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Auxiliary Chemical Therapies in the Treatment of Aggressive Periodontitis: Current Aspects

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Auxiliary Chemical Therapies in the Treatment of Aggressive Periodontitis: Current Aspects http://dx.doi.org/10.1590/1981-863720150002000091903 REVISÃO | REVIEW Auxiliary chemical therapies in the treatment of aggressive periodontitis: current aspects Terapias químicas auxiliares para o tratamento da periodontite agressiva: aspectos atuais Lauro Garrastazu AYUB1 Arthur Belém NOVAES JÚNIOR1 Márcio Fernando de Moraes GRISI1 Sérgio Luís Scombatti de SOUZA1 Daniela Bazan PALIOTO1 Mário TABA JÚNIOR1 ABSTRACT Aggressive periodontitis, a distinct clinical entity of periodontal disease, is characterized by a pronounced episodic and rapid destruction of periodontal tissues and may result in rapid and early loss of teeth. Some studies have shown that conventional mechanical debridement together with oral hygiene is often not sufficient to disease control. Recent studies of this condition have shown beneficial effects of auxiliary therapies or adjuncts such as the administration of systemic and locally antimicrobials. Among the local adjuncts, the literature presents antiseptics, antibiotics and photodynamic therapy. Antibiotics and anti-inflammatory represent systemic adjuncts. Regardless of the results presented by each of them, the difficulty of establishing a single protocol for all cases is recognized depending on the individual response shown by each patient. The aim of the present study was to review the current results about chemical adjuncts administration associated with conventional treatment in cases of aggressive periodontitis and suggest clinical protocols. Indexing terms: Aggressive periodontitis. Anti-bacterial agents. Anti-infective agents, local. Anti-inflammatory agentes. Mouthwashes. Photochemotherapy. RESUMO A periodontite agressiva, uma entidade clínica distinta da doença periodontal, é caracterizada por uma pronunciada destruição episódica e rápida dos tecidos periodontais e pode resultar em perda rápida e precoce dos dentes. Alguns trabalhos têm mostrado que o debridamento mecânico convencional juntamente com higiene oral muitas vezes não é suficiente para o controle da doença. Apesar de não existir consenso, estudos recentes desta condição mostram efeitos benéficos de terapias auxiliares ou coadjuvantes como a administração de antimicrobianos sistêmicos e locais. Entre os coadjuvantes locais, a literatura apresenta os antissépticos, antibióticos e terapia fotodinâmica. Dentre os sistêmicos são representados os antibióticos e antiinflamatórios. Independentemente dos resultados apresentados por cada um deles, se reconhece a dificuldade em se estabelecer um protocolo único para todos os casos em função da resposta individual apresentada por cada paciente. O objetivo do presente estudo foi revisar os resultados atuais sobre administração de coadjuvantes químicos associados à terapia convencional em casos de periodontite agressiva e sugerir protocolos clínicos. Termos de indexação: Periodontite agressiva. Antibacterianos. Anti-infecciosos locais. Antissépticos bucais. Anti-inflamatórios. Fotoquimioterapia. INTRODUCTION and alveolar bone destruction and c) family concentration of cases. Aggressive periodontitis (AP) comprises a group of The diagnosis of AP requires the exclusion of rapid progressive periodontitis forms, rare character and systemic diseases that may harm the host defense and routinely graves. Although it can affect any age, often its lead to premature teeth loss (periodontal manifestations of clinical manifestation occurs ata n early age and it has a systemic diseases). distinct tendency to develop in the same family. In 1999, The existence of particular forms of AP was also a consensus on the conditions and periodontal diseases recognized based on specific clinical and lab characteristics: was established for an World Workshop of the American localized aggressive periodontitis (LAP) and generalized Academy of Periodontology. In the absence of an etiological aggresssive periodontitis (GAP)2. classification, the aggressive forms of periodontal disease A successful treatment of AP is dependent of were defined on the basis of the following main features1: early diagnosis, directing the therapy to the elimination a) non-significant medical history; b) rapid attachment loss or deletion of pathogens, providing a favorable 1 Universidade de São Paulo, Faculdade de Odontologia, Departamento de Cirurgia e Traumatologia Buco Maxilo Facial e Periodontia. Av. do Café s/n., 14040-904, Ribeirão Preto, SP, Brasil. Correspondência para / Correspondence to: LG AYUB. E-mail: <[email protected]>. RGO, Rev Gaúch Odontol, Porto Alegre, v.63, n.2, p. 195-202, abr./jun., 2015 LG AYUB et al. environment in the long term. The differential element antimicrobial therapies have been reported in an attempt of AP treatment, however, refers to specific efforts to to improve clinical outcomes. Chemical auxiliaries so affect the composition and not only the quantity of the would present a significant relevance to the success subgingival microbiota. in the treatment of certain cases of AP6. However, the Despite this, the conventional treatment (scaling identification of these patients is not simple, since the and root planning) of the AP remains seen of nonspecific professional should be aware of possible failures caused way, with the goal of reducing the bacteria number and, by his limited experience with regard to conventional therewith, change the micro environmental conditions of therapy and the lack of collaboration/patient compliance these sites. This nonspecific therapy have been shown to be to treatment. effective in long term since these patients acquire good oral The literature has presented many protocols hygiene habits and are inserted into supportive periodontal of periodontal diseases treatment, including chemical therapy (SPT) programs. However, a small but relevant site adjunctive with conventional therapy (for review7-9). The or patient groups, does not respond appropriately to this AP, as known, evolves rapidly both by high pathogenicity treatment type3. Different factors have been proposed in present biofilm, as by deficient host response10. Figure 111 an attempt to explain the lack of response from that group represents the interrelation between the host response of patients to conventional treatment4, being one of the and microbial challenge and its influences in the onset and most investigated, the periodontal pathogens persistence progression of periodontal disease. Facing this situation, in affected sites5. the professional search a therapy to stop as soon as Based on these considerations, of which only possible the increasing clinical attachment loss by these the mechanical treatment (conventional) may not patients, keeping in mind that a “sub-intervention” could be effective for certain sites or patients, additional lead to progression and/or worsening of cases. Genetic Risk Factors Antibodies Citokyn es Immuno- Connective Clinical inflammator tissue and signs of PMN y response CitocinProstanoi onset and Microbial bone s of the host as de metabolism progressio challenge n of the Antigens disease LPS MetaloMatrix metalloprProtein Othes oteinasesases de virulence Matriz factors Products of tissue Aquired risk factors and the environment destruction and environmental changes Figure 1. Biological mechanisms of periodontal disease. Legend: PMN = polymorphonuclear; LPS = lipopolysaccharides. Source: adapted from Kornman11. 196 RGO, Rev Gaúch Odontol, Porto Alegre, v.63, n.2, p. 195-202, abr./jun., 2015 Auxiliary therapy for aggressive periodontitis For that, the use of an antimicrobial should be use and demonstrates its important antimicrobial effect on considered when the professional is facing many severe Gram-positive and Gram-negative bacterias15. episodes. The interruption of disease course and the conservation of clinical results achieved should be the Clinical presentations focus of the periodontist. Therefore, the study purpose is to review the Despite having been developed several products options presented in the literature regarding treatment with chlorhexidine as active ingredient (mouthwash, gels, protocols of the AP that include chemical adjuncts. In sprays, toothpasts and varnishes), the solutions and the addition, demonstrate which antimicrobials present better soft arrays (chip) for subgingival application that received results, when associated with conventional therapy, taking greater attention in the AP treatment. into consideration their clinical implications and the overall The idea of irrigating the periodontal pocket with health of patients. chlorhexidine solutions (0.12 or 0.2%) was tested by the researchers to achieve therapeutic levels in the environment. Use of chemical adjuncts Some have adopted the subgingival irrigation through The chemical adjuncts shown in the literature for a syringe as an adjunct to treatment convencional16-20, the AP treatment can be didactically divided in: local and while others evaluated the effect of chlorhexidine as part systemic. of ultrasonic instrumentation21-22. None of these studies found additional clinical effects the use of chlorhexidine Local as solution, when compared to treatment with manual The biggest challenge for local antimicrobials scaling and root planning or with ultrasonic device (using agents is the maintenance of therapeutic levels in water as solution). subgingival region for a suitable period of time. In some single-stage protocols for the treatment of AP, chlorhexidine (solution, spray and gel) is indicated Antiseptics as an adjunct efficient, being associated with better clinical microbiologic outcomes23-25. However,
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