Oral Diseases (2003) 9 (Suppl.

1), 6370
2003 Blackwell Munksgaard All rights reserved 1601-5665/03
http://www.blackwellmunksgaard.com

REVIEW ARTICLE

Use of antimicrobial agents during supportive periodontal

therapy
E Venezia, L Shapira
Department of Periodontology, Faculty of Dental Medicine, Hadassah and Hebrew University Medical Center, Jerusalem, Israel

Individual susceptibility to periodontal breakdown

involves an interplay of genes, periodontal pathogens and
other modulating factors. Anti-infective treatment, which
includes oral hygiene measures, mechanical debridement,
pharmacologic intervention and surgery, has been shown
to be effective in arresting the progression of periodontal
disease. Nevertheless, due to the chronic nature of the
disease, susceptible individuals who are not maintained
in a supervised recall program subsequent to the active
treatment phase, show signs of recurrent destruction.
Supportive periodontal therapy (SPT) is an integral part of
periodontal treatment for patients with history of periodontitis, and is needed to prevent recurrence of disease in
susceptible individuals. To prevent re-infection with periodontal pathogens, SPT includes elimination of dental
plaque and bacteria from the oral cavity, thereby preventing the recurrence of pathogens into the gingival area.
For individuals at risk of developing periodontitis, SPT
should combine self-performed and professional antiinfective therapy, using mechanical and pharmacological
means. The existing evidence suggests that the adjunctive
use of antimicrobial pharmacologic therapy during
SPT may enhance the results of mechanical debridement.
The use of antimicrobials varies between patients, and is
dependent on risk assessment and longitudinal monitoring
of the clinical status of the periodontium.
Oral Diseases (2003) 9 (Suppl. 1): 6370
Keywords: periodontitis/maintenance; periodontitis/therapy;
antimicrobials; periodontitis/supportive therapy

Introduction
The primary etiologic factor for periodontal diseases is
dental plaque bacteria. Several species of bacteria have
been found to be associated with a disease state, among
which Porphyromonas gingivalis, Bacteroides forsythus
Correspondence: Lior Shapira, Department of Periodontology,
Hebrew University, Hadassah School of Dental Medicine, PO Box
12272, Jerusalem 91120, Israel. Fax: +97 22 643 8705,
E-mail: shapiral@cc.huji.ac.il

and Actinobacillus actinomycetemcomitans are considered to be major periodontal pathogens (Socransky and
Haajee, 1992). Although the amount and virulence of
the bacteria are important factors in periodontal disease
progression, special emphasis is directed today to the
role of the host-response in this process (Van Dyke et al,
1993). Periodontal pathogens and their products elicit
an inammatory response in the gingiva, but the
resulting tissue destruction is probably mediated
through host-derived proinammatory mediators
released from activated immune cells (Gemmell et al,
1997; Kornman et al, 1997). The type and the magnitude of the inammatory response is a key factor in
determining the outcome of gingival inammation. This
new understanding of the molecular basis of periodontal
disease has opened up new approaches for the control of
periodontal infection.
While gingival inammation is a ubiquitous nding,
severe periodontitis only occurs in a subgroup of susceptible individuals (Albandar et al, 1999). Several studies
have shown that individual susceptibility to periodontal
disease has a genetic basis (Marazita et al, 1994; Shapira
et al, 1997). However, environmental factors, such as
smoking, acquired systemic diseases and the use of drugs
are also known to predispose to periodontal disease
(Scully et al, 1991). Anti-infective periodontal treatment,
which includes oral hygiene measures, mechanical
debridement, pharmacologic intervention and surgery,
has been shown to be eective in arresting the progression
of periodontal destruction (Lindhe and Nyman 1975;
Badersten et al, 1987; Ramfjord 1987). Nevertheless, the
chronic nature of the disease requires continuous monitoring and preventive treatment. Susceptible individuals
who completed the active treatment phase and were not
maintained in a supervised recall program, showed signs
of recurrent destruction (Axelsson and Lindhe, 1981;
Becker et al, 1984).

Current approach to supportive periodontal

therapy
Supportive periodontal therapy (SPT), or maintenance, is an integral part of periodontal therapy for

Antimicrobials and supportive periodontal therapy

E Venezia, L Shapira

64

patients with treated periodontal disease. This phase

of therapy is needed to prevent disease recurrence in
individuals with susceptibility to periodontal destruction. The frequency of professional SPT appointments
depends on patient susceptibility to periodontal disease
and individual risk assessment. For patients-at-risk, at
least four appointments per year have been recommended (Axelsson and Lindhe 1981; Ramfjord 1987).
The intervals between appointments should be determined by the clinician, based on the history of disease
progression, compliance with self-infection control, and
clinical parameters which are recorded during the SPT
(AAP Position Paper, 1998: American Academy of
Periodontology, 1998). The goals of the SPT program
are prevention of future periodontal destruction and
early monitoring of disease recurrence, but one should
realize that this mission can be dicult. Although most
studies support the concept that patients who receive
SPT are more likely to maintain their periodontal
attachment (Wilson, 1996), some patients experience
loss of attachment despite regular SPT. This may be due
to ineective therapy. Complete removal of subgingival
plaque can be dicult (Pattison, 1996), particularly in
sites with probing depths exceeding 5 mm (Waerhaug,
1978; Rabbani et al, 1981), and is highly dependent on
the clinical skills of the practitioner. These problems
suggest that adjunctive anti-infective therapy could be
benecial during SPT for sites with deep probing depth
or limited accessibility. With the advances in understanding of the microbial etiology of disease progression, it is logical to investigate the use of antimicrobial
agents in the SPT patients, particularly in individuals
and sites at high risk for future attachment loss.

Concepts for SPT plan

SPT should be based on the new concepts of the
bacterial specicity of periodontal disease. The main
goal of SPT in the susceptible individual is to eliminate
specic pathogens from the oral cavity, creating an
environment which will support the stability of the
attachment apparatus. The reservoir of the periodontal
pathogen is not located only in the dental plaque
and periodontal pockets but also in other oral sites
(Asikainen and Chen, 1999). To prevent re-infection,
SPT must target the periodontal pathogens in the entire
oral cavity, with particular attention to the biolm in
periodontal sites, which is the major reservoir of
pathogens with direct access to the periodontal tissues.
The goal of the professional and patient-based SPT
program is to suppress re-infection of periodontal
pockets with periodontal pathogens between SPT
appointments, even when oral hygiene measures are
not ideal. The rationale for 3-month intervals between
SPT appointments is based on data suggesting that
adequate suppression of the pathogens during the SPT
appointment should last for at least 3 months (Slots
et al, 1979; Mousques et al, 1980). Microbial testing
during SPT may show that in a particular patient, the
anti-infective therapy has not been ecient and
re-infection with periodontal pathogen has occurred,
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suggesting that shortening of intervals between SPT

appointments may be advised. The above concepts
suggest that SPT for individuals with history of periodontitis should combine mechanical and pharmacologic anti-infective therapy, for achieving the optimal
results.

Use of antimicrobials during SPT by the

professional
Subgingival irrigation
Because mechanical debridement might not remove all
pathogenic bacteria (Cugini et al, 2000), particularly in
deep pockets and furcations, it may be augmented by
using subgingival irrigation with antimicrobial solutions. The delivery of the solutions to the depth of the
pocket may be executed by using irrigating cannulas or
ultrasonic cleaning devices. Nosal et al (1991) have
shown that antimicrobial solutions delivered during
debridement through the ultrasonic scaler penetrated to
most of the pockets, up to 9 mm in depth. Similarly,
subgingival irrigation via a cannula placed several
millimeters under the gingival margins resulted in
7080% penetration to deep pockets (Boyd et al,
1992). The issue of whether irrigation with medications
in conjunction with mechanical debridement produced a
synergistic eect remains controversial. Several studies
demonstrated that subgingival irrigation with antimicrobials eectively reduced pathogenic bacteria and more
than 100 days were needed for the bacteria to re-infect
the pockets (MacAlpine et al, 1985; Southard et al,
1989). However, similar results were published for
routine mechanical therapy alone (Slots et al, 1979).
Compared with mechanical debridement alone, a few
studies demonstrated no synergism (MacAlpine et al,
1985; Wennstrom et al, 1987; Herzog and Hodges, 1988;
Krust et al, 1991), while others showed synergism with
only minimal improvement (Rosling et al, 1983;
Southard et al, 1989; Christersson et al, 1993). However, most of the above studies used very frequent
applications of antimicrobials that are not practical for
long-term SPT. Quirynen et al (1995) have suggested a
full-mouth disinfection approach to initial therapy,
which seems to be very suitable and logical for SPT.
They incorporated subgingival irrigation as part of the
professional anti-infective therapy, but the positive
eect of their approach might be primarily due to the
close time schedule of subgingival debridement rather
than due to the irrigations with antibacterials. Recently,
Slots and Jorgensen (2000) advised using mechanical
debridement followed by subgingival irrigation with
povidone-iodine during SPT appointments of periodontitis patients, primarily due to the bactericidal potential
in areas with dicult access, and the costbenet
advantage of the procedure. There is insucient evidence today to indicate this procedure as routine
supplementation to SPT, but the use of antimicrobials
for irrigation is simple and safe. Due to the short-term
eect of subgingival irrigations, additional antimicrobial
means should be indicated when a more prolonged
antimicrobial eect is desired.

Antimicrobials and supportive periodontal therapy

E Venezia, L Shapira

Sustained release delivery systems (Table 1)

It has been long recognized that the delivery of
antimicrobial agents to the diseased sites by systemic
administration of antibiotics is eective in altering the
progression of certain forms of periodontitis (Genco,
1981; van Palenstein Helderman, 1986). Systemic antibiotics, however, require the administration of large doses
in order to gain sufcient concentrations at the site of
the disease (Goodson, 1994). In addition, the routine use
of antibiotics over long periods is contraindicated
because of the development of resistant bacterial strains
and possible hypersensitivity reactions (van Winkelhoff
et al, 2000). Local antimicrobial therapy is an alternative approach aimed at providing an antimicrobial
concentration adequate to penetrate the biolm in the
periodontal pocket for prolonged time periods, thus
suppressing or eradicating the subgingival pathologic
microbiota and limiting tissue destruction. During the
last decade, several commercial local antimicrobial
substances have been developed for periodontitis.
Although there is a rational to suggest the use of local
antimicrobial substances during SPT, only a few studies
have targeted this optional use of local antimicrobial
drugs during SPT. The largest one investigated the use
of sustained-release chlorhexidine chip (Periochip,
Dexel Pharma Technologies Ltd., Jerusalem, Israel)
during SPT. Using a one-arm, multicenter uncontrolled
design (phase IV), Soskolne et al (2003) examined the
adjunctive use of chlorhexidine chip during routine SPT
over 2 years in 595 patients with good compliance to
SPT appointments. Once every 3 months, as part of the
SPT, the patients received chlorhexidine chips in all sites
with a probing depth of 5 mm or deeper. This study,
although lacking a control group, demonstrated a
gradual decrease in mean pocket probing depth (PPD)
of the treated sites of 0.95 mm. Most of the changes
were observed during the rst year, but the mean pocket
depth continued to decrease during the second year of
the study. After 2 years, 51% of the patients had at least
one pocket showing a reduction of 2 mm or more, and
60% of the sites had been reduced to less than 5 mm. By
comparing these study results to studies that examined
conventional SPT, it was concluded that the use of the
chlorhexidine chip during SPT in sites with a probing
depth of 5 mm and more is an eective treatment
option. However, 8% of the treated sites deteriorated
but they did not report on the percentage of deteriorating subjects, which complicated the comparison with
conventional SPT studies (Haajee et al, 1997; Tonetti
et al, 1998a). These conclusions were supported by a
smaller, but controlled, clinical trial. Heasman et al
(2001) used a randomized, split mouth, single-blind
study design and evaluated the ecacy of the chlorhexidine chip during 6 months of SPT among 26 nonsmoking patients. It was found that the adjunctive use of
the chlorhexidine chip to conventional mechanical
debridement in the maintenance phase had led to
increased reduction in mean probing depth and attachment gain which approached statistical signicance at
6 months. Another support for the use of local antimicrobials as an adjunct to routine SPT comes from

the study of van Steenberghe et al (1999), which used

minocycline-containing ointment (Cyanamid, Lederle
Division, Waune, NJ, USA) (2%), as part of SPT over
15 months, in comparison with vehicle alone (n 46
test; n 47 control). This study showed that after
stabilization of the clinical parameters by mechanical
treatment, a further reduction in PPD of 0.7 mm was
obtained over the rest of the 15-month study period. The
control group, treated with a placebo gel, showed no
further reduction in PPD, behaving as might be predicted.
In addition, microbiological (DNA) analysis revealed
that sites treated with minocycline always produced
statistically signicantly greater reduction in the number
of periodontal pathogens, which is one of the primary
goals of SPT. The adjunctive use of tetracycline bers
(Actisite, Alza Corp., Palo Alto, CA, USA) was also
reported to improve the results of routine SPT. Newman
et al (1994) compared the adjunctive use of tetracycline
bers with scaling and root planing vs. scaling and root
planing alone, during SPT in deep sites with signs of
bleeding on probing (BOP). It was found that the
adjunctive therapy signicantly enhanced the eectiveness of the mechanical therapy for the entire 6-month
follow-up duration of the study. An increased reduction
of 0.7 mm was observed in mean probing depth and the
percentage of bleeding sites was lower. In addition,
Tonetti et al (1998b), who evaluated the eectiveness of
adjunctive tetracycline bers used in mandibular class II
furcations during SPT, found a signicant eect,
although it was found to last for only 3 months.
The only study that did not support the adjunctive use
of local antimicrobials to routine SPT used metronidazole gel (Elyzol, Dental Gel, Dumex Ltd, Copenhagen,
Denmark) (25%). Riep et al (1999) found no adjunctive
eect for this device compared with mechanical therapy.
This single-blind study included 29 SPT patients in
which the test sites were treated by scaling and root
planing plus ve subgingival applications of metronidazole gel during 10 days, and the control sites by
scaling and root planing alone. Clinical and microbiological parameters were followed for 3 months and
showed similar eects for the two treatment modalities,
with the exception of Prevotella intermedia, a periodontal pathogen that was reduced only at the control sites.
In contrast to the use of local antimicrobial devices as
an adjunct to routine SPT, some studies investigated
their use as monotherapy. In a 9-month SPT study,
Garrett et al (2000) compared the use of doxycycline
polymer (AtridoxTM, Block Drug Corporation, Inc.,
Jersey City, NJ, USA) (n 67) to mechanical debridement (n 74). The results showed that there were no
dierences in the clinical parameters between the test
and control group, suggesting that the pharmacologic
SPT therapy may replace mechanical instrumentation.
Similar conclusions were drawn from studies using
metronidazole gel as monotherapy during SPT. Stelzel
and Flores-de-Jacoby (1996) compared two sequential
applications of metronidazole gel within 7 days with
single-visit subgingival debridement. Thirty patients in
their SPT phase participated in this randomized split
mouth design study and were monitored for clinical and

65

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Oral Diseases

Chlorhexidine
chip
Chlorhexidine
chip

Soskolne et al (2003)

Doxycycline
hyclate

Tetracycline
ber

Tetracycline
ber

Metronidazole

Metronidazole

Metronidazole

Metronidazole

Garrett et al (2000)

Newman et al (1994)

Tonetti et al (1998b)

Stelzel and Floresde-Jacoby (1996)

Stelzel and Floresde-Jacoby (1997)

Rudhart et al (1998)

Riep et al (1999)

Controlled
Randomized
Single blind

Controlled
Randomized
Single blind

Controlled
Randomized

Parallel groups Controlled

Split mouth

Split mouth

Split mouth

1 of S/RP

Single at baseline

Single at baseline

At baseline and
4 month

Debridement
Adjunctive

Adjunctive

1 of S/RP and 5 of
gel within 10 days
S/RP every 3 months
1 of S/RP and
minocycline at baseline,
1, 3 and 6 months

Monotherapy 2 of gel within 7 days

Debridement 1 of S/RP
Monotherapy 2 of gel within
7 days
Debridement 2 of S/RP
within 7 days
Monotherapy 2 of gel within
7 days
Debridement 1 of S/RP

Debridement

Adjunctive

Debridement

Adjunctive

Debridement

Monotherapy

Debridement

At baseline, 2 weeks,
and months 1, 3,
6, 9, 12

Single at baseline

Mechanical
debridement
Adjunctive

Every 3 months

Protocol

Adjunctive

Treatment

Controlled
Debridement
Randomized
Double blind Adjunctive

Phase IV
Multicenter
Controlled
Randomized
Single blind

Study type

Parallel groups Controlled

Randomized
Single blind
Multicenter
Split mouth
Controlled
Randomized
Single blind
Multicenter
Parallel groups Controlled
In furcations
Randomized
Single blind
Multicenter
Split mouth
Controlled
Randomized

Parallel group

Split mouth

Parallel group

Design

Pocket probing depth. bClinical attachment level. cBleeding on probing. dNot available.

48

29

46

24

30

123

105

141

93

24

595

No. of
subjects

1 year

3 months

175 days

24 months

6 months

6 months

6 months

9 months

15 months

6 months

2 years

0.4
0.9

1.7

NA
NA

1.31

1.14

0.7

1.6
1.7

0.5

NA
NA
NA

NA

0.9

1.56

1.08

0.72

1.6

1.32
0.59
0.51

1.5

0.32.4

0.51.4

1.81

1.08

1.28

0.75

0.9

1.2
1.13

0.5

0.43

0.15

NAd

1.9

0.78

0.45

0.95

Increase in
Observation
Decrease
period
in PPDa (mm) CALb (mm)

NA
NA

58%

48%

NA

NA

35%
50%
50%

42%

52%

52%

57%

45%

44%
(% of bleeding index)
No dierence
between groups

1.08
Bleeding index
32%

0.59

NA

Decrease in
sites with BOPc

66

Meinberg et al (2002) Minocycline

Minocycline

van Steenberghe
et al (1999)

Heasman et al (2001)

Agent used

Author

Table 1 Sustained release delivery systems

Antimicrobials and supportive periodontal therapy

E Venezia, L Shapira

Antimicrobials and supportive periodontal therapy

E Venezia, L Shapira

microbiological parameters for 24 weeks following the

treatment. No signicant dierences between the two
treatment modalities were detected. The long-term
results of this study (Stelzel and Flores-de-Jacoby,
1997), involving 24 SPT patients, demonstrated a
tendency to revert to baseline values towards the end
of the observation period, with no statistically signicant dierences between the two methods for 24 months
after completion of treatment. Rudhart et al (1998) in a
similarly designed study followed, for 175 days, 46 SPT
patients after completion of an application of metronidazole and subgingival scaling and root planing in
split mouth manner. Once again, it was demonstrated
that both treatments led to similar clinical and microbiological eects without statistically signicant dierences. Nevertheless, one should remember that although
no signicant statistical dierences were found, this does
not necessarily indicate an equivalency of the results, as
the equivalency hypothesis was not tested.
One monotherapy study showed superior clinical
results for local antimicrobial therapy. Meinberg et al
(2002) compared conventional SPT vs. the use of subgingival Minocycline microsphers (Arestin, OraPharma,
Inc., Warminster, PA, USA) for 1 year. Twenty four
control patients were maintained on a 3-month SPT
interval, while another 24 patients were treated at
baseline by scaling and root planing followed by
subgingival application of 1 mg minocycline into each
site that had a pocket probing depth of 5 mm or deeper
and bled on probing. The minocycline application
was repeated after 1, 3 and 6 months. No adjunctive
instrumentation was performed in the test group. After
1 year, the minocycline group showed further reduction
of 0.5 mm in mean probing depth and 25% of these
patients showed signicant attachment gain, compared
with 4% in the control subjects, suggesting superiority
for pharmacologic intervention over traditional SPT.
In summary, the data suggest that the use of local
antimicrobial with sustained-release properties may
enhance the clinical and microbiological results of
traditional SPT, i.e. as an adjunct to complete removal
of supra- and subgingival accretions every 3 months.
The use of the local antimicrobial therapy as
monotherapy during SPT is controversial. The unique
properties of the dental biolm make the associated
micro-organisms more resistant to antimicrobials, as
well as to the host defenses. To overcome this problem,
it seems important to disrupt the dental biolm prior to
the use of the intrapocket pharmacologic devices.
Sustained-released devises have an advantage due to
the prolonged antimicrobial activity achieved. The
negative results obtained with the metronidazole gel
might be due to its low substantivity in the gingival
sulcus or due to bacterial resistance to the drug.
Mouthrinsing
Mouthrinses with antimicrobial properties are mainly
indicated for home-use by the patient, for reducing the
levels of periodontal pathogens. The in-oce use of
mouthrinses prior to and after mechanical debridement
may reduce the levels of the periodontal pathogens in

the oral cavity and reduce the risk of bacteremia. The

in-oce use of antimicrobial mouthrinses during SPT
has never been investigated. However, data from
the group of Quirynen et al (Quirynen et al, 1995;
Vandekerckhove et al, 1996; Mongardini et al, 1999;
Quirynen et al, 1999) suggest that SPT with a full-mouth
disinfection approach, including starting mouthrinses
during the SPT appointment, may be of importance,
particularly due to the suppression of periodontal
pathogens in the entire oropharyngeal cavity.

67

Systemic antibiotic
Employment of systemic antibiotics for routine SPT can
give rise to a number of adverse eects and should be
prescribed for use only in special cases after proper
evaluation. The use of antibiotics during SPT should be
reserved for patients experiencing periodontal breakdown and recurrence of disease. The use of antibiotics
for active disease is discussed elsewhere in this
document.

Use of antimicrobials for personal SPT

Self-care between SPT appointments may involve various mechanical and antimicrobial approaches and
should be customized for each patient as a result of
his/her periodontal condition. Patients with a history of
periodontitis are at risk of developing recurrent disease,
but the degree of risk varies from patient to patient. For
example, patients who smoke (Lang et al, 1997) or have
uncontrolled diabetes are at increased risk of developing
recurrent periodontitis. Patients should be monitored
carefully at each SPT appointment and the self-care
program should be modied accordingly.
Mouthrinses
Patients who, as a result of therapy, have only shallow
periodontal pockets should concentrate on supragingival plaque control and elimination of pathogenic
bacteria from the oral reservoir. Chlorhexidine rinses for
8 days may be recommended after each SPT appointment, to ensure prevention of re-infection during the
34-month interval between SPT appointments (Slots
and Jorgensen, 2000). This recommendation is indirectly
supported by the full-mouth disinfection approach
(Quirynen et al, 1995). It should be considered that
sodium lauryl sulfate (SLS)-containing toothpastes may
inactivate chlorhexidine (Brakvoll et al, 1989) and the
choice of an appropriate toothpaste, without SLS, could
be of importance during that period.
Although many mouthrinsing products with antiplaque claims for long-term use are available, research
has focused on the parameters of plaque accumulation
and gingivitis as primary outcome variables, but not as
primary outcome variables of SPT, such as pocket depth
and specic microbiological parameters. In a controlled
study, Danser et al (2001) compared the use of amine
uoride/stannous uoride mouthrinse and dentifrice in
periodontitis patients during 2 years of SPT to the use of
control (NaF) mouthrinse and dentifrice. The amine
uoride/stannous uoride formulation was found to be
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Antimicrobials and supportive periodontal therapy

E Venezia, L Shapira

68

superior for control in terms of plaque reduction, but

not in terms of BOP or probing depth. One can
hypothesize that periodontitis patients may benet from
the plaque reduction properties of the mouthrinse, but
the daily use of these products as part of the SPT for the
prevention of periodontal breakdown or suppression of
periodonthal pathogens is not yet evidence-based.
However, because root caries may present a threat for
patients that complete active periodontal therapy,
uoride-containing mouthrinses may have a place in
an SPT program. Quirynen et al (2003) has demonstrated a shift in the ora toward cariogenic species a few
months after completion of full mouth disinfection. The
daily use of amine uoride/stannous uoride mouthrinses, which followed the short-term use of chlorhexidine rinses, prevented an increase in the proportions of
cariogenic bacteria. Taken together, the antiplaque
and anticariogenic properties of amine uoride/stannous uoride formula suggest that it may be included as
part of SPT therapy. However, this formula, as well as
new ones, should be investigated for their ability to
suppress re-infection with specic periodontal pathogens (with minor side-eects), in support of their
inclusion in SPT.
Irrigation
In patients with increased pocket depths that may
harbor periodontal pathogens, special eorts should be
employed to control the subgingival microbiota. Oral
rinses cannot penetrate the pockets deeper than
0.2 mm (Wunderlich et al, 1984), so they cannot
eectively control the re-infection of pockets with
increased probing depth. The use of oral irrigators
may facilitate the delivery of antimicrobial agents into
deep pockets and interproximal sites. The advantage of
self-administrated subgingival irrigation is the possibility of the patient preventing the re-population of
pathogens in the subgingival areas that were treated
during SPT appointments. Jet irrigator devices project
the antimicrobial solution 3 mm subgingivally or to
half the probing depth (Eakle et al, 1986; Boyd et al,
1992; Larner and Greenstein, 1993) and the attachment
of a subgingival tip to the irrigator may augment
subgingival penetration of the antimicrobial solution
(Braun and Ciancio, 1992). Irrigation in the depths of
the pocket may interfere with plaque maturation and
wash away bacteria in unattached plaque. The use of
antimicrobial agents with irrigation devices may support the washing action of the device, although this
added effect is a controversial issue (AAP position
paper, 1995: American Academy of Periodontology,
1995). The available data suggest that daily use of
supragingival irrigation with antimicrobial agents may
partially benet patients with deep periodontal pockets
during SPT, and the use of subgingival tip for selected
deep pockets may augment the effect of irrigation due
to deeper penetration properties. However, the manual
complexity of personal subgingival irrigation, low
compliance, cost and possible side-effects (risk for
abscess formation and bacteremia) may represent
pitfalls for this procedure. The optimal drug, dose

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and frequency of use needed for optimal subgingival

irrigation have yet to be determined.
Toothpastes
Using a toothbrush as a delivery device, it was found
that toothpastes can penetrate only up to 0.9 mm into
the periodontal pockets (Waerhaug, 1981). One cannot
expect that toothpastes containing antimicrobial agents
would inhibit the re-infection of pockets by pathogenic
ora. As for mouthrinses, antimicrobial agents in a
toothpaste formula may reach dicult to clean areas,
such as interdental spaces. When plaque control is not
ideal, one could hypothesize that its use may assist
patients during SPT. However, with the exception of
two studies (Rosling et al 1997a; Rosling et al, 1997b;
Bruhn et al, 2002), no study has shown that antimicrobial toothpaste may have microbiological and clinical
indications for patients at risk of developing periodontitis. Rosling et al (1997a, 1997b) have shown, in a
36-month study, that the use of triclosan-containing
toothpaste exhibited more pronounced alternations of
the subgingival microbiota than control toothpaste,
particularly for Prevotella intermedia. A gradual
increase in the mean PPD was observed in the control
subjects, while in the test group there was stability. In
addition, more sites with attachment loss were observed
in the control group. Due to the fact that the study
design included no professional subgingival debridement during the 36-month study, it is not clear if
patients in an SPT program would benet from the
antimicrobial toothpaste. However, its use may be
valuable as an adjunctive therapy for patients with
partial compliance to SPT appointments. Using another
formulation, Bruhn et al (2002) were not able to
demonstrate any advantage for triclosan regarding
BOP and probing depth reduction, which are major
outcome variables for SPT. At this stage, no recommendation can be concluded for use of specic toothpastes during SPT for periodontitis patients, but the
development of new formulations with more SPT
studies is needed.

Conclusion
The evidence for incorporating the use of antimicrobials
in professional and personal SPT is controversial. SPT is
indicated for patients with increased susceptibility to
periodontal pathogens and, from a microbiology point
of view, the use of antimicrobial agents as an adjunct to
mechanical debridement might be benecial for patients
at high-risk. The use of antiseptic solutions (mouthrinses
and irrigations) during SPT appointments may be an
additional instrument for reducing the reservoirs of
periodontal pathogens. For pockets with increased
probing depth, the use of local sustained delivery
devices have been shown to improve the results of
mechanical debridement and the data is sucient to
indicate this procedure as routine supplementation to
SPT for patients and sites at high-risk. However, the
high cost of the devices, particularly for multiple
pockets, put in question the cost-benet value of this

Antimicrobials and supportive periodontal therapy

E Venezia, L Shapira

therapeutic approach. The use of antimicrobial mouthrinses following SPT appointments, such as chlorhexidine, may assist to prevent re-infection of periodontal
pockets, but their use should be limited to short periods.
However, daily use of mouthrinses with plaque
reduction and anticariogenic properties may be
recommended.
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