One-Stage, Full-Mouth Disinfection: Fiction Or Reality?

FOCUS ARTICLE One-Stage, Full-Mouth Disinfection: Fiction or Reality? Marc Quirynen, Wim Teughels, Martine Pauwels, Daniel van Steenberghe Recent research indicated that periopathogens colonize, besides the pockets, also other niches within the oral cavity including: the soft tissues, the saliva, the tongue, and even the tonsils. Since the supragingival plaque and the bacteria in these niches have a major impact on the subgingival plaque colonisation but especially on the recolonation after debridement, it seems reason- able to expect that a one-stage, full-mouth disinfection protocol, involving the bacteria over the entire oro-pharyngeal area, has a significantly better outcome when compared to a more staged approach (e.g. with treatments per quadrant). Since several review papers recently discussed the benefits of a one-stage, full-mouth disinfection protocol, pointing to some shortcomings in the our research protocol or with an attempt to compare the data of the new approach with other studies (with unfortunately non comparable approaches), this review paper aims to clarify some of the confusion concerning the benefits of a one-stage, full-mouth disinfection approach. Key words: periodontal breakdown; periodontopathogens; mouth disinfection INTRODUCTION logy, 1996; Slots and Rams, 1991; Socransky and Haffajee, 1992; Wolff et al, 1994). The ef- Periodontal breakdown primarily develops when ficiency of the host defence is partially hereditary the microbial load within a periodontal pocket (Kinane and Hart, 2003) but environmental fac- overrules the local and systemic host defence tors such as bad oral hygiene, smoking, immuno- mechanisms. Such an imbalance occurs in differ- suppressive medication, stress and so on can fur- ent situations, including an aspecific increase in ther impair the immune defence mechanism. the total amount of bacteria, an outgrowth/over- Since, so far, the susceptibility of the host cannot growth of pathogenic species above a certain be modulated at a clinical level, with the excep- threshold level and/or a reduction in the efficien- tion of anti-inflammatory medications, periodontal cy of the immune response. Actinobacillus actino- therapy is focused on the reduction/elimination of mycetemcomitans, Tanneralla forsythensis and periodontopathogens in combination with the re- Porphyromonas gingivalis are still considered key establishment, often by surgical pocket elimina- periopathogens, but species such as Prevotella in- tion, of a more suitable environment (less anaero- termedia, Campylobacter rectus, Peptostrepto- bic) for beneficial microbiota. Several studies in- coccus micros, Fusobacterium nucleatum, deed indicate that the presence of the Eubacterium nodatum, Streptococcus intermedius above-mentioned periodontopathogens (persist- and spirochetes are also linked with periodontal ing or re-established after treatment) was associ- destruction (American Academy of Periodonto- ated with a negative clinical outcome of perio- Perio 2005; Vol 2, Issue 2: 85–90 85 Quirynen et al · One-stage, Full-Mouth Disinfection: Fiction or Reality? dontal treatment (Cugini et al, 2000; Haffajee et The one-stage full-mouth disinfection concept con- al, 1997; Renvert et al, 1996; Renvert et al, sists of a combination of therapeutic efforts: 1998; Socransky et al, 1998). • A full mouth scaling and root planing (the en- After mechanical debridement the subgingival mi- tire dentition in two visits within 24 hours (i.e. crobial load drops to 0.1% (Goodson et al, two consecutive days) to reduce the number 1991; Maiden et al, 1991). However, one of subgingival pathogenic organisms (Loos et week later the periodontal pocket is already re- al, 1988; Mousques et al, 1980), colonized by the initial number of bacteria, fortu- • An additional subgingival irrigation (three nately with a less pathogenic composition times repeated within 10 minutes) of all pock- (Harper and Robinson: 1987; Wade et al, ets with a 1% chlorhexidine gel in order to 1992). The origin of these bacteria is still a mat- suppress the remaining bacteria (Oosterwaal ter of debate. The multiplication of remaining et al, 1991), bacteria within the pocket (Petersilka et al, • Tongue brushing with a 1 % chlorhexidine gel 2002), or within either the junctional or pock- for one minute to suppress the bacteria in this etepithelium (Lamont and Yilmaz, 2002) and/or niche (Quirynen et al, 1999), the dentinal dentine tubuli (Adriaens et al, 1988; • Mouth rinsing with a 0.2 % chlorhexidine so- Giuliana et al, 1997) is often considered the ma- lution for two minutes to reduce the bacteria jor cause for this subgingival re-colonization. in the saliva (Schiott et al, 1976) and in the The impact of the supragingival area on this early pharynx, including the tonsils (by gargling). subgingival re-colonization was considered negli- • Optimal oral hygiene, supported during the gible. The availability of two-stage implants al- first two months by a 0.2 % chlorhexidine lows investigation into how a sterile abutment sur- mouth rinse (Magnusson et al, 1984) to re- face inserted in a gingival wound created above tard the re-colonisation of the pockets. an endosseous implant is colonized. A recent study revealed that these “pristine” pockets Our abovementioned studies were designed as showed a mature microbial flora within one week “proof of principle” experiments. In the control with a composition nearly identical to the one in groups a fast re-colonization of the treated pock- the existing neighbouring periodontal pockets ets could occur during the long time-intervals be- (Quirynen et al, 2005). This indicates that, even fore completion of the debridement of all quad- when only a supragingival origin is allowed, a rants (in total six weeks). Furthermore, only pa- fast subgingival colonization still occurs. The role tients with severe periodontitis (pockets ≥ 7mm) of the supragingival microbiota on the subgingival and with a lot of supra and subgingival plaque (re)colonization was so far underrated. and calculus were selected. Finally, patients In this perspective, the one-stage, full-mouth dis- were instructed to follow the oral hygiene in- infection was proposed by the Leuven team structions only for the treated quadrants, leaving (Quirynen et al, 1995) as a new treatment strat- the other quadrants with a poor plaque control. egy. It aims at eradicate, or at least suppress, all In the test group, on the other hand, a thorough periodontopathogens in a very short time span, reduction of the bacterial load within the oro- and this not only from the periodontal pockets but pharynx was achieved within one day. This did from all oro-pharyngeal habitats (mucous mem- not only consist of debridement of all periodon- branes, tongue, tonsils, saliva). As such, the re- tal pockets within two consecutive days, but al- colonization of the treated pockets by bacteria so included an extensive use of chlorhexidine in from untreated sites (called cross-contamination all niches for periopathogens (including the or intra-oral translocation) could indeed be de- tongue). These aspects of the test and control layed until a better healing of the pockets could groups have to be considered when the outcome be achieved. A series of prospective studies con- of the Leuven studies is compared with those of firmed the original data (Bollen et al, 1996; other papers. Bollen et al, 1998; De Soete et al, 2001; Mongardini et al, 1999; Quirynen et al, 1995; Quirynen et al, 1999; Quirynen et al, 2000; Vandekerckhove et al, 1996). 86 Perio 2005; Vol 2, Issue 2: 85–90 Quirynen et al · One-stage, Full-Mouth Disinfection: Fiction or Reality? REFLECTIONS IN RELATION • Even more convincing is the significance of the TO REVIEW PAPERS microbial improvements with the one-stage, full- mouth disinfection approach when compared In 2004 no less than four review papers (Barteczko to the standard therapy. This is generally neg- and Eberhard, 2004; Eberhard, 2004; Green- lected, although this superiority was clearly il- stein, 2004; Koshy et al, 2004) were published on lustrated in several papers (De Soete et al, the one-stage, full-mouth disinfection strategy. The 2001; Quirynen et al, 1999). The microbiol- data of the Leuven studies were often incorrectly ogists involved, using culture techniques or quoted or interpreted for aspects highlighted and DNA-DNA hybridization, were always mas- discussed in this paragraph. ked for the performed therapy. Thus these ob- • An often reappearing remark is the fact that in servations deserve even more attention. our studies the baseline probing depths and at- • The role of chlorhexidine in the full-mouth disin- tachment levels were measured immediately af- fection protocol can be questioned. We only ter scaling and rootplaning. This was unavoid- analysed this in one pilot study (Quirynen et al, able since the patients enrolled in the studies 2000). In this trial a third group (one-stage, full- showed significant amounts of supra and sub- mouth scaling and root planing without further gingival calculus, a factor that renders pocket disinfection with an antiseptic) was added to probing prior to scaling unreliable (Clerehugh et an already running study. The design of this pi- al, 1996). However, since this method had lot study is not optimal and bias of the exam- been applied in both test and control groups, it iners cannot be excluded. A large-scale study cannot contribute to differences between both is recommended in order to verify these find- treatment strategies. It only renders a compari- ings, as mentioned in the paper itself. This son with other clinical trials less obvious. does not impair the validity of the concept. • The results in the control group have been considered to be below what one can expect from a thorough mechanical debridement. One REFLECTIONS IN RELATION TO SIMILAR PAPERS should take into consideration that these patients WITH SIMILAR TREATMENT STRATEGIES did not receive any additional periodontal therapy over the entire eight months period. Due to Another paper questioned the outcome of our stud- the lack of oral hygienists in Belgium, the over- ies (Apatzidou and Kinane, 2004).

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