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Evaluation Op Adjunctive and Alternative Techniques in Periodontal Therapy

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Evaluation Op Adjunctive and Alternative Techniques in Periodontal Therapy EVALUATION OP ADJUNCTIVE AND ALTERNATIVE TECHNIQUES IN PERIODONTAL THERAPY Mehrdad Radvar D.D.S (Iran) Thesis submitted for the degree of PhD to the Faculty of Medicine, University^of Glasgow Periodontology Unit, Glasgow Dental Hospital and School, University of Glasgow ® M.Radvar, December 1995 ProQuest Number: 13818537 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a com plete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. uest ProQuest 13818537 Published by ProQuest LLC(2018). Copyright of the Dissertation is held by the Author. All rights reserved. This work is protected against unauthorized copying under Title 17, United States C ode Microform Edition © ProQuest LLC. 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Box 1346 Ann Arbor, Ml 48106- 1346 103 <4 I GLASGOW UNIVERSITY LIBRARY TABLE OF CONTENTS CONTENTS Page i LIST OF TABLES xi LIST OF FIGURES xvii ABBREVIATIONS xxi ACKNOWLEDGEMENTS xxi i i DECLARATION xxiv SUMMARY xxv CHAPTER 1 Introduction 1.1 General introduction 1 1.2 Definitions 2 1.2.1 The 'normal' periodontium: Clinical 2 and histological appearance 1.2.2 Diseased periodontium: Clinical 3 features and epidemiology 1.2.3 Diseased periodontium: Aetiology 7 and pathogenesis 1.2.3.1 Gingivitis 8 1.2.3.2 Periodontitis 9 1.2.3.3 Bacterial plaque 10 1.3 The role of bacteria in the 10 aetiology of periodontal disease 1.4 Host mediated tissue damage 12 1.5 The clinical assessment of 13 periodontium 1.5.1 Plaque index 13 1.5.2 Gingival index 15 GCF flow 18 Bleeding on probing 18 Probing depth and probing attachment 21 level 26 Electronic pressure sensitive probes 30 Treatment strategies in periodontal therapy 30 Resective therapy 30 Mechanical therapy 30 The practical limitation of the 32 traditional mechanical therapy Alternatives or adjuncts to root 33 planing Regenerative therapy 33 Antimicrobial therapy 34 A review of systemic antibacterial 34 therapy for the treatment of periodontal disease Introduction 34 Tetracyclines 35 Metronidazole 41 Other antibiotics 43 Concluding remarks from the systemic 44 antibiotic therapy Locally delivered antimicrobial 45 systems Introduction 45 Terminology 47 1.8.3 Classification 48 1.8.4 Kinetics of the release 49 1.8.5 A literature review of local drug 50 delivery systems in the treatment of periodontal disease 1.8.5.1 Hollow fibres 50 1.8.5.2 Acrylic strips 52 1.8.5.3 Ethyl cellulose films 53 1.8.5.4 Collagen films 55 1.8.5.5 Monolithic fibres 56 1.8.5.6 Supragingivally apllied anti-plaque 61 agents 1.8.5.7 Subgingival irrigation 61 1.8.5.8 Biodegradable systems and gels 62 (metronidazole gel, minocycline gel and other resorbable systems) 1.9 A critical conclusion of the 73 literature review 1.10 Laser 79 1.10.1 General introduction to lasers 79 1.10.2 Production of laser beam 79 1.10.3 Laser interaction with tissues 80 1.10.4 Types of lasers 81 1.10.2 N d :YAG Laser 81 1.10.3 The effects of lasers on the pulp 82 1.10.4 Lasers in periodontics 83 1.10.4.1 Soft tissue surgery 83 iii 1.10.4.2 Treatment of dentinal 85 hypersensitivity 1.10.4.3 Lasers and the root surface 85 1.10.4.4 The bactericidal effect of lasers 90 1.10.5 Concluding remarks from the laser 91 literature 1.11 Aims 93 CHAPTER 2 Materials, methods and preliminary experiments 2.1 Introduction 95 2.2 The clinical study of subgingival 96 antimicrobial systems: preliminary studies, materials and methods 2.2.1 The Florida probe in measurements of 96 probing pocket depth and probing attachment level 2.2.2 Preliminary study; Comparison between 99 two versions of the Florida probe for attachment level measurements 2.2.2.1 Introduction 99 2 .2 .2.2 Material & methods 100 2.2.2.3 Results 100 2.2.2.4 Discussion 101 2.2.3 Preliminary study; The intra-examiner 103 reproducibility of duplicated measurements of probing depth and attachment levels. 2.2 .3.1 Introduction and methods 103 2.2.3.2 Results and Discussion 104 iv 2.2.4 Preliminary study; The estimation of 105 sample size for the study of subgingival antimicrobial therapy 2.2.4.1 Introduction 105 2.2.4.2 Material & methods 107 2.2.4.3 Results 109 2.2.4.4 Discussion 110 2.2.5 Material and methods used in the 113 clinical study of the subgingival antimicrobial systems 2.2.5.1 Clinical design 113 2.2.5.1 Patient screening and selection 114 2.2.5.3 Clinical indices 115 2.2.5.4 The Modified Gingival Index 115 2.2.5.5 The Plaque Index 116 2.2.5.6 Gingival crevicular fluid measurements 117 2.2.5.7 Calibration of Periotron 118 2.2.5.8 The probing pocket depth and probing 118 attachment levels 2.2.5.9 Bleeding on probing (BOP) 119 2.2.5.10 Suppuration 119 2.2.5.11 Controlled randomisation; criteria for 119 patient allocation to treatments 2.2.5.12 Treatments 120 2.2.5.13 Statistical analysis 123 2.3 The laser in vitro studies 126 V 2.3.1 Preliminary study; Preliminary 1 2 6 evaluation of the effect of an Nd:YAG laser on calculus 2.3.1.1 Introduction 126 2.3.1.2 Materials and methods 127 2.3.1.3 Results 128 2.3.1.4 Discussion 129 2.3.2 Preliminary study; Selection of laser 130 settings 2.3.2.1 Introduction and methods 130 2 .3 .2 .2 Materials and methods 131 2.3.2.3 Results 131 2.3.2.4 Discussion and conclusion 131 2.3.3 Preliminary study; Explanation of 132 cracking of the laser treated surface 2.3.3.1 Introduction 132 2.3 .3.2 Material and methods 132 2.3.3.3 Results and conclusion 133 2.3.4 Material and methods used in the main 133 in vitro laser experiment 2.3.4.1 Introduction 133 2.3.4.2 Tooth collection and preparation 134 2.3.4.3 Study design 135 2.3.4.4 The N d :YAG laser 136 2.3.4.5 Laser usage and safety 136 2.3.4.6 Laser treatment 137 2.3.4.7 Fixation 138 VI 2.3.4.8 Dehydration 138 2.3.4.9 Sputter coating 139 2.3.4.10 Scanning electron microscopy (SEM) 139 2.3.4.11 Index of laser damage 139 2.3.4.12 Statistical analysis 140 2.4 The clinical laser study 141 2.4.1 Introduction; the rationale for the 141 choice of laser settings 2.4.2 Study design; patient and site 143 selection 2.4.3 Treatments 143 2.4.4 Clinical measurements 144 2.4.5 The Plaque Index and the Modified 144 Gingival Index 2.4.6 Pocket depth 144 2.4.7 Bleeding index 145 2.4.8 Microbial sampling and culture 145 2.4.9 Extraction and SEM 146 2.4.10 statistical analysis 146 CHAPTER 3 Results 3.1 The clinical study of local 148 antimicrobial delivery systems 3.1.1 Introduction 148 3.1.2 Dropped out subjects and excluded 148 sites 3.1.3 Study visits 150 vii 3.1.4 Demographic characteristics of the 150 patients 3.1.5 Baseline data 151 3.1.6 Mean reduction in probing pocket depth 152 3.1.7 Mean change in probing attachment 155 level 3.1.8 The effect of baseline probing pocket 157 depth on the treatment outcome 3.1.9 Change in the recession 157 3 .1.10 Changes between visits 158 3 .1.11 The percentage of sites which showed 160 pocket depth reduction/attachment gain above 3 x standard deviation of measurements 3.1.12 Bleeding on probing 162 3.1.13 Suppuration 164 3.1.14 The Plaque Index 166 3.1.15 The Modified Gingival Index 166 3.1.16 The effect of smoking status on the 168 treatment outcome 3.1.17 The effect of previous history of 171 periodontal surgery on pocket depth reduction 3.1.18 The gingival crevicular fluid volume 171 (GCF) 3.1.19 Adverse effects 171 3.1.20 Time taken for the treatments 172 3.1.21 Sites requiring interventional 172 treatment viii 3.2 An evaluation of the effect of Nd:YAG 174 laser on calculus, cementum and dentine, an in vitro study 3.2.1 Calculus 174 3.1.2 Cementum and dentine 175 3.3 Evaluation of the Nd:YAG laser in 177 periodontal pocket therapy 3.3.1 Plaque Index and Modified Gingival 177 Index 3.3.2 Probing pocket depth 177 3.3.3 Total anaerobic counts 178 3.3.4 Bleeding on probing 178 3.3.5 Scanning Electron Microscopy (SEM) 179 CHAPTER Discussion 4.1 Introduction 180 4.2 The clinical study of locally 181 delivered antimicrobial systems 4.2.1 Clinical response 181 4.2.1.1 Significant improvement after 181 treatments 4.2.1.2 Rebound towards baseline 182 4.2.1.3 Healing period after root planing 182 alone 4.2.1.4 The effects of locally delivered 183 antimicrobial systems on probing pocket depth, attachment level and recession 4.2.1.5 Bleeding on probing 186 4.2.1.6 Suppuration 187 ix 4.2.1.7 The Plaque Index, the Modified 189 Gingival Index, and the GCF volumes 4.2.2 Methodological considerations 192 4.2.2.1 Screening of the sites 192 4.2.2.2 Patient population 194 4.2.2.3 Parallel design 195 4.2.2.4 Sample size estimation 196 4.2.2.5 Measurements of attachment level and 197 pocket depth 4.2.3 The effect of baseline pocket depth 198 on the response to treatment 4.2.4 The effect of smoking 201 4.2.5 Th effect of previous surgery 206 4.2.6 Safety 206 4.2.7 Treatment time and cost-effectiveness 207 4.3 The in vitro laser study 208 4.4 The clinical laser study 212 4.5 Conclusion and further studies 217 References 219 List of publications 266 x List of Tables Tables ...............................................
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