AIMETTI

Nonsurgical periodontal treatment

Essayist: Mario Aimetti

Abstract „ Quadrant/sextant wise instrumenta- tion (conventional staged debride- The primary goal of nonsurgical peri- ment, CSD). odontal therapy is to control microbial „ Instrumentation of all pockets within periodontal infection by removing bac- BIPVSQFSJPEXJUI GVMMNPVUIEJT- terial biofilm, , and toxins from infection [FMD]) or without (full mouth periodontally involved root surfaces. A [FMSRP]) lo- review of the scientific literature indi- cal antiseptics. Both procedures can cates that mechanical nonsurgical peri- be associated with systemic antimi- odontal treatment predictably reduces crobials. the levels of inflammation and probing „ CSD or FMD in combination with laser pocket depths, increases the clinical at- or photodynamic therapy. tachment level and results in an apical shift of the . Another par- Patients with ameter to be considered, in spite of the constitute a challenge to the clinician. To lack of scientific evidence, is the reduc- date there are no established protocols tion in the degree of , as for controlling the disease. However, clinically experienced. data from the literature on the applica- It is important to point out that nonsur- tion of the FMD protocol combined with gical periodontal treatment presents lim- amoxicillin-metronidazole systemic ad- itations such as the long-term maintain- ministration are promising. ability of deep periodontal pockets, the A new classification in supra- and sub- risk of disease recurrence, and the skill crestal nonsurgical periodontal therapy of the operator. A high number of post- will be proposed. The supracrestal ther- treatment residual pockets exhibiting apy includes the treatment of , and > 5 mm deep nonsurgical coverage of recession-type are related to lower clinical stability. The defects, treatment of suprabony defects successful treatment of plaque-induced and papilla reconstruction techniques. periodontitis will restore periodontal Within subcrestal periodontal therapy, it health, but with reduced . is of paramount importance to preserve In such cases, anatomical damage from both marginal tissues and connective previous will persist fibers inserted in the root at and inverse architecture of soft tissue the apical part of the bony defects. may impair home plaque removal. The clinician can select one of the fol- lowing therapeutic options according to the individual patient’s needs:

251

THE INTERNATIONAL JOURNAL OF ESTHETIC 70-6.&t/6.#&3t46..&3 SCIENTIFIC SESSION

Nonsurgical periodontal individualized professional subgingival therapy: what does it instrumentation.8 mean? In the treatment of aggressive perio- dontitis, the association of the mechanical Development of a properly sequenced instrumentation with systemic antibiotics treatment plan is a derivative of the peri- would seem more effective from a clinical odontal assessment and diagnosis. Per- and microbiological point of view.9 iodontal therapy is diagnosis-driven and should address all local and host factors that impact on the development and pro- Objectives and limitation gression of periodontal diseases. In ad- of nonsurgical periodontal dition, it must take in account the expec- therapy tations and the socioeconomic status of the patients and the final endpoints of Regardless of the diagnosis of gingivitis, the operative protocol. chronic or aggressive periodontitis the Periodontal diseases are plaque-in- nonsurgical periodontal treatment is the duced inflammatory conditions affecting cornerstone of the periodontal therapy. It the periodontium, and if left untreated, is aimed at removal of supra- and sub- they may lead to destruction of the tooth- gingival plaque and calculus deposits supporting apparatus and eventually and, together with proper supragingival to tooth loss. Periodontal breakdown practices, at control of mi- is the results of a complex interplay of crobial infection and recovery of peri- bacterial aggression and host response odontal health. modified by hereditary, systemic and Proper supragingival plaque control environmental factors such as diabetes can effectively reduce gingivitis and it mellitus, connective tissue and hemato- is critical to achieve long-term control of logic disorders, and smoking habits. periodontitis.  Oral hygiene instruc- Some of these factors can be modified tions should be given to all patients to reduce patient’s susceptibility to peri- undergoing periodontal therapy. In our odontitis, but not all. Thus, the reduction/ opinion, patients are more motivated elimination of periodontal pathogens is to accept treatment recommendations still the primary goal of the periodontal when they are given the opportunity to therapy. The pathogens are organized see infection in their own mouths and in biofilm attached to the root surface they understand the value of treating in a protected environment, which pre- periodontal disease in relation to their vents the access of the host immune overall health. The clinician must individ- response, but also of the antimicrobial ualize the message to different patients agents.  Only therapies achieving the and instruct them in the use of tooth- mechanical disruption of the subgingi- brushing methods and oral hygiene val biofilm have shown to be effective devices more suitable for their gingival and, hence, periodontal health can be features. maintained only provided there is ade- Subgingival instrumentation compris- quate plaque control by the patient and es scaling and root planing by manual

252

THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6.&t/6.#&3t46..&3 AIMETTI

a b

Fig 1 (a) Baseline clinical image (frontal view) revealing heavy plaque and calculus accumulation, gin- gival inflammation and severe teeth migration in the second sextant. (b) Twelve years later the complete recovery of the gingival health as well as the spontaneous dental repositioning were achieved by nonsur- HJDBMQFSJPEPOUBMUIFSBQZ PDDMVTBMBEKVTUNFOUBOETVQQPSUJWFUIFSBQZXJUISFDBMMTFWFSZNPOUIT5IF anterior teeth were stabilized by means of extracoronal splintings. (Courtesy Dr Mariani.)

a b

Fig 2  3BEJPHSBQIJDJNBHFTPGUIFDMJOJDBMDBTFQSFTFOUFEJO'JHBUCBTFMJOF(a)BOEZFBSTMBUFS (b). A complete recovery of the periodontal health was evident together with the appearance of the lamina dura. The correct relocation of the anterior teeth in the was accompanied by the coronal migration of the alveolar bone crest. and ultrasonic devices. Tooth scaling is tum. When patient enters the mainte- a key component in treating gingivitis, nance therapy the SRP can be replaced while scaling combined with root planing by the periodontal in which (SRP) is the gold standard for the non- the removal of root cementum is not surgical management of periodontitis. longer necessary. The objective is to provide a root sur- Narrative and systematic reviews face compatible with periodontal health have documented the efficacy of SRP in by removing adherent and unattached the treatment of periodontitis. It re- bacterial plaque, microbial toxins, de- sults in reductions in bleeding on prob- posits of calculus and contaminated ing (BoP), probing depth (PD), subgin- cementum. Due to its strict adherence gival bacterial loads and gains in clinical to the root cementum it is impossible to attachment level (CAL).Another param- remove effectively subgingival calculus eter to be considered, in spite of the lack without removing the underlying cemen- of scientific evidence, is the reduction in

253

THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6.&t/6.#&3t46..&3 SCIENTIFIC SESSION

the degree of tooth mobility, as clinically Clinical studies reported that subgin- experienced. gival instrumentation failed to eliminate Nonsurgical periodontal treatment DBMDVMVTJOPGQFSJPEPOUBMQPDLFUT can also lead to spontaneous reposi- XJUIBEFQUIPGNN JOPGQPDLFUT tioning of pathologically migrated teeth XJUIBEFQUIPGUPNNBOEJOPG 'JHTBOE BOEUPDMPTVSFPGEJBTUF- QPDLFUT NNEFFQ JOPGTJOHMF mas. Control of infection and inflam- SPPUFEUFFUIBOEJOPGNVMUJSPPUFE mation, elimination of abnormal occlusal teeth.  'JH 3FDFOUMZ UIFJNQSPWF- forces and reorientation of supracrestal ments in ultrasonic devices, mainly with collagen fibers play an important role in the modifications of the working tips, the repositioning of teeth. have increased the effectiveness of ul- The reduction in PD following mechan- trasonic scalers to reach deeper into ical instrumentation results from both the periodontal pockets or furcation areas. shrinkage of the pocket soft tissue wall, Some studies suggest less cementum manifested as recession of the gingival removal and less operative discomfort margin, and the gain in clinical attach- compared to manual SRP but these find- ment. The magnitude depends on the ings are not universally demonstrated. initial PD. A review by Cobb reported It is our opinion that a combined in- a mean PD reduction and CAL gain of strumentation approach is indicated to NNBOENN SFTQFDUJWFMZ GPS optimize the treatment outcomes and JOJUJBM1%TPGUPNNBOEPGNN the choice of the treatment modality BOENN SFTQFDUJWFMZ GPSQPDLFUT should be based on the periodontal an- JOJUJBMMZöNNEFFQ In general, clin- atomic features and the individual pa- icians should evaluate post-SRP heal- tients’ needs. JOHBUUPXFFLTGPMMPXJOHUSFBUNFOU When analyzing the SRP outcomes it "GUFSXFFLT NPTUPGUIFIFBMJOHIBT is important to take in account the long- taken place but soft tissues maturation term maintainability of deep periodontal NBZDPOUJOVFGPSBOBEEJUJPOBMUP pockets, and the risk of disease recur- months or longer. rence. Post-treatment residual pockets The limitations of SRP are well recog- exhibiting BoP and more than 5 mm nized. The efficacy of the SRP seems deep are related to lower clinical stability to be directly related to the professional XJUIBOPEETSBUJPNPSFUIBOGPSEJT- skill and the anatomical features but not ease progression. Besides anatomical to the modality of debridement as ultra- damage from previous periodontal dis- sonic devices have achieved similar re- ease will persist and inverse architecture sults than hand instrumentation. The of soft tissue may impair home plaque results are dependent on local factors, removal. The choice between non-sur- such as deep and tortuous pockets and gical therapy alone and combined non- furcations, as well as on patient’s factors surgical and surgical therapy has to take such as smoking habits, uncontrolled di- in account the medical history, expecta- abetes mellitus and poor self-performed tions, psychological profile and degree plaque control which may limit the clinic- of compliance (full mouth plaque score al outcomes. <'.14> PGUIFQBUJFOU BOEUIFm-

254

THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6.&t/6.#&3t46..&3 AIMETTI

a bc

Fig 3 Electron scansion microscopic images of microbial plaque on the root surface of a hopeless tooth extracted at the completion of hand and ultrasonic instrumentation at magnifications of (a)¨ (b)¨  and (c)¨  $PVSUFTZ%S4DJQJPOJ

nal purpose of the treatment. If a patient tion by periodontal pathogens of the al- requires a prosthetic rehabilitation it is ready treated periodontal sites from the necessary to surgically correct the ana- remaining untreated pockets and from tomical defects caused by the disease intraoral bacterial reservoirs, such as and to achieve postoperative PDs less tongue, tonsils, and other mucous mem- UIBONNBOEBCTFODFPG#P1UPPQUJ- branes, that could lead to a disease re- mize the long-term prognosis. currence.  In an attempt to improve subgingival Based on these premises the Leu- instrumentation new treatment proto- ven research group proposed the one- cols, the adjunctive use of systemic an- stage full-mouth disinfection protocol timicrobials, and new technologies have (OSFMD) which consisted of full-mouth been suggested. SRP combined with a disinfection of all intraoral niches by means of the topi- cal application of , within Advances in non-surgical  IPVST VTVBMMZ JO  TFTTJPOT PO  treatment protocols consecutive days). They reported clinical and microbiological advan- Traditionally, SRP was carried out ei- tages compared to the CSD therapy in ther quadrant- or sextant-wise in ses- chronic and aggressive periodontitis sions usually scheduled at weekly inter- patients. vals (conventional staged debridement Other researchers proposed the treat- [CSD]).0WFSUIFMBTUZFBST NBOZ ment protocol of the full-mouth SRP (FM- clinical trials have been carried out in SRP). The supra- and subgingival instru- an effort to assess whether it would be NFOUBUJPOXBTDPNQMFUFEJOIPVSTPS advantageous to change the stand- less with no adjunctive use of antiseptics BSEUPXFFLQFSJPEPGOPOTVSHJDBM agents. When the FMSRP was com- periodontal treatment to a full-mouth pared to the standard approach neither IPVSBQQSPBDI5IFSBUJPOBMFGPSUIF clinical nor microbiological differences latter strategy was to prevent reinfec- were detected. 

255

THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6.&t/6.#&3t46..&3 SCIENTIFIC SESSION

a b

Fig 4 Clinical images of ulcero-necrotic gingivitis treated by the administration of antimicrobials and an- tiseptics, and then by the ultrasonic instrumentation (a). Care was taken not to damage the marginal peri- odontal tissues. In spite of the destructive features of the pathology, this procedure and the thick gingival biotype made it possible to limit the soft tissues contraction and to preserve the interdental papillary height in the second sextant (b). (Courtesy Dr. Mariani.)

Recently, the full-mouth therapeutic effective self-performed supragingival concept has been analyzed in two sys- plaque control is critical to achieve tematic reviews.  They concluded short- and long-term control of inflam- that in patients with chronic periodon- matory periodontal disease. titis the full-mouth approach achieved The full-mouth approach may be in- more favorable outcomes in terms of dicated for patients with severe and PD reduction and CAL gain in deep generalized aggressive periodontitis. pocket sites compared to the CSD Despite standard-wise therapy, some treatment. However, differences were aggressive periodontitis patients may of small magnitude and clinically not experience ongoing periodontal at- significant. Therefore, the selection of tachment loss probably due both to the one treatment modality over the other persistence of pathogenic bacteria in should be account for professional periodontal soft tissues and the recon- skill, patient preferences and cost-ef- tamination by pathogens residing in fectiveness. extra-dental reservoirs. Key pathogens It is important to point out that full such as Aggregatibacter actinomy- mouth instrumentation is completed in cetemcomitans, , two visits, and thus, the therapist has , Prevotella inter- fewer opportunities to deliver, check, media and and reinforce oral hygiene instructions. were found to colonize nearly all the Considering that periodontitis patients above-mentioned intra-oral niches. should be monitored closely and fre- In such patients the reduction of the mi- quently by the therapist to optimize crobial load in few hours may increase home plaque control, a strict program the likelihood of long-term improve- of recall appointment has to be sched- ment in the periodontal condition. uled after the full-mouth therapy. The

256

THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6.&t/6.#&3t46..&3 AIMETTI

Supra and subcrestal lead to the recovery of the interdental nonsurgical periodontal papillae. This may be attributed to the treatment increased vascularization and cellular proliferation in the connective gingival Nowadays, the final goals of the therapy, tissue due to the “aseptic inflammation” even in terms of esthetics, play a pivotal process. role on how we perform non-surgical The suprabony pockets are classified periodontal instrumentation. For this rea- in pseudo pockets and suprabony de- son, a new classification in supra- and fects. The pseudo pockets are due to subcrestal non-surgical periodontal anatomical conditions, as altered pas- therapy has been proposed. sive eruption, drugs assumption, as cal- The supracrestal periodontal therapy cioantagonists and cyclosporine A, or includes the treatment of gingivitis, the gingival neoformations. In such cases non-surgical coverage of recession- the nonsurgical treatment often results in type defects, the recapture of the in- the resolution of the gingival overgrowth terdental papillae and the treatment and in the recovery of the physiological of suprabony defects. The subcrestal position of the gingival margin related to periodontal therapy includes the non- UIFDFNFOUFOBNFMKVODUJPO 'JH  surgical treatment of intrabony defects. Patients with a diagnosis of gingivitis or exhibiting pseudo pockets due to gin- gival enlargement have to be treated by gentle supra and subgingival scaling in UIFSFTQFDUPGTPGUUJTTVFT 'JH  Shallow gingival recessions can be successfully treated by means of SRP and polishing of the exposed root sur- faces. It has been demonstrated that the removal of microbial toxins by polishing prevents further progression of gingival recessions. The reduction of root con- vexity by SRP promotes the coronal shift of the gingival margin. The coronal displacement of gingival margin may result from a mechanism similar to the creeping attachment observed after mu- cogingival surgery. (Fig 5) In presence of anatomical favorable a b conditions, the light scarification of the Fig 5 Miller’s Class I recession type defect lo- interdental gingival tissues, according to DBUFEBUUPPUIUSFBUFECZSPPUQMBOJOHBOEQPM- (a) the technique proposed by Shapiro et ishing . The coronal displacement of the gingival margin and the almost complete root coverage were BM DPNCJOFEXJUIBOBEFRVBUFIPNF achieved by both the detoxification and the gentle and professional plaque control may reduction of the root convexity (b).

257

THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6.&t/6.#&3t46..&3 SCIENTIFIC SESSION

bc

a

de f

Fig 6 Angiomatous neoformation between the upper central incisors in frontal (a), lateral (b) and overall frontal (c) view. The neoformation even involved the fornix and the skin surface on the maxillozygomatic area. The patient underwent two surgical sessions to remove the neoformation. Due to the relapse of the lesion she was advised to extract the upper incisors. The histological analysis of a tissue specimen excised during the nonsurgical instrumentation confirmed the diagnosis of lobular capillary hemangioma of the interdental papilla. One year later, following the nonsurgical periodontal treatment and frequent sessions of motivation and instructions in proper home plaque control measures, the complete recovery of the gingival architecture was achieved without loss of interdental soft tissue (d and e)'SPOUBMWJFXZFBSTMBUFS(f).

The treatment of suprabony defects advocated in order to further decrease differs according to the defect location. the PD. In the esthetic area the clinician must When SRP is performed in intraosse- carry out a subgingival instrumentation ous defects the therapist must keep in in the respect of marginal soft tissues. It mind the need for a subsequent surgical is obvious that the gingival biotype plays approach. If the treatment plan involves a pivotal role and that a progressive api- regenerative surgical procedures it is cal shift of the gingival margin is expect- of paramount importance to preserve ed to happen over time. In the posterior the volume of marginal and interdental areas greater soft tissue shrinkage is tissues allowing for flap designs which

258

THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6.&t/6.#&3t46..&3 AIMETTI

guarantee optimal defect coverage at gival plaque control and professional wound closure. If the osseous resec- SFNPWBM PG TVCHJOHJWBM CJPmMN 5IF tive surgery is scheduled it is important antimicrobial concentration in the peri- to preserve the connective fibers insert- odontal tissues and in the crevicular ed in the root cementum at the apical fluid may be inadequate for the desired part of the bony defects.55 Thus, in the antibacterial effects without mechanical clinical setting the choice of both the in- disruption of the .  struments and the techniques depends With regards to the timing of drug ad- on the final goal of the global treatment ministration, the antimicrobials agents planning. would seem to be more effective if ad- ministrated when the biofilm has been disrupted but has still not reorgan- Systemic antimicrobial ized. Thus, mechanical instrumentation therapy should be performed in the shortest time span and the antibiotic intake should The recognition that specific bacteria start on the day of SRP completion so are the causative agents of periodontal as to achieve effective antimicrobial diseases makes the prospect of target- concentration in the gingival crevicular ed antibiotic therapy an attractive goal. fluid. Systemic antimicrobial therapy aims at Adjunctive antimicrobial therapy with reducing or eradicating specific peri- systemic antibiotics kills bacteria out of odontal pathogens that are not reached the range of root surface instrumenta- by subgingival mechanical instrumen- tion and affects periodontal pathogens tation. The two major periodontopathic in other areas of the oral cavity. This bacteria Aggregatibacter actinomycet- additional effect will reduce bacterial emcomitans and Porphyromonas gingi- counts on the tongue and other mucosal valis may invade gingival epithelial cells surfaces, thus potentially delaying in re- and connective tissue, but both micro- colonization of subgingival sites by the bial species can be suppressed by the pathogenic bacteria. The added clinical administration of antimicrobials.  benefits of systemic antimicrobial com- The adjunctive benefits of the sys- bined with SRP over SRP alone have temic antibacterial therapy in the treat- been observed in deep pocket sites ment of periodontitis have been report- BOESBOHFECFUXFFOBOENNGPS ed in systematic reviews presented at $"-HBJOBOECFUXFFOBOENN North American and European Work- for PD reduction. shops. Metronidazole, tetracycline and It is important to point out that none of the combination of metronidazole and the commercially available pharmaco- amoxicillin achieved the best results, but logic agents is effective as a monother- there is not enough evidence to support apy to treat periodontal diseases. There a drug regimen, including appropriate is scientific evidence that the intake of dosage and duration.59 antimicrobials has to be combined with The disadvantages related to drugs both proper self-performed supragin- intake include uncertain patient compli-

259

THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6.&t/6.#&3t46..&3 SCIENTIFIC SESSION

a b

c d

e f

Fig 7  ZFBSPME$BVDBTJBOXPNBOQSFTFOUFEXJUIUIFDIJFGDPNQMBJOUPGEJGmDVMUJFTJOTQFFDIBOE mastication due to advanced mobility of several teeth. Good general health, amount of microbial plaque inconsistent with the severity of periodontal tissue destruction, familiar aggregation supported the diagnosis of generalized aggressive periodontitis. Clinical images at baseline (a, c, e)BOEZFBSTMBUFS(b, d, f). The patient underwent the OSFMD in according to the protocol by Quirynen et al in association with TZTUFNJDBOUJCJPUJDJOUBLF5IFTVQQPSUJWFQFSJPEPOUBMUIFSBQZXBTQFSGPSNFEFWFSZNPOUIT5IFQBUJFOU EJTQMBZFEBHPPEDPNQMJBODFXJUIBQMBRVFJOEFYTDPSFBOEBOPQUJNBMUJTTVFTSFTQPOTF(b, d, f). The left upper central incisor was extracted during the etiological therapy and the crown was splinted to the neighboring teeth as provisional treatment. The patient refused the implant rehabilitation and the whitening treatment. At present the splinting is still in place.

260

THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6.&t/6.#&3t46..&3 AIMETTI

Fig 8 Buccal view of the first, third, fourth and the sixth sextants. You can observe the optimal patient’ self- performed oral hygiene, the healthy condition of the marginal periodontal tissues and the partial recapture of the interdental papillary tissue.

a

Fig 9 Radiological images PGUIFDBTFJO'JHBUCBTFMJOF (a)BOEZFBSTMBUFS(b). We can observe the radiological appearance of the lamina dura and the remineralization of the supportive bone. b

261

THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6.&t/6.#&3t46..&3 SCIENTIFIC SESSION

ance, increased risk of adverse drug re- New technologies actions such as toxicity and hypersen- sitivity, the potential for the selection of Microscopy, lasers, photodynamic ther- multiple antibiotic-resistant organisms, apy and air-polishing instruments may and the overgrowth of opportunistic aid in the antimicrobial treatment of peri- pathogens. odontal diseases. The emergence of antibiotics resist- Effective periodontal treatment pre- ance is a result of their indiscriminate supposes a reliable identification of cal- use. Dentists can play a central role in culus. Tactile perception has tradition- halting antimicrobials resistance by re- ally been used for calculus detection stricting their prescription to certain pa- but it failed to identify all subgingival tients and periodontal conditions. The accretions. The use of an operative administration of antimicrobials may be microscope may improve both calcu- of clinical relevance in patients with ag- lus detection and elimination. In addi- gressive periodontitis or severe and pro- tion, the ability to visually debride the gressing forms of periodontitis. root surfaces may improve the chances Patients with aggressive periodontitis of success in a more conservative and constitute a challenge to the clinician. minimally invasive way. The severity of the disease has been at- Lasers are the most promising new tributed both to the high susceptibility type of devices in non-surgical manage- of the host and to the virulence of the ment of periodontitis. In spite of the high subgingival microbiota. To date there variety of lasers, a limited number has are no established protocols for control- been employed in dentistry. Periodon- ling the disease. However, data from the tal lasers include diode lasers, Er:YAG literature on the application of the FMD (erbium doped: yttrium, aluminium, protocol combined with amoxicillin-met- and garnet) and Nd:YAG (neodymium ronidazole systemic administration are doped: yttrium, aluminium, and garnet)  QSPNJTJOH 'JHTUP *OQBUJFOUTXJUI lasers and CO lasers. The applica- adequate home plaque control (FMPS tion of a dental laser in the treatment of  BOEHPPEDPNQMJBODFUPBTUSJDU is based on the maintenance therapy the combined purported benefits of subgingival curet- USFBUNFOUSFTVMUFEJOBEEJUJPOBMNN tage, significant decreases in subgingi- JONFBO1%SFEVDUJPOBOEJODMJOJD- val pathogenic bacteria, and hemosta- al attachment gain in deep pocket sites. sis. However, when used directly to In addition, A. actinomycetemcomitans root surface for calculus removal it can XBTFMJNJOBUFEGSPNPGUIFUSFBUFE cause excessive heat and results in root TVCKFDUTBUNPOUITBGUFSUIFSBQZ9 damage. The Er:YAG laser technology The systemic amoxicillin plus metroni- has shown higher clinical applicability dazole would also seem to enhance the for its efficacy in removing subgingival effects of full-mouth SRP in moderate-to- plaque and calculus without significant- advanced periodontitis patients. Sites ly damaging the root surface. on molars benefited significantly more Despite the large number of publica- than non-molar sites. tions there is still controversy among

262

THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6.&t/6.#&3t46..&3 AIMETTI

clinicians regarding the use of laser- Standard air-polishing devices are mediated therapy in the treatment of based on the air spray of sodium bicar- chronic periodontitis. There is limited bonate for supragingival polishing and evidence suggesting that lasers achieve stain removal. They cannot be used for greater reduction in subgingival micro- subgingival instrumentation because of biota compared to conventional thera- their high abrasiveness. Recently, in- py.Indeed, most bactericidal effects dications for the use of the air polishing have been observed in laboratory stud- technology have been expanded from ies and have little relevance to the pro- supra- to subgingival use by the devel- tected environment of the periodontal opment of a new low-abrasive amino ac- biofilm. id glycine-based powder delivered with In addition, there is considerable con- a low-pressure device. It is effective in flict in clinical outcomes. Recent system- removing the subgingival biofilm minimiz- atic reviews reported no greater clinical ing trauma to hard and soft tissues and benefits from the application of dental it is perceived as more comfortable than lasers as mono-therapy or in combina- hand and power-driven instrumentation. tion with SRP as compared to conven- Current evidence of the efficacy of the tional mechanical instrumentation.  glycine powder air spray derived from Photodynamic therapy is a minimally studies that enrolled patients in support- invasive procedure that attempts to kill ive maintenance therapy. They report- bacteria via the chemical process of the ed no significant differences in either oxidation. It relies on the combination clinical or microbiological parameters of three components: a nontoxic pho- compared to conventional hand and/or tosensitizer agent such as an organic ultrasonic instrumentation in the short- dye or a similar compound capable of term period.  absorbing light of a specific wavelength, It is important to point out that the a visible light (usually a low wavelength glycine polishing does not remove min- diode laser) and the molecular oxygen eralized microbial deposits. Thus, its which is converted to reactive oxygen application alone in the initial non-sur- species primarily superoxide or singlet gical treatment of periodontitis patients oxygen. The cytotoxic product can- is questionable. In addition, the clinic- OPUNJHSBUFNPSFUIBONNBGUFSJUT al outcome of air polishing versus other formation, thus making it ideal for local types of antimicrobial agents has yet to application of the photodynamic thera- be determined. py without endangering distant biomol- In conclusion, the use of new tech- ecules, cells and organs. nologies for the nonsurgical treatment of This technology has some limitations. periodontal diseases needs to be evalu- It does not have any capability to me- ated in well designed and adequately chanically remove plaque and calculus powered studies and the overall quality and it may not kill more than one-third of the body of evidence is still insufficient of the bacteria in oral biofilms. Thus, to support evidence-based decision- it may not substantially suppress patho- making. genic bacteria in periodontal pockets.

263

THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6.&t/6.#&3t46..&3 SCIENTIFIC SESSION

Conclusions the clinician must select the operative protocol and devices more suitable for A sequence of interrelated steps is in- assuring periodontal health and long- herent to effective periodontal treat- term teeth survival. ment: accurate diagnosis, compre- Although professional dental care is hensive treatment, and periodontal of great importance for achieving such maintenance. The primary goal of the therapeutic goals, proper daily plaque periodontal therapy is to decrease the control and patient compliance are es- levels of pathogenic bacteria and, thus, sential part of successful periodontal to reduce the potential for progressive therapy. inflammation and recurrence of dis- ease. Through scaling and root plan- ing is still considered the gold standard Acknowledgements in periodontal therapy. On the basis of the diagnosis, the medical history, the The author thanks Dr Federica Romano, University Researcher at the Section of De- needs and expectations of the patient, partment of Surgical Sciences University of Torino, and the final endpoints of the treatment for drafting the article.

References

 "NFSJDBO"DBEFNZPG1FSJ-  4UFXBSU14 $PTUFSUPO+8 tematic review. Periodontol odontology. Position paper. Antibiotic resistance of o Guidelines for periodon- bacteria in biofilms. Lancet $MBZEPO/$$VSSFOUDPO- tal therapy. J Periodontol o cepts in toothbrushing and o 8. Sanz M, Teughels W. Inno- interdental cleaning. Perio-  /JTIJIBSB5 ,PTFLJ5 vations in nonsurgical peri- EPOUPMo Microbial etiology of peri- odontal therapy: consensus 3ZBO.&/POTVSHJDBM PEPOUJUJT1FSJPEPOUPM report of the Sixth European approaches for treatment of o Workshop on Periodon- periodontal diseases. Dent  1BHF3$ ,PSONBO,45IF tology. J Clin Periodontol $MJO/"No pathogenesis of human  4VQQM o WBOEFS8FJKEFO(" 5JN- periodontitis: an introduc- 9. Aimetti M, Romano F, Guzzi merman MF. A systematic UJPO1FSJPEPOUPM N, Carnevale G. Full-mouth review on the clinical effi- o disinfection and antimicro- cacy of subgingival debride-  4BO[. 2VJSZOFO.&VSP- bial therapy in generalized ment in the treatment of pean Workshop in Periodon- aggressive periodontitis: a chronic periodontitis. J Clin tology Group A. Advances randomized placebo-con- 1FSJPEPOUPM 4VQQM in the etiology of periodon- trolled trial. J Clin Periodon-  o titis. Consensus report of UPM )BMMNPO88 3FFT5% the 5th European Workshop %SJTLP$)/POTVSHJDBMQFSJ- Local anti-infective therapy: in Periodontology. J Clin odontal therapy. Periodontol mechanical and physical 1FSJPEPOUPM 4VQQM o approaches. A systematic  o #BLFS,"5IFSPMFPG review. Ann Periodontol 5. Nunn ME. Understanding dental professionals and o the etiology of periodontitis: the patient in plaque "ESJBFOT1" "ESJBFOT an overview of periodontal control. Periodontol LM. Effects of nonsurgical risk factors. Periodontol o periodontal therapy on hard o )VKPFM11 $VOIB$SV[+  and soft tissues. Periodontol  .BSTI1%%FOUBMQMBRVFBT Loesche WJ, Robertson PB. o a microbial biofilm. Caries Personal oral hygiene and 4VWBO+&&GGFDUJWFOFTT 3FTo chronic periodontitis: a sys- of mechanicalnonsurgical

264

THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6.&t/6.#&3t46..&3 AIMETTI

pocket therapy. Periodontol %BSCZ*# )PEHF1+ 3JH- mucous membranes. J Peri- o gio MP, Kinane DF. Clinical PEPOUPMo #SVOTWPME." ;BNNJUU,8  and microbiological effect ,PTIZ( $PSCFU&'  Dongarl AL. Spontaneous of scaling and root planing Ishikawa I. A full-mouth correction of pathologic in smoker and non-smoker disinfection approach migration following peri- chronic and aggressive tononsurgical periodontal odontal therapy. Int J Peri- periodontitis patients. J Clin therapy— Prevention of odontics Restorative Dent 1FSJPEPOUPMo reinfection from bacterial o  SFTFSWPJST1FSJPEPOUPM 4JHI+ %FTIQBOEF3/ 4BO[* "MPOTP# $BSBTPM o Pathologic migration spon- M, Herrera D, Sanz M. 2VJSZOFO. #PMMFO$.  taneous correction following Nonsurgical periodontal Vandekerckhove BN, periodontal therapy. Quin- therapy. J Evid Base Dent Dekeyser C, Papaioan- UFTTFODF*OUo 1SBDU4o nou W, Eyssen H. Full- vs. $PCC$./POTVSHJDBM 3BCCBOJ(. "TI..+S  partial mouth disinfection in pocket therapy: Mechani- Caffesse RG. The effective- the treatment of periodon- cal. Ann Periodontol ness of subgingival scaling tal infections: Short-term o and root planing in calcu- clinical and microbiological #BEFSTUFO" /JMWFVT3  lus removal. J Periodontol observations. J Dent Res Egelberg J. Effect ofnonsur- o o gical periodontal therapy. I: (FMMJO3( .JMMFS.$ +BWFE #PMMFO$. .POHBSEJOJ moderately advanced peri- T, Engler WO, Mishkin DJ. C, Papaioannou W, Van odontitis. J Clin Periodontol The effectiveness of the Steenberghe D, Quirynen o Titan-S sonic scaler versus M. The effect of a one-stage (SFFOTUFJO(/POTVSHJ- curettes in the removal of full-mouth disinfection on cal periodontal therapy subgingival calculus. A different intra-oral niches. JOBMJUFSBUVSF human surgical evaluation. Clinical and microbiological review. J Am Dent Assoc +1FSJPEPOUPMo observations. J Clin Peri- o  PEPOUPMo 5VOLFM+ )FJOFDLF" 'MFN-  8BMNTMFZ"% -FB4$ -BO- 2VJSZOFO. .POHBSEJOJ ming T. A systematic review dini G, Moses AJ. Advanc- C, de Soete M, Pauwels of efficacy of machine- es in power driven pocket/ M, Coucke W, van Eldere driven and manual subgin- root instrumentation. J Clin J, van Steenberghe D. The gival debridement in the 1FSJPEPOUPM 4VQQM role of chlorhexidine in the treatment of chronic peri-  o one-stage full-mouth disin- odontitis. J Clin Periodontol 0EB4 /JUUB) 4FUPHVDIJ5  fection treatment of patients  4VQQM o Izumi Y, Ishikawa I. Current with advanced adult peri- )JOSJDIT+ 4PNFSNBO concepts and advances in odontitis. Long-term clinical MJ, Iacono V, Genco RJ. manual and power-driven and microbiological obser- Research, Science and instrumentation. Periodontol vations. J Clin Periodontol Therapy Committee of the o o American Academy of Peri- .BUVMJFOF( 1KFUVSTTPO 2VJSZOFO. %F4PFUF.  odontology. Position paper: BE, Salvi GE, Schmidlin K, Boschmans G, Pauwels sonic and ultrasonic scalers #SBHHFS6 ;XIMFO. -BOH M, Coucke W, Teughels in periodontics. J Periodon- NP. Influence of residual W. Benefit of “one-stage UPMo pockets on progression of full-mouth disinfection” is #PXFS3$'VSDBUJPONPS- periodontitis and tooth loss: explained by disinfection phology relative to peri- SFTVMUTBGUFSZFBSTPG BOESPPUQMBOJOHXJUIJO odontal treatment. Furcation maintenance. J Clin Peri- hours: a randomized con- entrance architecture. J PEPOUPMo trolled trial. J Clin Periodon- 1FSJPEPOUPMo %FBT%& .FBMFZ#- UPMo EPT4BOUPT,. 1JOUP4$  Response of chronic and 8FOOTUSÚN+- 5PNBTJ Pochapski MT, Wambier aggressive periodontitis to C, Bertelle A, Dellasega DS, Pilatti GL, Santos FA. USFBUNFOU1FSJPEPOUPM E. Full-mouth ultrasonic Molar furcation entrance o debridement versus quad- and its relation to the width %BOTFS.. 5JNNFSNBO.'  rant scaling and root plan- of curette blades used in van Winkelhoff AJ, van der ing as an initial approach periodontal mechanical Velden U. The effect of peri- in the treatment of chronic therapy. Int J Dent Hyg odontal treatment on peri- periodontitis. J Clin Peri- o odontal bacteria on the oral PEPOUPMo

265

THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6.&t/6.#&3t46..&3 SCIENTIFIC SESSION

+FSW“F4UPSN1. 4FNBBO "JNFUUJ. 3PNBOP'  dontitis: the use of systemic E, Al Ahdab H, Engel S, Fim- Peccolo D, Debernardi C. antimicrobials against the mers R, Jepsen S. Clinical Nonsurgical periodontal subgingival biofilm. J Clin outcomes of quadrant root therapy of gingival reces- 1FSJPEPOUPM 4VQQM planing versus full-mouth sion defects: evaluation of  o root planing. J Clin Peri- the restorative capacity of )FSSFSB% .BUFTBO[1  PEPOUPMo marginal gingiva. J Peri- Bascones-Martinez A, Sanz 4XJFSLPU, /POOFONBDIFS PEPOUPMo M. Local and systemic CI, Mutters R, Flores-de- )BSSJT3+$SFFQJOHBUUBDI- antimicrobial therapy in peri- Jacoby L, Mengel R. One- ment associated with the odontics. J Evid Base Dent stage full-mouth disinfection connective tissue with 1SBDUo versus quadrant and full- partial-thickness double .BSTI1%%FOUBMQMBRVF mouth root planning. J Clin pedicle graft. J Periodontol biological significance of 1FSJPEPOUPMo o a biofilm and community  4IBQJSP"3FHFOFSBUJPOPG life-style. J Clin Periodontol &CFSIBSE+ +FSW“F4UPSN interdental papillae using  4VQQM o PM, Needleman I, Worthing- periodic curettage. Int J  -BSTFO54VTDFQUJCJMJUZPG ton H, Jepsen S. Full-mouth Periodontics Rest Dent Porphyromonas gingivalis treatment concepts for o in biofilms to amoxicillin, chronic periodontitis: a sys- $PSUFMMJOJ1 5POFUUJ. doxycycline and metronida- tematic review. J Clin Peri- Focus on intrabony defects: zole. Oral Microbiol Immunol PEPOUPMo guided tissue regen- o -BOH/1 5BO8$ ,SÊIFO- FSBUJPO1FSJPEPOUPM ,SBZFS(8 -FJUF34  NBOO." ;XBIMFO." o Kirkwood KL. Nonsurgical systematic review of the 55. Carnevale G. Fiber retention chemotherapeutic treat- effects of full-mouth debride- osseous respective sur- ment strategies for the ment with and without gery: a novel conservative management of periodontal antiseptics in patients with approach for pocket elimi- diseases. Dent Clin N Am chronic periodontitis. J Clin nation. J Clin Periodontol o 1FSJPEPOUPMo o .PNCFMMJ" $JPODB/  "JNFUUJ. 3PNBOP' (V[[J 5SJCCMF(% -BNPOU3+#BD- Almaghlouth A, Décaillet N, Carnevale G. One-stage terial invasion of epithelial F, Curvoisier DF, Giannop- full-mouth disinfection as cells and spreading in peri- oulou C. Are there specific a treatment approach for odontal tissue. Periodontol benefits of amoxicillin plus generalized aggressive o metronidazole in Aggregati- periodontitis. J Periodontol 4MPUT+ 5JOH."DUJOPCBDJM- bacter actinomycetemcom- o lus actinomycetemcomitans itans-associated periodon- "YFMTTPO1 -JOEIF+&GGFDU and Porphyromonas gingi- titis? A double masked, of controlled oral hygiene valis in human periodontal randomized clinical trial of procedures on caries and disease: occurrence and efficacy and safety. J Peri- periodontal disease in USFBUNFOU1FSJPEPOUPM PEPOUPMo adults. Results after six o .FJTTOFS( ,PDIFS5 years. J Clin Periodontol 58. Herrera D, Sanz M, Jepsen Calculus detection tech- o S, Needleman I, Roldan S. nologies and their clinical #FJLMFS5 "CEFFO(  A systematic review on the application. Periodontol Schnitzer S, Salzer S, effect of systemic antimi- o Ehmke B, Heinecke A, crobials as an adjunct to "PLJ" 4BTBLJ,. 8BUB- Flemmig TF. Microbio- scaling and root planing in nabe H, Ishikawa I. Lasers logical shifts in intra- and periodontitis patients. J Clin in nonsurgical periodontal extraoral habitats following 1FSJPEPOUPM 4VQQM UIFSBQZ1FSJPEPOUPM mechanical periodontal  o o therapy. J Clin Periodontol 59. Haffajee AD, Socransky $PCC$. -PX4# $PMV[[J o SS, Gunsolley JC. Systemic DJ. Lasers and the treat- "JNFUUJ. 3PNBOP'  anti-infective periodon- ment of chronic peri- Debernardi C. Effectiveness tal therapy. A systematic odontitis. Dent Clin N Am of periodontal therapy on review. Ann Periodontol o the severity of cyclosporine o 4DIXBS[' "PLJ" 4DVMFBO A-induced gingival over-  )FSSFSB% "MPOTP# -FPO A, Becker J. The impact growth. J Clin Periodontol R, Roldan S, Sanz M. Anti- of laser application on o microbial therapy in perio- periodontal and peri-implant

266

THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6.&t/6.#&3t46..&3 AIMETTI

wound healing. Periodontol tion in nonsurgical perio- profile. Lasers Med Sci o dontal therapy: a systematic o *TSBFM. $PCC$. 3PTT- review. J Clin Periodontol ,POUUVSJ/BSIJ7 .BSL- mann JA, Spencer P. The  4VQQM  kanen S, Markkanen H. FGGFDUTPG$0 /E:"( 4IBSNBO8. "MMFO$.  Effects of air-polishing on and Er:YAG lasers with and van Lier JE. Photodynamic dental plaque removal without surface coolant on therapeutics: basic princi- and hard tissues as evalu- tooth root surfaces. An in ples and clinical applica- ated by scanning electron vitro study. J Clin Periodon- tions. Drug Discov Today microscopy. J Periodontol UPMo o o )FSSFSP" (BSDJB,BTT .PBO+ #FSH,5IFQIPUP- 1FUFSTJMLB(+4VCHJOHJWBM AI, Gomez C, Sanz M, degradation of porphyrins air-polishing in the treat- Garcia-Nunez JA. Effect of in cells that can be used ment of periodontal biofilm two kinds of Er:YAG laser to estimate the lifetime of JOGFDUJPO1FSJPEPOUPM systems on root surface in singlet oxygen. Photochem o comparison to ultrasonic 1IPUPCJPMo 8FOOTUSÚN+- %BIMFO(  scaling: an in vitro study. 'POUBOB$3 "CFSOFUIZ"%  Ramberg P. Subgingival Photomed Laser Surg Som S Ruggiero K, Douc- debridement of periodontal o ette S, Marcantonio RC, pockets by air polishing $PCC$.-BTFSTJOQFSJ- Boussios CI, Kent R, Good- in comparison with ultra- odontics: a review of the son JM, Tanner AC, Soukos sonic instrumentation during literature. J Periodontol NS. The antibacterial effect maintenance therapy. J Clin o of photodynamic therapy 1FSJPEPOUPMo ,BSMTTPO.3 %JPHP-PG- in dental plaque-derived  gren CI, Jansson HM. The biofilms. J Periodontal Res 4DVMFBO" #BTUFOEPSG,%  effect of laser therapy as an o Becker C, Bush B, Einwag adjunct to non-surgical peri- /PWBFT"#+S 4DIXBSU[ J, Lanoway C, et al. A para- odontal treatment in sub- Filho HO, de Oliveira RR, digm shift in mechanical jects with chronic periodon- Feres M, Sato S, Figue- biofilm management? Sub- titis: a systematic review. J iredo LC. Antimicrobial gingival air-polishing: a new 1FSJPEPOUPMo photodynamic therapy in way to improve mechanical  the nonsurgical treat- biofilm management in the 4DIXBS[' "PLJ" #FDLFS ment of aggressive peri- dental practice. Quintes- J, Sculean A. Laser applica- odontitis: microbiological TFODF*OUo

267

THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6.&t/6.#&3t46..&3