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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- B 24-IPVS QFSJPE XJUI (GVMM NPVUI EJT-
terial biofilm, calculus, and toxins from infection [FMD]) or without (full mouth
periodontally involved root surfaces. A scaling and root planing [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 gingival margin. Another par- Patients with aggressive periodontitis
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 tooth mobility, 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 gingivitis,
bleeding on probing 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 periodontium. is of paramount importance to preserve
In such cases, anatomical damage from both marginal tissues and connective
previous periodontal disease will persist fibers inserted in the root cementum 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:

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Nonsurgical periodontal individualized professional subgingival

therapy: what does it instrumentation. 8


In the treatment of aggressive perio-
mean?
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.1 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. 2 Periodontal breakdown oral hygiene 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.10
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. 3-5 periodontitis. 11,12 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.6,7 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.13
maintained only provided there is ade- Subgingival instrumentation compris-
quate plaque control by the patient and es scaling and root planing by manual

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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-
HJDBM QFSJPEPOUBM UIFSBQZ, PDDMVTBM BEKVTUNFOU BOE TVQQPSUJWF UIFSBQZ XJUI SFDBMMT FWFSZ 4 NPOUIT. 5IF
anterior teeth were stabilized by means of extracoronal splintings. (Courtesy Dr Mariani.)

a b

Fig 2 3BEJPHSBQIJD JNBHFT PG UIF DMJOJDBM DBTF QSFTFOUFE JO 'JH 1 BU CBTFMJOF (a) BOE 12 ZFBST MBUFS
(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 alveolar process 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 debridement in which
(SRP) is the gold standard for the non- the removal of root cementum is not
surgical management of periodontitis.14 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. 15-18 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

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the degree of tooth mobility, as clinically Clinical studies reported that subgin-
experienced. gival instrumentation failed to eliminate
Nonsurgical periodontal treatment DBMDVMVT JO 10% PG QFSJPEPOUBM QPDLFUT
can also lead to spontaneous reposi- XJUI B EFQUI PG < 5 NN, JO 23% PG QPDLFUT
tioning of pathologically migrated teeth XJUI B EFQUI PG 5 UP 6 NN BOE JO 35% PG
('JHT 1 BOE 2) BOE UP DMPTVSF PG EJBTUF- QPDLFUT > 6 NN EFFQ, JO 10% PG TJOHMF-
mas.19 Control of infection and inflam- SPPUFE UFFUI BOE JO 30% PG NVMUJ-SPPUFE
mation, elimination of abnormal occlusal teeth.30,31 ('JH 3) 3FDFOUMZ, UIF JNQSPWF-
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.20 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.32
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.21 The magnitude depends on the ings are not universally demonstrated. 33
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
1.29 NN BOE 0.55 NN, SFTQFDUJWFMZ, GPS optimize the treatment outcomes and
JOJUJBM 1%T PG 4 UP 6 NN BOE PG 2.16 NN the choice of the treatment modality
BOE 1.19 NN, SFTQFDUJWFMZ, GPS QPDLFUT should be based on the periodontal an-
JOJUJBMMZ ö 7 NN EFFQ.22 In general, clin- atomic features and the individual pa-
icians should evaluate post-SRP heal- tients’ needs.
JOH BU 4 UP 6 XFFLT GPMMPXJOH USFBUNFOU. When analyzing the SRP outcomes it
"GUFS 6 XFFLT, NPTU PG UIF IFBMJOH IBT is important to take in account the long-
taken place but soft tissues maturation term maintainability of deep periodontal
NBZ DPOUJOVF GPS BO BEEJUJPOBM 9 UP 12 pockets, and the risk of disease recur-
months or longer.23 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 XJUI BO PEET SBUJP NPSF UIBO 10 GPS EJT-
skill and the anatomical features but not ease progression. 34 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. 24,25 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.26-29 <'.14> < 20%) PG UIF QBUJFOU, BOE UIF m-

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a b c

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) ¨48, (b) ¨155,
and (c) ¨1,600. ($PVSUFTZ %S 4DJQJPOJ.)

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-
UIBO 4 NN BOE BCTFODF PG #P1 UP PQUJ- branes, that could lead to a disease re-
mize the long-term prognosis. currence.36,37
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 chlorhexidine, within
Advances in non-surgical 24 IPVST (VTVBMMZ JO 2 TFTTJPOT PO 2
consecutive days). 38 They reported
treatment protocols
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.39-41
vals (conventional staged debridement Other researchers proposed the treat-
[CSD]).35 0WFS UIF MBTU 10 ZFBST, 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 NFOUBUJPO XBT DPNQMFUFE JO 24 IPVST PS
advantageous to change the stand- less with no adjunctive use of antiseptics
BSE 4- UP 6-XFFL QFSJPE PG OPOTVSHJDBM agents.42 When the FMSRP was com-
periodontal treatment to a full-mouth pared to the standard approach neither
24-IPVS BQQSPBDI. 5IF SBUJPOBMF GPS UIF clinical nor microbiological differences
latter strategy was to prevent reinfec- were detected.43,44

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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. 45,46 They concluded short- and long-term control of inflam-
that in patients with chronic periodon- matory periodontal disease. 48
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. 47
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, Tannerella forsythia,
two visits, and thus, the therapist has Treponema denticola, Prevotella inter-
fewer opportunities to deliver, check, media and Porphyromonas gingivalis
and reinforce oral hygiene instructions. were found to colonize nearly all the
Considering that periodontitis patients above-mentioned intra-oral niches. 49
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. 47 The

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Supra and subcrestal lead to the recovery of the interdental


papillae. This may be attributed to the
nonsurgical periodontal
increased vascularization and cellular
treatment
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- UIF DFNFOU-FOBNFM KVODUJPO ('JH 6).
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
UIF SFTQFDU PG TPGU UJTTVFT ('JH 4).50
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. 51 The coronal
displacement of gingival margin may
result from a mechanism similar to the
creeping attachment observed after mu-
cogingival surgery.52 (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-
DBUFE BU UPPUI 1.3 USFBUFE CZ SPPU QMBOJOH BOE QPM-
interdental gingival tissues, according to
ishing (a). The coronal displacement of the gingival
the technique proposed by Shapiro et margin and the almost complete root coverage were
BM,53 DPNCJOFE XJUI BO BEFRVBUF IPNF achieved by both the detoxification and the gentle
and professional plaque control may reduction of the root convexity (b).

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b c

d e 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). 'SPOUBM WJFX 17 ZFBST MBUFS (f).

The treatment of suprabony defects advocated in order to further decrease


differs according to the defect location. the PD.17
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

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guarantee optimal defect coverage at gival plaque control and professional


wound closure. 54 If the osseous resec- SFNPWBM PG TVCHJOHJWBM CJPmMN.61 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 dental plaque. 62,63
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
should be performed in the shortest time
therapy
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.58-60
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. 56,57 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- BOE SBOHFE CFUXFFO 0.2 BOE 0.6 NN GPS
ed in systematic reviews presented at $"- HBJO BOE CFUXFFO 0.2 BOE 0.8 NN
North American and European Work- for PD reduction.60
shops.58-60 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-

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a b

c d

e f

Fig 7 28-ZFBS-PME $BVDBTJBO XPNBO QSFTFOUFE XJUI UIF DIJFG DPNQMBJOU PG EJGmDVMUJFT JO TQFFDI BOE
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) BOE 16 ZFBST MBUFS (b, d,
f). The patient underwent the OSFMD in according to the protocol by Quirynen et al 38 in association with
TZTUFNJD BOUJCJPUJD JOUBLF. 5IF TVQQPSUJWF QFSJPEPOUBM UIFSBQZ XBT QFSGPSNFE FWFSZ 3 NPOUIT. 5IF QBUJFOU
EJTQMBZFE B HPPE DPNQMJBODF XJUI B QMBRVF JOEFY TDPSF < 10% BOE BO PQUJNBM UJTTVFT SFTQPOTF (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.

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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.

Fig 9 Radiological images


PG UIF DBTF JO 'JH 7 BU CBTFMJOF
(a) BOE 16 ZFBST MBUFS (b). We
can observe the radiological
appearance of the lamina
dura and the remineralization
of the supportive bone. b

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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.64 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.66 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. 58-60 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 ('JHT 7 UP 9). *O QBUJFOUT XJUI lasers and CO2 lasers.67 The applica-
adequate home plaque control (FMPS tion of a dental laser in the treatment of
< 15%) BOE HPPE DPNQMJBODF UP B TUSJDU chronic periodontitis is based on the
maintenance therapy the combined purported benefits of subgingival curet-
USFBUNFOU SFTVMUFE JO BEEJUJPOBM 0.7 NN tage, significant decreases in subgingi-
JO NFBO 1% SFEVDUJPO BOE 1.00 JO DMJOJD- val pathogenic bacteria, and hemosta-
al attachment gain in deep pocket sites. sis.68,69 However, when used directly to
In addition, A. actinomycetemcomitans root surface for calculus removal it can
XBT FMJNJOBUFE GSPN 53% PG UIF USFBUFE cause excessive heat and results in root
TVCKFDUT BU 6 NPOUIT BGUFS UIFSBQZ.9 damage.70 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.71
on molars benefited significantly more Despite the large number of publica-
than non-molar sites.65 tions there is still controversy among

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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.79 Recently, in-
py.72 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.72 id glycine-based powder delivered with
In addition, there is considerable con- a low-pressure device.80 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.80
tion with SRP as compared to conven- Current evidence of the efficacy of the
tional mechanical instrumentation. 73,74 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.80 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.81,82
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.82 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.75 The cytotoxic product can- is questionable. In addition, the clinic-
OPU NJHSBUF NPSF UIBO 0.02 NN BGUFS JUT 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.76 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. 77 Thus, to support evidence-based decision-
it may not substantially suppress patho- making.
genic bacteria in periodontal pockets.78

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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 author thanks Dr Federica Romano, University
the diagnosis, the medical history, the
Researcher at the Section of Periodontology 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.

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