They showed significant improvement in both groups, but failed to show that FMD produced a better result.23 When the microflora was analysed they could not show that FMD resulted in greater reduction in the bacteria.24 In a third paper, they reported both therapies were associated with a reduction in antibody titre and an increase in avidity, but no significant differences between test and control groups.25 The only difference they reported was that the FMD group reported more post‐SRP pain.23. The choice of FMD or QSRP depends on the operator, patient, time required to debride the oral cavity, cost, efficiency and post‐SRP pain as both methods seem equally effective.32 The original FMD protocol is intense and may not be realistic in private practice. A range of curved tips designed for multi‐rooted teeth is available (Fig 6). Use the link below to share a full-text version of this article with your friends and colleagues. Modern technology has made removal of microbial deposits by the patient and dental professionals more efficient. Microbiological and SEM-EDS Evaluation of Titanium Surfaces Exposed to Periodontal Gel: In Vitro Study. Curettes may be universal or area‐specific. Bone sparing agents are used to reduce the amount of bone resorption by inhibiting osteoclastic activity. For sites 1–3 mm deep, he noted little change in PD and a slight loss of attachment of 0.3–0.9 mm, suggesting that SRP at these sites causes more damage than good. More recent reports have also shown limited additional benefit of a single‐visit (often just one hour) or full‐mouth cleaning within 24 hours irrespective of hand or ultrasonic cleaning and choice of irrigant.26-30 Lately, a meta‐analysis and review of FMD31 concluded, given the papers they assessed, that FMD was no more beneficial than QSRP. The initial phase of periodontal treatment should also include removal of caries with temporary or permanent restoration depending on the prognosis of the teeth. Hopeless teeth should ideally be removed and endodontically‐involved teeth dressed and temporized. Microbiological findings, Quadrant root planing versus same‐day full‐mouth root planning III. In an earlier study, Christersson et al.65 reported difficulty in reducing levels of Aggregatibacter actinomycetemcomitans (formerly Actinobacillus) by SRP alone in localized juvenile periodontitis patients. As with brushing, advice should be tailored to the patient and the most appropriate device for the size of the interproximal space chosen. This seems to make no difference in the healing response.1 Ultrasonics may also be used to remove overhanging margins of restorations. The sharp pointed tip prevents much subgingival use. The emphasis of our practice is conservative periodontal therapy. Learn more. It consists of patient motivation and oral hygiene instruction as well as mechanical removal of. The tip moves in an elliptical path and allows all surfaces to be used for debridement. The full text of this article hosted at iucr.org is unavailable due to technical difficulties. Hydroxyapatite also absorbs this wavelength making this laser suitable to not only soft tissues, but hard tissue ablation. Polishing of restorations and removal of staining will decrease the rate and amount of plaque build‐up in subjects with good oral hygiene. Although statistically significant, 0.5 mm may not be clinically significant given the extra cost and time involved. (Diagram reproduced with permission from Haffajee and Socransky.6). Toothpicks and interdental brushes are simple to use. Generally speaking the more severe the disease is at outset, the poorer the outcome and the greater the likelihood of further treatment. Chlorhexidine is the most well known antiseptic and has been shown to be good in reducing levels of plaque and inflammation with a long substantivity. The conventional treatment of plaque‐induced periodontal disease is usually debridement of the whole mouth by quadrant or sextant (QSRP) over a number of visits depending on the severity. Both sonic and ultrasonic scalers generate heat during use requiring a coolant, most commonly water. There is very little change in bone height at sites with horizontal bone loss.72 Vertical defects display some infill and gain in bone height.73 However, these changes may not be seen on radiographs. Wound biofilms: Lessons learned from oral biofilms. Non-surgical removal of plaque and calculus has been part of the initial phase of the management of patients with gingivitis. Minimum intervention dentistry: periodontics and implant dentistry. Many different toothbrushing methods have been suggested, but none has been shown superior to another. Products shown in the photographs were given to the author by the manufacturers. A visit to the chemist or supermarket will reveal a plethora of different toothbrushes (Fig 2). Photodynamic therapy: a targeted therapy in periodontics, https://doi.org/10.1111/j.1834-7819.2009.01146.x. The use of lasers in the treatment of plaque‐induced periodontal diseases is relatively recent, having first been reported in the mid 1980s. It also comments on full‐mouth disinfection, the use of lasers and host modulation. Please check your email for instructions on resetting your password. Some of the plethora of interdental cleaning aids. Hand instruments leave the root surface with a smooth feel, whereas ultrasonics leave a rougher, grittier surface. If a patient has a standard of oral hygiene sufficient to prevent periodontal disease then they probably do not need to use an adjunct. Each successive wave of colonization makes the foundations for the next more pathogenic group eventually resulting in the most pathogenic group, the red complex. Replacing the pathogenic flora with a “more friendly” flora has just started to receive attention and may be promising. The advent of molecular and DNA identification methods has allowed a more exact and comprehensive evaluation of the effects of SRP on the bacterial flora, especially the red group, further confirming their role in the pathogenesis of periodontal disease. While the test subjects experienced greater improvements in clinical parameters, the differences were statistically significant, but not clinically significant. Antimicrobial properties of laser treatment in periodontal therapy. The book will enable practicing clinicians and students to successfully meet the challenge of excellent patient care, by providing , in a concise and simplified format, both classic and contemporary practical measures that address all aspects of non-surgical periodontal disease management. This hasn’t changed and, once disease is established in a patient, probably will not change in the future. Scaling and Root Planing. They are much easier to hold and use. A review of antibiotics is outside the scope of this article and will be ably discussed by Heitz‐Mayfield later in this supplement.15 The antiseptics are used in toothpastes, mouthwashes, sprays, gels, irrigators and varnishes. Non‐modifiable factors, such as genetic profile, e.g., IL‐1 polymorphism3 have to be accepted, but factored into the treatment plan and expected outcomes. The original protocol involved full‐mouth scaling and root planing within 24 hours, brushing the dorsum of the tongue for one minute with 1% chlorhexidine (CHX) gel, rinsing twice with 0.2% CHX mouthwash for one minute, subgingival irrigation three times within 10 minutes with 1% CHX gel and repeated eight days later and twice daily rinsing by the patient with 0.2% CHX mouthwash for 14 days.21 The initial study reported the outcome in 10 patients and showed a significantly greater reduction in probing depth in the FMD group compared to the conventional protocol after two months.21 The effect was more pronounced at deeper sites. One suggestion about brushing methods is to modify the patient’s existing technique to make sure it is thorough, methodical and removes as much plaque as possible rather than teaching the patient a completely new technique. Deep sites could take up to nine months for their full response to therapy and it is probable that decisions at reassessment, taken only eight weeks after the last SRP visit, have not allowed for the time taken for healing at deep sites. Lasers possess excellent tissue ablation, bacteriocidal and detoxification properties leaving little or no smear layer and any scatter may stimulate surrounding cells improving healing. Apatzidou and Kinane23 repeated these studies in test and control groups of 20 chronic periodontitis subjects. The decision to use a mouthwash is more likely to be patient choice than clinical. Recently, the Bass or modified Bass technique has been in favour. They showed significant improvement in both groups, but failed to show that FMD produced a better result.23 When the microflora was analysed they could not show that FMD resulted in greater reduction in the bacteria.24 In a third paper, they reported both therapies were associated with a reduction in antibody titre and an increase in avidity, but no significant differences between test and control groups.25 The only difference they reported was that the FMD group reported more post‐SRP pain.23. This includes changing patient behavior through educating the patient on their condition, oral hygiene, scaling and addressing modifiable risk factors (such as smoking). Therefore, it is hard to draw definite conclusions. It consists of patient motivation and oral hygiene instruction as well as mechanical removal of supra and subgingival plaque deposits. Electric toothbrushes are designed to overcome some of the limitations of manual brushing (Fig 3). Ultrasonics have an advantage in cleaning furca as they are usually narrower than the furcal opening. I. Long‐term clinical observations, Quadrant root planing versus same‐day full‐mouth root planing I. However, other advancements need to be used in conjunction with mechanical debridement at this time. Diode lasers are excellent for soft tissue surgery and have recently been developed for calculus detection in combination with a laser fluorescence probe. Ultrasonic devices can be further divided into piezoelectric and magnetostrictive. In the experience of the author, sometimes non‐surgical management is undertaken to better ascertain the patient’s motivation and interest, or to gauge the prognosis of teeth, especially when deciding which teeth to extract. Periodontal considerations in older individuals. A review of antibiotics is outside the scope of this article and will be ably discussed by Heitz‐Mayfield later in this supplement.15 The antiseptics are used in toothpastes, mouthwashes, sprays, gels, irrigators and varnishes. Continual root planing of surfaces over a period of time may result in substantial loss of the root surface. Ultrasonic instruments have the advantage of being quicker, less fatiguing, easier to use and the flushing action of the coolant. In terms of sales, it is the market leader by far. The amount of recession is related to the initial probing depth with the deeper sites exhibiting more recession.1 Coupled with the reduction in inflammation is an increase in collagen fibres in the connective tissue beneath the pocket and formation of a long junctional epithelial attachment. (Diagram reproduced with permission from Haffajee and Socransky.6). I. Long‐term clinical observations, Quadrant root planing versus same‐day full‐mouth root planing I. Non-surgical periodontal therapy is an umbrella term used to describe all the non-surgical methods by which periodontal disease can be treated. Many of the modern toothbrush designs fulfill these requirements. Surgical and non‐surgical treatment of periodontal diseases Leticia Helena Theodoro Research and Study on Laser in Dentistry Group (GEPLO), Department of Surgery and Integrated Clinic, Division of Periodontics, University Estadual Paulista (UNESP), Araçatuba, SP, Brazil It consists of patient motivation and oral hygiene instruction as well as mechanical removal of supra and subgingival plaque deposits. Interdental brushes are most commonly cylindrical or conical and come in a range of sizes. Non-Surgical Treatment for Moderate to Severe Gum Disease in Pittsburgh With the Perioscope, we can treat over 90% of our patients who have periodontitis without surgery. Every patient with untreated periodontitis should undergo a course of initial or hygiene phase, as it is beneficial for all sites.1 Patient motivation and excellent oral hygiene are vital for a successful outcome, not only in the short term, but also for the long term.2 The success of subsequent surgical procedures depends on the standard of home care. Lasers possess excellent tissue ablation, bacteriocidal and detoxification properties leaving little or no smear layer and any scatter may stimulate surrounding cells improving healing. Evaluating clinical and laboratory effects of ozone in non-surgical periodontal treatment: a randomized controlled trial. Common brands are EMS Piezon (Electro Medical Systems, Nion, Switzerland) and NSK Varios (NSK Tech, Sydney, Australia). An alternating magnetic field in response to an electrical current causes the movement of the tip in magnetostrictive machines. Non-Surgical Management of Periodontal Diseases: The Mainstay of Dental Therapy Speaker: Paul Levi, Jr., Associate Clinical Professor Course Details: A discussion of dental plaque and its etiologic effect on dental caries and periodontitis will initiate the Webinar, which will cover the following. Using this system Aoki et al.37 showed effective removal of calculus from the root surface with some surface ablation confined to cementum. The application of beneficial bacteria is not new with “probiotics” being applied for gastrointestinal disturbances, otitis media and caries for over 40 years.34. Very often, early stages of periodontal disease are effectively treated with non-surgical periodontal therapy. Severely advanced periodontitis, The long‐term effect of a plaque control program on tooth mortality, caries, and periodontal disease in adults. It has been shown beyond doubt that the accumulation of plaque leads to gingival inflammation and its removal leads to a reduction in inflammation.7 Therefore, removal of plaque by patients is a vital part of non‐surgical management. Although statistically significant, 0.5 mm may not be clinically significant given the extra cost and time involved. The purpose of this review was to assess recent changes. Our patients know to brush their teeth twice a day, but most do not do this particularly well. Although the early laser evaporated calculus efficiently, they caused substantial thermal damage of the underlying tooth structures. The root cementum is colonized by bacteria and contaminated by bacterial products, which affect the healing.69 It recommended that as part of treatment the infected root surface should be removed to improve the response and provide a root surface compatible with soft tissue reattachment. On units with a separate coolant supply, saline or chlorhexidine and other mouthwashes can be used, although this has no proven benefit over sterile water.17 The coolant also acts to flush the pocket and collapsing bubbles cause cavitation. 2014 Aug;3(3):62-5. Working off-campus? There are also the well‐known issues with patients taking bisphosphonates.56, Supragingival oral hygiene without subgingival debridement has little effect on the subgingival microflora.57, 58 However, post‐SRP good oral hygiene can reduce the numbers of the periopathogenic bacteria subgingivally, but only in pockets less than 5 mm deep.59, 60 Proper supragingival oral hygiene can reduce and delay the recolonization of pockets.61. Recently, the Bass or modified Bass technique has been in favour. The protection provided by the glycocalyx prevents ingress of the host immune response, but also antibiotics and antiseptics. Deep sites could take up to nine months for their full response to therapy and it is probable that decisions at reassessment, taken only eight weeks after the last SRP visit, have not allowed for the time taken for healing at deep sites. Examples of the different types of toothbrushes available. Hilana Paula Carillo Artese I; Celso Oliveira de Sousa I; Ronir Raggio Luiz II; Carmelo Sansone I; Maria Cynésia Medeiros de Barros Torres I. I Department of Dental Clinic, Division of Graduate Periodontics, School of Dentistry, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil It is difficult to compare the many studies in terms of protocols and types of lasers used, but in some lasers may remove some calculus and plaque to a level equivalent to that of hand or ultrasonic instrumentation. In his 1996 review, Cobb74 summarized the outcomes of SRP based on initial probing depths. Lang et al.9 showed, using a group of dentally aware subjects, that with excellent oral hygiene skills, once every 48 hours is the minimum to maintain gingival health. Clinical findings, Quadrant root planing versus same‐day full‐mouth root planing II. Cytokine and matrix metalloproteinase expression in fibroblasts from peri‐implantitis lesions in response to viable orphyromonas gingivalis. Non‐modifiable factors, such as genetic profile, e.g., IL‐1 polymorphism3 have to be accepted, but factored into the treatment plan and expected outcomes. Hence, it is very suitable for soft tissue procedures. Some of the plethora of interdental cleaning aids. A fundamental change in the last decade is our understanding that plaque is a biofilm. The disadvantages may be pain and sensitivity during use, thermal damage to tooth structure, poorer tactile sensation and the creation of an aerosol. In the piezoelectric scaler, an alternating current across a crystal in the handle results in a dimensional change that then makes the tip move. The more strokes and the greater the force used the greater the loss of hard tissue.71 The amount removed varied from 34 μm after five strokes to 343 μm after 40 strokes. However, they show a history of significant side effects, most notably thermal damage to the root surface. Hydroxyapatite also absorbs this wavelength making this laser suitable to not only soft tissues, but hard tissue ablation. Traditionally scaling and root planing instruments have been divided into hand and powered instrumentation. At sites 7 mm+ the changes were the greatest with a reduction in PD of 1.2–2.9 mm on average and a gain in AL of 0.5–1.6 mm. This included carbonization, microcracking, melting and resolidification of the root surface and dentine. It has been shown that sites 4 mm or less can be well debrided76 and good patient oral hygiene can influence the microflora in pockets up to 4 mm reducing the build‐up of the periopathogenic microflora.58, 59 Interestingly, Badersten et al.1 reported that the deeper the site, the longer it took to achieve maximal healing. However, it has been shown that periopathogens can be transmitted intra‐orally from “uncleaned” sites or from reservoirs such as the tongue, tonsils, cheeks and other mucous membranes.19, 20 This led Quirynen et al.21 to suggest that a disinfected site may be recolonized before the completion of treatment and the concept of full‐mouth disinfection (FMD). Microbiological and SEM-EDS Evaluation of Titanium Surfaces Exposed to Periodontal Gel: In Vitro Study. Controlling Systemic Risk Factors.Several risk factors have well established associations with both periodontal and systemic diseases, such as diabetes, smoking, stress, immunodeficiency, medications, obesity, hormones, and nutrition. Common area‐specific curettes are the series of Gracey curettes, designed for specific teeth or surfaces, i.e., 11/12 for anterior surfaces of molars and 13/14 for distal surfaces of these teeth, where they are generally more effective than universal curettes. It also comments on full‐mouth disinfection, the use of lasers and host modulation. Toothbrushes do not clean interproximally and interdental cleaning is poorly performed by people in general.13 Plaque accumulation, gingival inflammation and periodontal disease are more pronounced interproximally than on other surfaces.14 There are many interdental cleaning aids available and are, most commonly, floss (or tape), woodsticks or interdental brushes (Fig 4). Therefore, it is necessary to disturb the biofilm when prescribing antimicrobials to allow greater access, but also to increase the multiplication rate of the bacteria making the antibiotic much more effective. The author has been involved in presenting educational programmes relating to oral health care products for a number of different manufacturers, but has no direct financial interest in these products or the companies which manufacture them. Generally speaking the more severe the disease is at outset, the poorer the outcome and the greater the likelihood of further treatment. Certificates. An aggressive approach is not warranted as the infected layer can be removed by gentle scaling with hand instruments or ultrasonics and endotoxin can be removed using only a microbrush.70 Root planing will remove all the cementum and some of the superficial dentine. Mongardini et al.22 published a longer follow‐up of up to eight months post‐treatment in 24 adult and 16 generalized early‐onset periodontitis (GEOP) patients, again showing that FMD was better than generalized early‐onset periodontitis (QSRP). In addition, twice daily fits much better into forming a habit than once every 48 hours.11 The average person cleans their teeth for less time than they think. A controlled, prospective clinical study, Host modulation with tetracyclines and their chemically modified analogues, Subantimicrobial dose doxycycline enhances the efficacy of scaling and root planing in chronic periodontitis: a multicenter trial, Treatment with subantimicrobial dose doxycycline improves the efficacy of scaling and root planing in patients with adult periodontitis, Adjunctive subantimicrobial dose doxycycline in smokers and non‐smokers with chronic periodontitis, Modified‐release subantimicrobial dose doxycycline enhances scaling and root planing in subjects with periodontal disease, The use of crevicular fluid prostaglandin E2 levels as a predictor of periodontal attachment loss, Suppression of inflammation and bone resorption by indomethacin during experimental periodontitis in dogs, Flurbiprophen: a potent inhibitor of alveolar bone resorption in beagles, Effects of flurbiprophen on the progression of periodontitis in Macaca mulatto, Flurbiprofen treatment of human periodontitis: effect on alveolar bone height and metabolism, Altering the progression of human alveolar bone loss with the non‐steroidal anti‐inflammatory drug flurbiprofen, The effect of systemically‐administered flurbiprofen as an adjunct to toothbrushing on the resolution of experimental gingivitis, Host‐response therapeutics for periodontal diseases, Periodontal host modulation with antiproteinase, anti‐inflammatory, and bone‐sparing agents. 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