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Treatment of Juvenile Periodontitis with Microbiologically Modulated Periodontal Therapy (Keyes Technique)

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Treatment of Juvenile Periodontitis with Microbiologically Modulated Periodontal Therapy (Keyes Technique) PEDIATRICDENTISTRY/Copyright @1985 by TheAmerican Academy of Pediatric Dentistry Volume7 Number4 Treatment of juvenile periodontitis with microbiologically modulated periodontal therapy (Keyes Technique) Thomas E. Rams, DDS, MHS Paul H. Keyes, DDS, MS William E. Wright, DDS, MS Abstract Antimicrobial therapeutic strategies widely referred to A wide variety of therapeutic approaches have as the Keyes Technique were directed at suppression of been used to manage juvenile periodontitis (JP) pa- the periodontopathicmicroflora of 7 juvenile periodontitis patients whowere treated and followed for at least 22 tients, even though the exact nature of its etiology months. has been understood poorly until recently. Almost all Followingcollection of baseline clinical and of these approaches have employed clinical peri- microbiological parameters,the patients received odontal parameters alone to guide therapy diagnost- meticulous scaling and root planing of all teeth with ically, and determine its success or failure. 1-6 Most concomitantirrigation to probing depth of saturated also have placed emphasis in treatment on mechan- inorganic salt solutions and 1%chloramine-T. The ical control of bacteriologically undefined dental patients were recalled at approximately 2- to 3-month plaque, and surgical correction of anatomic and mor- intervals for maintenancecare which was modulated by phologic defects associated with JP disease progres- clinical parametersand phase-contrast microscopic sion (i.e., infrabony pockets, inflamed gingival findings. Six patients received at least 2 courses of tissues). 1-6 systemic tetracycline (1 gin/day for 14 days) during the Antimicrobial therapy targeted at specific disease- study. Patient hometreatments included daily application of a sodium bicarbonate/3%hydrogen peroxide paste, and associated bacterial species in the subgingival plaque inorganic salt irrigations. microbiota also has been suggested for treatment of Clinical reevaluations madean average of 29.6 months jp.7,s This rationale was applied initially to the treat- posttreatment showedstatistically significant (p(.01) ment of adult periodontitis lesions, and has been re- 9 decreases in bleeding on probingin all patients. ferred to widely as the Keyes Technique, or Significant decreases in probing depth, and gains in microbiologically1°- modulated periodontal therapy. clinical attachmentlevels also were found in all patients, 13 As a therapeutic strategy for the control of specific particularly in advancedsites initially 4-6 mmand >-7 plaque infections ~4,15 associated with human peri- mmin probing depth. Amongsites with initial odontal diseases, it incorporates microbiological eval- attachment loss >-5 mm, 25.8% experienced a >-3 mm uations of the subgingival flora, such as with phase- gain in clinical attachmentlevel from baseline with contrast microscopy, into diagnostic decision-making therapy. Significant decreases in motile organismsand and patient management. 16-21 Additionally, chemical crevicular polymorphonuclearleukocytes present in the subgingival plaque of the patients also occurredwith the antimicrobial agents are utilized in both office ther- antimicrobial therapy employed. apy and patient home treatment procedures as ad- These findings demonstratethat juvenile periodontitis juncts to mechanical plaque removal techniques, such patients can be treated successfully and maintainedon a as~6- root21 planing, flossing, and toothbrushing. long-term basis without periodontal surgery when The concept of directing therapeutic measures at appropriate antimicrobial therapy is directed at the specific microbial pathogens in JP has been supported subgingival periodontopathic microbiota. by recent cultural studies of subgingival plaque from PEDIATRICDENTISTRY: December 1985/Vol. 7 No. 4 259 JP subjects. These studies repeatedly have associated any renal disorders, hypertension, sodium intake re- elevated numbers of certain species of gram-negative strictions, or previous allergic reactions to tetracycline rods with localized JP sites, especially Haemophilus antibiotics. All patients underwent complete physical (formerly Actinobacillus) actinomycetemcomitans(Ha). 23-25 and hematological examinations (including CBC, SMA- Further, Ha has been shown to elaborate a number 12, and urinalysis) conducted by the NIH Clinical of potential virulence factors (e.g., leukotoxin, colla- Center medical staff to exclude the presence of any genase, immunoglobulin proteases, fibroblast growth contributing systemic medical disorders. None of the inhibitors, and bone resorption factors), which may subjects had any systemic disorders reported to be be important in the pathogenesis of ]p.26 associated with periodontal manifestations in adoles- Some morphologic studies with phase-contrast, cents, such as diabetes mellitus, sarcoidosis, Down’s darkfield, and transmission electron microscopy also syndrome, cyclic neutropenia, agranulocytosis, Pap- have revealed large numbers of spirochetes and mo- illon-Lef~vre syndrome, of Ch6diak-Higashi syn- tile rods in localized JP subgingival plaque.7"8"21"27-31 drome. In vitro evaluations of neutrophil and Consistent with these findings, elevated serum titers monocyte functions were unavailable at the start of of antibodies specific to antigenic determinants of these studies, and were not determined for the pa- Treponemaspecies also have been reported in individ- tients followed. None of the patients had received uals with localized jp.32,33 However, there is evi- any type of periodontal prophylaxis or systemic an- dence that not all localized JP patients harbor high tibiotic therapy during the previous 6-month period. proportions of motile bacteria in their subgingival mi- croflora, 4"23’34"35 and the exact role of these organ- Diagnostic Procedures isms in JP is not well understood. The purpose of the present investigation was to determine whether the principles of microbiologically Clinical Examinations modulated perioclontal therapy (Keyes Tech- Clinical parameters for all teeth were assessed in- nique)7,s, lo-13, 16-20 could be applied successfully to dependently by a single NIDRstaff periodontist (au- the long-term clinca[ managementof JP. thor WEW)who was unaware of the patient’s course of therapy (single-blind evaluation). Periodontal probing depths and clinical attachment levels were Methods and Materials measured to the nearest mm at interproximal and This longitudinal therapeutic investigation was buccal surfaces of all teeth with a calibrated probe, as conducted within the clinical research facilities of the described38 by Philstrom et al. National Institute of Dental Research (NIDR), of the The degree of gingival inflammation for each tooth National Institutes of Health (NIH) in Bethesda, was determined by scoring the amount of bleeding Maryland. The patients studied were selected from seen after gentle probing to the "bottom" of the gin- persons referred to the NIDRdental clinic for peri- gival sulcus. A sulcular bleeding score was assigned odontal disease treatment. Seven untreated patients as follows:.0 = no bleeding, 1 = spot bleeding point younger than 22 years of age with idiopathic JP, as only, 2 = bleeding along the gingival margin. defined by Baer, 36 were treated and followed for at least 22 months posttreatment (Table 1). Five of the Microbiological Examinations JP patients were classified as having localized cases At each patient appointment, the composition of (first molars, incisors, and additional teeth equaling the subgingival plaque was monitored with phase- <14 total teeth), and 2 patients had generalized cases contrast microscopy at chairside to assess the effec- (->14 total teeth involved), based on the number tiveness of the therapeutic measures. No cultural or affected teeth. 37 The 5 females and 2 males in the immunologic monitoring was conducted as part .of study had a meanage of 18 years (range = 12-21 years), this study. and 193 teeth on initial examination. The follow-up Enumeration of disease-associated morphotypes in clinical observations on the patients ranged from 22 subgingival plaque samples with phase-contrast mi- to 39 months posttreatment, with a mean of 29.6 croscopy followed procedures previously de- months. scribed, 7"16-21 and included counts of spirochetes, All patients were in good general health and pre- brush formations, motile rods (large-, medium-, and sented with radiographic evidence of >50%bone loss small-sized), oral protozoa (i.e., Entamoebagingivalis, associated with the permanent first molars and inci- Trichomonas tenax), .and accumulated crevicular poly- sors (Fig 1), and clinical attachment loss of ->7 morphonuclear leukocytes. at these sites. Comprehensive medical and dental Briefly, subgingival plaque was removed carefully histories were obtained, with particular emphasis on from periodontal sites with a sterile curette, placed 260 TREATMENTOF JUVENILE PERIODONTITIS: Ramset al. FIG 1. Typical molar/incisor angular defects associated with untreated JP lesions. into 0.02 ml of sterile water on a microscopic slide, eral months after the last posttreatment clinical eval- coverslipped, and examined immediately at 400x and uations were made. 600x with a high quality, phase-contrast microscope. The highest scoring fields for each of the bacterial and Therapeutic Procedures cellular morphotypes then were recorded. Based on previous research,17-18-21 patients with periodontal pockets harboring ^ 125/highest scoring Professional Office Therapy fields of either spirochetes,
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