CE Sponsored by Colgate in Partnership With the American Academy of Periodontology — Key Tenets of Periodontal Debridement

INTRODUCTION

Periodontal debridement is a central component of initial periodontal therapy. Despite clinicians’ best efforts, however, some patients will not respond as expected, and their periodontal health will continue to decline. There are many challenges to periodontal debridement, and one of the biggest is that success depends on patient compliance in maintaining healthy habits and good oral hygiene.

This continuing education article, “Key Tenets of Periodontal Debridement,” provides a timely review of the benefits and limitations of nonsurgical periodontal therapy and adjunctive approaches that can help support optimal treatment outcomes.

Colgate-Palmolive Co. is delighted to have provided an unrestricted educational grant to support this educational series in collaboration with the American Academy of Periodontology.

—Matilde Hernandez, DDS, MS, MBA
Scientific Affairs Manager Professional Oral Care
Colgate Oral Pharmaceuticals

FROM THE AMERICAN ACADEMY OF PERIODONTOLOGY

Amid many advancements in periodontal therapy, debridement, along with scaling and root planing, are often key to treating periodontal disease. Although each has its own insurance code — and uses may vary, based on the clinical situation — these procedures can help restore a patient’s periodontal health.

In this insightful continuing education article, educator and American Academy of Periodontology (AAP) member Keerthana Satheesh, DDS, MS, highlights debridement’s effectiveness, limitations and varied approaches. This procedure is one line of defense against advanced infection that is available to the clinical teams whose work is integral to patient wellness and successful treatment outcomes.

The AAP is proud to work with Decisions in Dentistry and Colgate-Palmolive to provide evidence-based information that supports the highest levels of professional care.

—Steven R. Daniel, DDS
President, American Academy of Periodontology

Periodontal disease is a prevalent condition that affects 47.2% of Americans age 30 and older.¹ The clinical signs arise from inflammatory and destructive changes in the periodontium. These clinical signs include formation of periodontal pockets, loss of clinical attachment and resorption of the alveolar bone. The etiology is multifactorial and involves a complex interaction between oral biofilm and the host. Biofilms are diverse and highly organized microbial communities composed of a protective extracellular matrix. Bacterial colonization of the periodontal pockets produces virulence factors that can initiate the inflammatory cascade that can directly damage the host tissue, or cause indirect damage through the inflammatory pathways.² Examples of inflammatory mediators include arachidonic acid metabolites, such as prostaglandin E2, and cytokines, such as Interleukin 1 and tumor necrosis factor-α.^3–5

Prevention is the best approach, and supporting patients in developing an effective self-care regimen is critical, as is patient compliance with a recare schedule. Oral health professionals should recommend antimicrobial oral hygiene products, including dentifrice and mouthrinse, as well as oral hygiene aids, to patients based on their individual needs and risk.

Microbial pathogens that grow in biofilms, however, are highly resistant.² The most effective treatment to control biofilm — a critical step in successfully managing periodontitis — is physical disruption of the bacteria through scaling and root planing.⁶ Scaling and root planing are the gold standard in nonsurgical periodontal therapy.

A major goal of periodontal therapy is to suppress the extent of the subgingival bacteria and thereby reduce or eliminate the inflammatory periodontal lesion.^2,7–11 Scaling and root planing involve supragingival and subgingival instrumentation. While scaling includes removal of plaque, calculus and stains, root planing involves removing cementum or surface dentin that is contaminated with endotoxins and microorganisms.⁶ Scaling and root planing are also known as periodontal debridement (Figure 1), a term first coined by Smart et al¹² to describe the light overlapping strokes used for instrumenting with a sonic or ultrasonic scaler. Other investigators have described the term more broadly as instrumentation — using both hand and mechanical instruments — that is thorough enough to remove toxic substances from the root surface without over-removal of the cementum. The goal for nonsurgical periodontal therapy is to produce a root that is biologically capable of healthy attachment.^13–16

Meticulous instrumentation is a time-consuming and difficult procedure that includes both manual instrumentation and use of sonic or ultrasonic scalers. Compared to sonic and ultrasonic scalers, curets leave a smoother surface.^17–19 A drawback of curets, apart from being technique sensitive, is they eventually require sharpening to maintain clinical effectiveness. Numerous studies have also indicated that, in general, manual instrumentation achieves similar clinical end points as the use of sonic or ultrasonic scalers.^{7,9,10,13,20–22} Current nonsurgical treatment protocol consists of root debridement with sonic or ultrasonic devices and finishing with curets.^17,23 Clinical periodontal debridement includes supragingival debridement, subgingival debridement and scaling and root planing. The term is not to be confused with gross debridement.

EFFICACY OF NONSURGICAL THERAPY

Periodontal debridement is effective in decreasing probing depths and bleeding on probing, as well as improving clinical attachment levels.^24–27 Greater probing depth reduction is seen in deeper pockets (Table 1). The reduction in probing depths most likely stems from either shrinkage of the gingival margin (which results in a decrease in soft tissue inflammation and edema), or gains in clinical attachment. About half of the probing depth reduction comes from gains in clinical attachment, especially with probing depths of 4 to 6 mm, or 7 mm or more.^2,7,28,29 The gain in clinical attachment is mostly from a long junctional epithelium.³⁰

Periodontal debridement changes the microbiological profile. Significant reductions in the percentage of motile microbes and spirochetes,^7,31–33 Porphyromonas gingivalis and other gram negative anaerobic microbes^31,34–37 were noted following periodontal debridement. A concomitant increase in the number of nonmotile bacteria and percentage of cocci that are associated with periodontal health was also reported.^7,31–33,38

Periodontal debridement helps improve glycemic control in patients with diabetes, as research has shown a mean reduction of 0.29% in hemoglobin A1c at three to four months — although ongoing professional periodontal therapy is needed to maintain clinical improvements beyond six months.³⁹ Although the effect of periodontal debridement on decreasing adverse outcomes in pregnancy and childbirth has been debated, a 2012 meta-analysis by Kim et al⁴⁰ reported a significant decrease in risk of preterm birth with periodontal debridement in high-risk groups. Additional research is needed in this area.

Periodontal debridement must be followed with a reevaluation of treatment outcomes (Figure 2 and Figures 3A and 3B); this is a critical appointment that is scheduled four to six weeks after treatment. Although most healing is complete after six weeks, repair and collagen maturation may continue for an additional six to nine months.^2,28,29

LIMITATIONS OF PERIODONTAL DEBRIDEMENT

Several factors have been discussed as causes for less-than-desirable outcomes following periodontal debridement. A patient’s failure to maintain good oral hygiene and noncompliance in returning to regular maintenance care are two common factors.^13,41,42 Insufficient debridement may also result in reinfection.^{7,13,24,36,43} Complete calculus removal is difficult to achieve;⁴⁴ in one study, for example, complete calculus removal in sites deeper than 5 mm  was only possible in 11% of cases.⁴⁵ The operator’s experience⁴⁶ and ability to detect calculus,⁴⁴ distance of the deposit from the cemento-enamel junction,⁴⁷ and anatomy of the area^48,49 are a few possible causes for residual deposits following periodontal debridement.⁶ In addition, scaling and planing of diseased root surfaces can open up dentinal tubules, allowing invasion by periodontal pathogens into exposed tubules and thereby serving as a reservoir for reinfection of the pocket.^2,50,51

Other causes for a limited outcome include systemic disease, such as diabetes, which has a significant impact on long-term success.^13,52,53 Genetic susceptibility to periodontitis is also responsible for disease recurrence,^13,54,55 while smoking is associated with compromised healing following periodontal debridement.^56,57

ADJUNCTIVE APPROACHES

Due the limitations of periodontal debridement, newer tools for improved access have been introduced, as have antimicrobial therapies and adjuncts to conventional instrumentation techniques. Oral health professionals can now choose from a wider and refined selection of power scalers and slim ultrasonic tips, as well as periodontal endoscopes designed to improve visualization. Some operators utilize laser detoxification as adjunctive therapy. Thus far, however, each approach offers only marginal benefits when decontaminating the root surface.²⁴

Adjunctive use of antimicrobials was developed in an effort to improve the clinical and microbiological outcomes of nonsurgical periodontal therapy.⁵⁸ Every chemotherapeutic adjunct follows a medical mechanical model in which the agent is used to enhance the efficacy of periodontal debridement.⁵⁹ The antimicrobial adjuncts include application of antiseptics,^60,61 or sustained-release local drugs that are designed to prevent plaque accumulation and disinfect the root surfaces and adjacent periodontal tissues.^62,63 Systemic approaches include the use of antibiotics and host modulating agents.^13,64,65

Locally Delivered Antimicrobials: When used as adjuncts to periodontal debridement, most locally delivered antimicrobials (LDAs) will result in a probing depth reduction of approximately 0.3 to 0.5 mm and attachment level gains of 0.5 to 1 mm.^20,66,67 Randomized clinical trials (with a minimum duration of six months) showed clinical attachment gains of 0.4 mm for chlorhexidine chips, 0.64 mm for doxycycline gel, and 0.24 mm for minocycline microspheres.⁶⁸ Some clinicians recommend the use of LDAs as adjuncts in patients with chronic periodontitis who are at risk for disease progression.⁵⁹ Local antimicrobials have been shown to provide additional benefits in patients who smoke⁶⁹ and individuals with periodontitis and diabetes.⁷⁰

The statement on LDAs from the American Academy of Periodontology (AAP) recommends that clinicians consider their use in chronic periodontitis patients as an adjunct to periodontal debridement when localized recurrent and/or residual 5-mm probing depths with inflammation are still present following conventional therapy. The statement also recommends that alternative treatments should be considered when multiple sites of 5-mm probing depths exist in the same quadrant, the previous use of LDAs has failed to control periodontitis, and in the presence of anatomical defects.⁷¹

Systemic Antibiotics: The use of systemic antibiotics has been shown to help improve clinical parameters following periodontal debridement in patients with aggressive periodontitis, refractory periodontitis, and in periodontitis with specific microbiological profiles.^72–74 Several antibiotics have been evaluated, among which a combination of amoxicillin and metronidazole was found to be the most effective. Beyond improvements seen with periodontal debridement, the use of amoxicillin and metronidazole resulted in an additional probing depth reduction of 0.58 mm and clinical attachment gains of 0.42 mm on average.^24,75 More recently other antibiotics, such as azithromycin, have shown to be valuable adjuncts for patients with deeper pocket probing depths.⁷⁶

That said, in light of safety concerns and the risk of antimicrobial resistance, the routine use of systemic antibiotics is not recommended. The decision to use these agents should be made carefully for select patients — and only after weighing the risks and benefits. It is critical that antibiotics are not used as stand-alone treatment, and that any prescriptions are accompanied by thorough periodontal debridement.^24,74

Host Modulation: Periodontitis is a microbial disease that requires a susceptible host, thus, host modulation is based on the concept of altering the host-mediated inflammatory response. Subantimicrobial-dose doxycycline has been studied extensively as an adjunct to nonsurgical periodontal therapy. In a meta-analysis, a subantimicrobial-dose doxycycline regimen (20 mg twice daily for three months), along with periodontal debridement, was shown to have a significant impact on the clinical parameters at nine months posttreatment.⁷⁷

Periodontal Endoscopy: This technique utilizes an imaging system, along with the use of specially modified curets and probes, to help clinicians visualize and treat calculus, root surfaces and soft tissue. The ability to view and remove calculus utilizing magnified images is said to improve the clinical results of periodontal therapy. A recent meta-analysis comparing traditional scaling and root planing to periodontal endoscopy reported that the endoscope facilitated superior calculus removal — although the procedure took longer. There was no difference in clinical outcome, however, as measured by the gingival index, bleeding on probing and pocket probing depth.⁷⁸

Laser Therapy: Laser use in dentistry continues to expand, and various types of lasers have been used as adjuncts for scaling and root planing. Currently, lasers have no defined and accepted protocols for standard usage. The majority of studies involve a small number of subjects and display a significant variation in study design. In addition, results are highly variable between studies. Additional research with larger sample sizes is needed to evaluate the benefit of lasers in periodontal treatment.⁷⁹ Based on the literature, there is insufficient evidence to suggest that a laser of any given wavelength is superior. The only laser that shows any additional benefit as a periodontal adjunct is the diode laser in photodynamic therapy.^79,80

A multidisciplinary panel of the American Dental Association Council of Scientific Affairs concluded the nonsurgical use of lasers other than the diode as adjuncts to scaling and root planing was limited to “expert opinion against” due to uncertainty regarding their clinical benefits and benefit-to-adverse-effects balance.⁸¹ A statement from the AAP cautions clinicians to be aware of the potential for root surface damage during in vivo calculus removal with certain lasers. For example, the erbium yttrium aluminum garnet is a hard tissue laser and the operator would not be able to visualize what is being operated upon with the laser.⁸¹

Surgical Periodontal Therapy: While there are several therapeutic adjuncts to nonsurgical periodontal therapy, one of the definitive approaches to reducing pocket depths is surgical periodontal therapy. The aim of surgery is to create accessibility for scaling and root planing. A flap access helps operators visualize the root surface during instrumentation. Regeneration is also possible based on the anatomy of the defect. Therefore, when the multiple residual probing depths are present following nonsurgical periodontal therapy, a referral to a periodontist is indicated.

CONCLUSION

The goal of periodontal treatment is to preserve, improve and maintain the dentition. The majority of patients can retain their dentition with appropriate treatment, effective plaque control and regular maintenance. Although periodontal debridement is the cornerstone of nonsurgical periodontal therapy, it is only the first step in treating advanced conditions.

Patients presenting with periodontal disease will need periodontal debridement and subsequent reevaluation to assess the results of the initial therapy. While adjuncts are available to help improve the outcome of debridement in select cases, in advanced cases, the patient may benefit from early referral to the periodontist for surgical treatment and follow-up.

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From Decisions in Dentistry. October 2017;3(10):37–42.