type Defect

The case report aimed at treating a fenestration-type defect with multidisciplinary conventional and advanced surgical techniques. Fenestrations are isolated areas in which the exposed root surface is covered only by the periosteum and gingiva, but the remaining cortical bone remains intact. Root coverage is indicated in cases of root hypersensitivity, treatment of shallow caries lesions, cervical abrasions, and esthetic and cosmetic needs. In this case report, after proper hygiene instruction and dental biofilm control, a fenestration-type defect was treated using guided tissue regeneration (anorganic bovine matrix and resorbable membrane) and a connective tissue grafts, associated to an endodontic apicoectomy. After reevaluation, the remaining gingival recession was treated with a second gingival connective tissue graft covered with q double papillae type in order to reconstruct the periodontal tissues of the involved tooth. In this clinical case, the interaction between the different areas of dentistry has made it possible to correct a fenestration-type defect, following procedures based on scientific evidence, restoring periodontal health, esthetics, self-esteem, and meeting the patient's expectations regarding her initial complaint. This case report shows the important role of interdisciplinary approach to treating a patient with a complex periodontal defect that required different types of knowledge and abilities to achieve the best results based on the current status of dentistry possibilities.

Evidence-based decision making: replacement of the single missing tooth

Single-tooth replacement may be effected through various methods, including the use of a resin-bonded fixed partial denture, a conventional fixed partial denture, and a single implant-supported crown. Although the introduction of newer therapeutic modalities, surgical and restorative techniques, and restorative materials has significantly expanded available treatment options, a greater demand is now placed on the diagnostic and treatment planning acumen of the clinician. The questions confronting each clinician are when to apply each treatment modality and how to use these therapeutic approaches to their maximum benefit for the patient. This article focuses on the factors that should be considered when making such clinical decisions and offers a framework within which to formulate appropriate treatment algorithms.

Supragingival plaque may modify the effects of subgingival bacteria on attachment loss

BACKGROUND

Bacterial interactions in response to local and systemic factors may explain important features of the pathogenesis of periodontal disease. This study evaluates the role of supragingival plaque level on the relationship between subgingival microorganisms and the risk of attachment loss.

METHODS

The study population consisted of 386 white women aged 45 years and older who had at least seven teeth. Subgingival plaque samples were taken from the mesio-buccal surface of six maxillary and six mandibular teeth using paper point technique. The samples were pooled, and immunofluorescence microscopy was performed to identify the following target microorganisms: Actinobacillus actinomycetemcomitans (Aa), Tannerella forsythensis (Tf), Campylobacter rectus (Cr), Prevotella intermedia (Pi), Capnocytophaga species (Cs), Porphyromonas gingivalis (Pg), Eubacterium saburreum (Es), and Fusobacterium nucleatum (Fn). The presence or absence of supragingival plaque and clinical attachment loss (CAL) were assessed at the same 12 sites where subgingival plaque samples were taken. The association of each microorganism with CAL was tested using multiple logistic regressions controlling for age, smoking status, and diabetes. Odds ratios (OR) and their 95% confidence intervals (CI) were calculated.

RESULTS

At low supragingival plaque levels, only the presence of Pg was significantly associated with CAL (OR: 6.41, 95% CI: 1.30 to 31.70); all remaining microorganisms were also associated with increased but non-significant risk of CAL. At high supragingival plaque levels, the presence of Tf (OR: 2.40, 95% CI: 1.42 to 4.04) and Pg (OR: 3.71, 95% CI: 1.63 to 8.42) was significantly associated with increased risk of attachment loss. By contrast, the presence of Cs (OR: 0.55, 95% CI: 0.30 to 1.01) and Es (OR: 0.35, 95% CI: 0.15 to 0.82) was associated with decreased risk of attachment loss. Fn, Pi, and Cr were not significantly associated with CAL at either low or high supragingival plaque levels.

CONCLUSIONS

This study suggests that the association of certain subgingival microorganisms with CAL changes in relation to supragingival plaque levels in older adult women. It also suggests that the overall effect of dental plaque is a function of the balance between pathogenic and other microorganisms that colonize this environment. Therefore, all microorganisms in the biofilm, including those with no apparent association with overt disease and those with negative associations, may play roles in the pathogenesis of periodontal diseases.

A systematic review of professional mechanical plaque removal for prevention of periodontal diseases

AIM

To investigate the effect of professional mechanical plaque removal (PMPR) on the prevention of periodontal diseases.

METHODS

We searched for randomized controlled trials, controlled clinical trials and cohort studies from 1950 to October 2004. Screening and data abstraction were conducted independently and in duplicate. Critical appraisal of studies was based on objective criteria and evidence tables were constructed.

RESULTS

From 2179 titles and abstracts, 132 full-text articles were screened and 32 studies were relevant. Evidence exists that PMPR in adults, particularly in combination with oral hygiene instruction (OHI), may be more effective than no treatment judged by surrogate measures. The evidence for a benefit of PMPR+OHI over OHI alone is less clear. The optimum frequency of PMPR has not been investigated although more frequent PMPR is associated with improved markers of health. The strength of evidence for these results ranges from weak to moderate due to risk of bias, inconsistent results, lack of appropriate statistics and small sample size.

CONCLUSIONS

There appears to be little value in providing PMPR without OHI. In fact, repeated OHI might have a similar effect as PMPR. Some forms of PMPR might achieve greater patient satisfaction. There is little difference in beneficial or adverse effects of different methods of PMPR.

Microbiological response to mechanical treatment in combination with adjunctive therapy. A review of the literature

The recognition of the microbial origin and the specificity of periodontal infections has resulted in the development of several adjunctive therapies (antibiotics and/or antiseptics) to scaling and root planing in the treatment of chronic adult periodontitis. This article aims to review the "additional" effect of a subgingival irrigation with chlorhexidine, or a local or systemic application of tetracycline or metronidazole, performed in combination with a single course of scaling and root planing in patients with chronic adult periodontitis. All treatment modalities are compared with scaling and root planing, based on their impact on: the probing depth (PD); total number of colony forming units per ml (CFU/ml); the proportions and/or the detection-frequency of Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, and Prevotella intermedia; and/or on the percentages of cocci, spirochetes, motile, and other micro-organisms on dark field microscopy examination. All treatment modalities, including scaling and root planing without additional chemical therapy, resulted in significant reductions in the probing depth and the proportions of periodontopathogens, at least during the first 8 weeks post-therapy. However in comparison to a single course of scaling and root planing, the supplementary effect of adjunctive therapies seems to be limited. In general, only the irrigation with chlorhexidine 2%, the local application of minocycline, and the systemic use of metronidazole (in case of large proportions of spirochetes) or doxycycline (in case of large proportions of A. actinomycetemcomitans) seem to result in a prolonged supplementary effect when compared to scaling and root planing. Therefore, the use of antibiotics on a routine basis, especially in a systemic way, in the treatment of chronic adult periodontitis, can no longer be advocated, considering the increasing danger for the development of microbial resistance.

Long-term evaluation of periodontal therapy: I. Response to 4 therapeutic modalities

Eighty-two periodontal patients were treated in a split mouth design with coronal scaling (CS), root planing (RP), modified Widman surgery (MW), and flap with osseous resection surgery (FO) which were randomly assigned to various quadrants in the dentition. Therapy was performed in 3 phases: non-surgical, surgical, and supportive periodontal treatment (SPT) < or = 7 years. Clinical data consisted of probing depth (PD), clinical attachment level (CAL), gingival recession (REC), bleeding on probing (BOP), suppuration (SUP), and supragingival plaque (PL). Because of the necessity to exit many CS treated sites due to breakdown, data for CS were reported only up to 2 years. All therapies produced mean PD reduction with FO > MW > RP > CS following the surgical phase for all probing depth severities. By the end of year 2 there were no differences between the therapies in the 1 to 4 mm sites. There were no differences in PD reduction between MW and RP treated sites by the end of year 3 in the 5 to 6 mm sites and by the end of year 5 in the > or = 7 mm sites. FO produced greater PD reduction in > or = 5 mm sites through year 7 of SPT. Following the surgical phase, FO produced a mean CAL loss and CS and RP produced a slight gain in 1-4 mm sites. RP and MW produced a greater gain of CAL than CS and FO following the surgical phase in 5 to 6 mm sites, but the magnitude of difference decreased during SPT. Similar CAL gains were produced by RP, MW, and FO in sites > or = 7 mm. These gains were greater than that produced by CS and were sustained during SPT. Recession was produced with FO > MW > RP > CS. This relationship was maintained throughout SPT. The prevalences of BOP, SUP, and PL were greatly reduced throughout the study and were comparable between sites treated by RP, MW, and FO while the CS sites had more BOP and SUP.

Repopulation of periodontal pockets by microbial pathogens in the absence of supportive therapy

This clinical study evaluated the reinfection incidence by Actinobacillus actinomycetemcomitans (Aa), Porphyromonas gingivalis (Pg), and Prevotella intermedia (Pi) in periodontal pockets following scaling and root planing (SRP) and intra-pocket irrigation with antimicrobial agents in a patient population who did not receive supportive maintenance therapy. The number of target organisms was determined utilizing DNA probes. Forty-one (41) inflamed pockets > or = 5 mm with attachment loss and containing at least one target species were selected in 6 adult patients. Following a baseline clinical and bacterial examination, all patients received thorough SRP. In addition, 1 to 2 teeth in each patient were randomly assigned to each of the following 4 treatment modalities: 1) control group, no irrigation; 2) saline group, irrigation with 2 cc of 0.85% saline; 3) tetracycline group, irrigation with 2 cc of aqueous tetracycline HCl, 50 mg/ml (5%); and 4) chlorhexidine group, irrigation with 2 cc, respectively. All selected sites were non-adjacent. No additional therapy was rendered during the entire 1-year observation period. Clinical parameters and microbial analyses were recorded again at 1 week, and 1, 3, 6, 9, and 12 months post-treatment. The effect of antimicrobial irrigation on the reinfection rate of sites by Aa, Pg, and Pi was compared with that of the control groups (1 and 2) by ANOVA. No statistically significant differences were observed among the irrigation treatment groups with regard to any of the clinical or bacterial parameters studied. Therefore, the 4 treatment groups were combined into a single group whereby the rate of bacterial repopulation following extensive scaling and root planing could be ascertained. The infection incidence of sites at baseline (of total sites), 1 week and 12 months (of sites originally infected at baseline) was 14/41, 3/14, and 7/14 for Aa; 33/41, 6/33, and 12/33 for Pg; and 37/41, 3/37, and 12/37 for Pi, respectively. Thus, half or fewer of the originally infected sites became reinfected at 12 months despite lack of maintenance therapy. The results suggest that 1) a single episode of pocket irrigation with antimicrobial agents following thorough scaling and root planing did not affect the rate of repopulation of periodontal pockets by the tested pathogens; 2) thorough scaling and root planing has a lasting suppressive effect on selected periodontal pathogens for the majority of sites in patients with adult periodontitis; 3) pre-operative probing depth, the amount of gingival fluid flow and the composition of the subgingival microflora may serve as predictors for reinfection in the absence of maintenance care; and 4) reinfection of the treated sites by Aa, Pg, and/or Pi may constitute a risk factor that diminishes the effect of therapy in the absence of supportive maintenance care.

The role of supragingival plaque in the control of progressive periodontal disease. A review

Levels of supragingival plaque and calculus have been related to progressive periodontal disease, and control of supragingival plaque in conjunction with professional tooth cleaning subgingivally forms the basis for the management of progressive periodontal disease. However, the contribution towards the management of progressive periodontal disease brought about by supragingival plaque control alone is not clear. There are studies which address, directly or indirectly, the contribution of supragingival plaque control alone towards the management of progressive periodontal disease. The effects of supragingival plaque control alone have been evaluated clinically, histologically and microbiologically, and taken together, the evaluations suggest that these effects may not be as marked as when professional subgingival tooth cleaning is also performed. These studies, however, given the patterns of periodontal disease found in adults in many communities, can form the basis for advocating high individual levels of supragingival plaque control as a community measure in the management of periodontal disease. Further long-term investigations into this approach may be warranted.

Periodontal response to mechanical non-surgical therapy: a review

This literature review is concerned with the ability of personal oral hygiene and mechanical instrumentation to establish and maintain periodontal health. Clinical, microbiologic, and histologic responses to non-surgical therapy are evaluated to provide guidelines for expected treatment results. Factors that may limit the effectiveness of non-surgical therapy as a closed procedure are also addressed. These include length of therapy, skill of therapists, patient compliance, responsibility of clinician for maintenance, and disease activity status of the patient.

Periodontics in general practice: professional plaque control

Traditionally the primary emphasis of preventive periodontics was daily patient performed plaque control. Recent studies indicate that frequent professional subgingival toothcleaning is a mandatory treatment for prevention of recurrent periodontitis. Pathogenic subgingival bacterial complexes are disrupted by frequent cleaning and require time to reestablish. Disease progression is prevented if the recall interval does not exceed the time required for reestablishment of a pathogenic plaque. Legally, patients have acquired the duty to comply with the prescribed recall interval. Both the patient and the practitioner will benefit from a preventive program that includes frequent professional subgingival toothcleaning.

Ultrastructural examination of human periodontal pockets following the use of an oral irrigation device in vivo

To date, there are no ultrastructural studies that have examined untreated chronic periodontal pockets immediately following dental debridement with an oral irrigation device. This study used both scanning electron microscopic and transmission electron microscopic methodology to examine previously untreated human periodontal pockets after their exposure to a pulsating oral irrigation with saline solution. A comparison of 16 untreated controls with 16 test specimens revealed qualitative differences in microbial morphotypes at various pocket depths. Control specimens at all pocket depths examined (0-6 mm), exhibited a mixed microbial flora consisting of cocci, short rods, and filamentous organisms. Specifically at 3- to 4-mm and 5- to 6-mm levels in control specimens, spirochetes, fusiforms, and branching organisms were obvious. In contrast, test specimens exhibited a few cocci and short rods at 0- to 2-mm and 3- to 4-mm levels and a mixed flora at the 5- to 6-mm level. There was no observable difference between control and test specimens concerning epithelial topography, cavitations, microulcerations, spatial relationships, and individual cell appearance. Both control and test specimens exhibited a mild spirochete invasion of the epithelial strata. Collectively these observations suggest that pulsating oral irrigation effects a qualitative change on subgingival plaque and is not injurious to the soft tissues.

Effects of subgingival irrigation on periodontal status

Periodontal diseases are localized, plaque-related infections. Often, clinical signs of inflammation are not eradicated by supragingival plaque control, dictating that subgingival microbial populations must be reduced. Confirmation that it is possible to deliver medicaments to the base of deep pockets stimulated numerous investigations. This report evaluates the role of site-specific pharmacotherapy to enhance periodontal status.

Periodontics in general practice: perspectives on nonsurgical therapy

Clinical studies have shown that nonsurgical treatment is a highly effective method of periodontal therapy. It can be instituted in both shallow and deep pockets; however, an objective evaluation of post-scaling soft tissue changes should be recorded to determine the response to therapy. Closed scaling and root planing has limitations as a definitive procedure for the removal of calculus from deep pockets and surgical treatment may be indicated for nonresponding sites. The condition of the tissue, not the probing depth, should dictate the course of action. During maintenance therapy all practitioners should recognize unsuccessfully treated or recurrent periodontitis and provide interceptive treatment to avoid a case of "supervised neglect." Periodontal treatments should be provided by the general practitioner. This can result in improved oral health for the patients and constitute a professionally rewarding part of dental practice.

The effect of plaque control after scaling and root planing on the subgingival microflora in human periodontitis

The aim of the present study was to evaluate the effect of a strict supragingival plaque control regimen on bacterial repopulation following scaling and root planing. 7 patients with moderate to severe inflammatory periodontal disease received a full-mouth scaling and subgingival curettage. Using a split-mouth design, 2 sites of opposite quadrants were submitted to professional supragingival plaque control 3 X a week while the contralateral sites served as controls. Clinical and bacterial examination were performed on days 7, 14, 28, 49, 56, 63 and 70 following therapy. All clinical parameters (P1I, GI, probing depth, attachment levels) showed significant improvement after scaling and root planing. Shifts in the subgingival bacterial population observed by dark field were also noticed following curettage: there was a decrease in the proportions of spirochetes and motile rods and an increase in that of coccoid cells. However, bacterial distribution tended to return to base line values towards the end of the observation period. No difference in the pattern of bacterial recolonization of the subgingival area could be detected between the sites under strict supragingival plaque control and the control sites.

The effect of Keyes' method of oral hygiene on the subgingival microflora compared to the effect of scaling and/or surgery

The present study was conducted on 18 individuals to determine if Keyes' method of oral hygiene would present an alternative to traditional periodontal therapy in terms of establishing a subgingival microflora compatible with periodontal health. Oral hygiene, gingival conditions and subgingival microbial proportions assessed by dark field microscopy were measured at baseline, then once every 2 weeks for the remainder of this 8-week study. In addition, probing depths and bleeding on probing were evaluated. Group I (9 patients) was treated non-surgically, while Group II (9 patients) had received surgical therapy within the last 4 years. Both groups received routine scaling and root planing (Sc/RP) on one arch at time 0, and both were instructed to use Keyes' method of oral hygiene on one side of the mouth while the other side served as a control. This yielded a split-plot experimental design which permitted examination of the effects of Keyes' method of oral hygiene, Sc/RP and surgery. The results revealed no statistically significant differences between Keyes' method of oral hygiene and conventional oral hygiene in patients treated with a single session of Sc/RP. When scaling was not employed, Keyes' method was more effective than conventional oral hygiene. Surgical status was found to be the most significant factor in reducing clinical indicator values and establishing control of the subgingival microflora. In summary, oral hygiene alone had only minimal effects on subgingival microbial proportions. The primary antimicrobial effect observed, as evidenced by shifts in subgingival morphotype proportions, was produced by the Sc/RP procedure. This effect was enhanced by improved access (surgical status).

Effect of combined systemic antimicrobial therapy and mechanical plaque control in patients with recurrent periodontal disease

The aim of the present study was to analyze the effect of systemic antimicrobial therapy and mechanical plaque control in patients with recurrent periodontal disease. 9 patients volunteered for the combined therapy. At a baseline examination they were randomly distributed into 2 groups, one given tetracycline therapy for 2 weeks and the other metronidazole therapy for 1 week. A mechanical plaque control program comprising oral hygiene training, professional cleaning of all teeth and subgingival debridement at diseased sites was carried out at the baseline examination and at all recall visits, i.e. once every month during the first 6 months and then after 9, 12, and 18 months. The results demonstrated clinically and microbiologically that a combination of an initial antimicrobial and a continuous systematic mechanical plaque control program may be a valuable therapeutic approach in a strictly selected group of refractory patients. Recurrent periodontal lesions which still displayed severe inflammation despite renewed conventional therapy showed a marked reduction in probing depths, bleeding and suppuration from the pockets, and further, a reduced presence of spirochetes and motile rods during the trial. The results indicate that the level and longevity of success is also related to whether or not self-performed oral hygiene measures are sufficiently carried out. No superior effect of the combined program could be observed in cooperating patients receiving tetracycline as compared with those given metronidazole.

Comparison of surgical and nonsurgical treatment of periodontal disease. A review of current studies and additional results after 61/2 years

Many well designed clinical studies have established the effectiveness of periodontal therapy. Surgical procedures have been shown to be effective in treating periodontitis when followed by appropriate maintenance care. Scaling and root planing alone have recently been compared to scaling and root planing plus soft tissue surgery in several longitudinal trials. A review of the literature indicates several important findings including a loss of clinical attachment following flap procedures for shallow (1-3 mm) pockets and no clinically significant loss after scaling and root planing. These studies also generally report either a gain or maintenance of attachment level for both procedures in deeper pockets (greater than or equal to 4 mm). For these pockets, neither procedure has been shown to be uniformly superior with respect to attachment gain. All reports indicate that both treatment methods result in pocket reduction. However, the literature also indicates that scaling and root planing combined with a flap procedure results in greater initial pocket reduction than does scaling and root planing alone. This difference in degree of pocket reduction between procedures tends to decrease beyond 1-2 years. It has been shown that both treatment methods result in sustained decreases in gingivitis, plaque and calculus and neither procedure appears to be superior with respect to these parameters. Additional data from the study at the University of Minnesota indicate that similar results are maintained up to 61/2 years following active therapy. Pocket depth did not change for shallow (1-3 mm) pockets treated by either scaling and root planing alone or scaling and root planing followed by a modified Widman flap. For pockets 4-6 mm, both treatment procedures resulted in equally effective sustained pocket reduction. Deep pockets (greater than or equal to 7 mm) were initially reduced more by the flap procedure. After 2 years, no consistent difference between treatment methods was found in degree of pocket reduction. However, as compared to baseline, pocket reduction was sustained to 61/2 years with the flap and only 3 years with scaling and root planing alone. After 61/2 years, sustained attachment loss in shallow (1-3 mm) pockets was found after the modified Widman flap. Scaling and root planing alone in these shallow pockets did not result in sustained attachment loss. For pockets initially 4-6 mm in depth, attachment level was maintained by both procedures but scaling and root planing resulted in greater gain in attachment as compared to the flap at all time intervals.(ABSTRACT TRUNCATED AT 400 WORDS)

"Critical probing depths" in periodontal therapy

The present investigation was carried out on 15 individuals who were referred for treatment of moderately advanced periodontal disease. All patients were first subjected to a Baseline examination comprising assessment of oral hygiene and gingival conditions, probing depths and attachment levels. Following case presentation and instructions in oral hygiene measures, the patients were given periodontal treatment utilizing a split mouth design. In one side of the jaw scaling and root planing were performed in conjunction with a modified Widman flap procedure while in the contralateral jaw quadrants the treatment was restricted to scaling and root planing only. The period from initial treatment to 6 months after treatment was considered to be the healing phase and from 6-24 months after treatment the maintenance phase. During the healing phase the patients were recalled for professional tooth cleaning once every 2 weeks. During the maintenance phase the interval between the recall appointments was extended to 3 months. Reexaminations were carried out 6, 12 and 24 months after the completion of active treatment. The results revealed that treatment resulted in loss of clinical attachment in sites with initially shallow pockets, while sites with initially deep pockets gained clinical attachment. With the use of regression analysis "critical probing depths" were calculated for the two methods of treatment used. It was found that the critical probing depth value for scaling and root planing was significantly smaller than the corresponding value for scaling and root planing used in combination with modified Widman flap surgery (2.9 vs 4.2 mm). In addition, the surgical modality of therapy resulted in more attachment loss than the non-surgical approach when used in sites with initially shallow pockets. On the other hand, in sites with initial probing depths above the critical probing depth value more gain of clinical attachment occurred following Widman flap surgery than following scaling and root planing. The data obtained from the reexaminations 12 and 24 months after active treatment demonstrated that the probing depths and the attachment levels obtained following active therapy and healing were maintained more or less unchanged during a maintenance care period which involved careful prophylaxis once every 3 months. However, the data also disclosed that the level of oral hygiene maintained by the patients during healing and maintenance was more critical for the resulting probing depths and attachment levels than the mode of initial therapy used.(ABSTRACT TRUNCATED AT 400 WORDS)