Fact or Fiction: Debunking Current Trends In Nonsurgical Periodontal Therapy

Periodontal patients pose a unique challenge to the dental team. Tooth loss, increased mobility, and attachment loss complicate ways to maintain and rehabilitate a patient’s oral health and function. As more materials and treatment modalities come to market, it is increasingly difficult for providers to discern what is most appropriate for each patient. Salivary testing, antibiotic therapy, specialized hand and power instruments, and laser therapy may benefit some forms of periodontal and peri-implant disease but are less effective for others. Understanding the limitations of these trends and the role of systemic health can positively impact the periodontal-restorative interface and minimize how certain inflammatory conditions contribute to the rate of disease progression. Identifying the right materials and techniques for each patient will improve periodontal parameters, treatment satisfaction, and most importantly, quality of life.

Air Polishing

Bacteria normally present in lower numbers have been shown to challenge the host immune response through a destructive process called dysbiosis.¹ Hand and power instruments were once forcefully used to remove endotoxins released by these bacteria along the root surface, altering its shape over time. Endotoxins were thought to inhibit fibroblast attachment and early wound healing.² However, newer research demonstrates a dramatic shift to minimize tooth and implant substance loss during instrumentation. It was later discovered that endotoxins were removed rather easily as a surface phenomenon with a majority lost to oral hygiene alone.³

Current materials and techniques in nonsurgical periodontal therapy (NSPT) should reflect these therapeutic goals. Air polishing using erythritol and glycine-based powders, for example, allows for gentler and more effective supra- and subgingival biofilm removal around narrow interdental spaces, root grooves and concavities, and furcations.⁴ Their small particle size and sweet taste are a marked improvement from sodium bicarbonate, which is highly abrasive and harmful to exposed roots, demineralized surfaces, and restorations. These newer powders can be used supra- and subgingivally, broadening the scope of air polishing to patients with generalized recession and/or active periodontal diseases.⁴

After biofilm management, root surfaces should be instrumented with hand and power scalers for calculus removal. This is especially true in pockets beyond 6 mm, where air polishing becomes less effective.⁴ Calculus is an independent, pathologic element from biofilm and contributes to attachment loss and inflammation, if left untreated.⁵ Randomized controlled trials using a combined, air polishing approach have shown comparable reductions in bleeding on probing and pocketing to conventional scaling and root planing with hand and ultrasonic scalers.⁶ Air polishing can supplement the majority of biofilm and stain removal, minimizing repetitive strain injuries from hand instrumentation and lending to a friendlier patient experience.⁴ This will decrease clinician fatigue over time and may strengthen patient-provider relations.

Implant maintenance has also evolved to treat new etiologies of peri-implantitis. A thin, titanium dioxide layer forms at time of implant placement, which lends to its biocompatibility and passivation.⁷ Frictional forces from implant insertion, abutment micro-movements, or mechanical debridement shed titanium ions into the surrounding tissues, leading to metallosis. Titanium dissolution disrupts the unique peri-implant biofilm, making way for more virulent, opportunistic bacteria and dysbiosis, which can be resistant to antibiotics.⁸ Hygiene instruments should be tailored accordingly. After proper isolation, erythritol or glycine subgingival air polishing is used for biofilm removal.⁹ Scalers with Rockwell C hardness titanium 28-31 and/or titanium piezoelectric tips can carefully be used to reduce scratching or fretting of the implant body and titanium dissolution into the surrounding tissues. An antimicrobial varnish can then be applied around the mucosa to slow bacterial leakage for at least 3 months.¹⁰

Salivary Testing

Saliva contains hormones, antibodies, growth factors, enzymes, and microbes that can be useful in early disease detection. However, there are currently no United States Food and Drug Administration-approved salivary tests that accurately screen and diagnose periodontal and peri-implant diseases.¹¹ These point-of-care tests require high specificity and sensitivity due to the low molecular levels in saliva compared to blood. They are further complicated by the different ways to collect, stimulate, and store salivary samples and bacterial proteases that degrade biocomponents in saliva.¹¹

Recent studies have examined the potential of novel proteins, nucleic acids, and metabolites to determine disease susceptibility or progression.^11-13 For example, salivary microRNA was analyzed in peri-implantitis patients with 179 microRNAs deregulated in the presence of disease. Decreased expression of one particular sample, miR-4484, was found in healthy and diseased patients 4 to 6 months after implant placement, revealing a possible marker for early peri-implantitis.¹² Other studies have measured changes in salivary analytes in response to NSPT. Anti-inflammatory proteins, such as fetuin-A, improved 6 months following scaling and root planing in patients with severe periodontitis.¹³

While the aforementioned markers could be associated with disease, further clinical validation is needed in larger cohorts before salivary tests are used as diagnostic or risk assessment tools in periodontal or peri-implant therapy.¹¹ Therefore, the effective removal of biofilm and calculus will always be important to treatment success. Dental hygienists should be encouraged to focus on proper instrumentation and oral hygiene education rather than these distractive tests.

Adjunctive Antibiotic Use

The utilization of adjunctive antibiotics to combat pathogenic bacteria identified in plaque, gingival crevicular fluid, and/or salivary samples has seen a surge in recently. How and when medications are administered as part of NSPT should be reserved for specific instances. Minocycline 1 mg microspheres can be locally delivered and sustained-released into periodontal pockets at least 5 mm deep. They have a negligible effect on clinical attachment gain, up to 0.55 mm. Chlorhexidine gluconate 2.5 mg dental inserts have an equally marginal effect on clinical attachment gain of 0.24 to 0.56 mm.^14,15 This is the same error difference in over-angulating a periodontal probe. Local chemotherapeutic agents are therefore ineffective in disease management and maintenance.^14-16

The systemic use of antibiotics more effectively improves clinical parameters but has its own pitfalls with increased antimicrobial resistance, gastrointestinal side effects, and allergic reactions.¹⁶ Systemic antibiotic delivery works best for patients with formerly termed “aggressive” or “juvenile” periodontitis, continued periodontal breakdown despite diligent mechanical therapy, inflammatory conditions such as type 2 diabetes mellitus (T2DM), and acute or recurrent infections.¹⁷ The combination of amoxicillin and metronidazole, in particular, should be given at the highest dose for the shortest duration (ie, 500 mg each for 7 days) as part of initial therapy, covering the patient during his or her scaling and root planing procedures.^18,19

Laser Therapy

In a continued effort to improve therapeutic outcomes, other, more patient-friendly technologies have been introduced. Lasers, for example, emit an intense coherent beam of monochromatic electromagnetic light that lend to a variety of intra- and extraoral uses depending on their wavelength, power density, and mode. Infrared lasers serve as adjuncts to conventional scaling and root planing but collectively fail to establish superiority.²⁰ They marginally improve tissue health during nonsurgical treatment and maintenance with changes in clinical attachment and probing depth less than 1 mm that last up to 6 months.²⁰ Given these poor, short-term results, infrared lasers should not substitute or supplement traditional instrumentation.

In periodontal pockets, Nd:YAG lasers remove diseased sulcular epithelium and vaporize periopathogens such as Porphyromonas gingivalis and Tannerella forsythia. A histologic study found that when used as part of the laser-assisted new attachment procedure (LANAP), true regeneration of cementum, periodontal ligament, and bone was seen in 50% of treated teeth.²¹ However, this study had a very small sample size, treating otherwise hopeless teeth with nonreproducible results. Case selection is therefore important. LANAP may still provide definitive options for periodontal patients who cannot undergo conventional flap or regenerative surgery due to anatomical or medical limitations.

Other infrared lasers have gained popularity in dentistry. Er:YAG lasers are reserved for caries, calculus, and bone removal due to their high water and hydroxyapatite absorption rates. They are particularly safe and effective in the detoxification of implant surfaces.²² Diode and CO₂ lasers have only shown slight improvements in bleeding scores when used subgingivally.²⁰ Even still, best-evidence reviews have found no clinically significant, long-term benefits to the adjunctive use of the described lasers around teeth and implants.^22,23 Dentists and dental hygienists considering laser-assisted therapy must undergo proper training and state credentialing.

Case Report

The following case outlines the steps taken to treat necrotizing periodontitis. A 39-year old man presented to a private practice concerned about his smile, oral malodor, and increasing “gum pain” (Figures 1-7). His medical history was significant for T2DM, hypothyroidism, depression, and bipolar disorder. He was noncompliant with his insulin. He smoked more than 20 cigarettes daily for 15 years, occasionally used smokeless tobacco products, and formerly abused heroin. He reported occasional fevers and intraoral swelling.

His periodontal tissues were generally pink-red, ulcerated, and loosely attached with heavy plaque, calculus, and debris. A gray pseudomembrane lined his lower buccal mucosa. He also presented with moderate-to-severe horizontal bone loss, furcation invasions, and secondary occlusal trauma. Probing depths ranged from 4 to 10 mm with associated attachment loss, bleeding on probing, and suppuration. According to the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions, he was classified as having necrotizing periodontitis.²⁴

After a thorough patient evaluation and review of different techniques and materials, a comprehensive treatment plan was developed, and consents were obtained. The treatment plan included:

1. Medical consultation to ensure glycemic control and rule out any other contributing pathology, including human immunodeficiency virus/acquired immunodeficiency syndrome, which is often associated with necrotizing diseases.
2. Full-mouth debridement with oral hygiene instructions and tobacco cessation counseling.
3. Full-mouth laser therapy to arrest disease progression.
4. Restorative treatment with his dentist to stabilize caries.
5. Periodontal maintenance every 3 months, transitioning to longer based on stability and oral hygiene compliance.

The patient was first referred to his physician for proper management of his T2DM due to diabetes-related symptoms and an elevated casual blood glucose reading at his initial exam. With nutritional counseling and medication adherence, his HbA1c stabilized below 7%. A complete blood count and antibody testing revealed no underlying infections or immunodeficiencies. The patient continued regular care with his physician.

Full-mouth debridement was completed by the dental hygienist to remove the supragingival biofilm and improve diagnostic accuracy prior to surgery. Oral hygiene measures were reviewed. Tobacco cessation was advised and reinforced at each visit. Laser periodontal therapy was completed over 1 week, split by the right and left sides, while the patient was covered by an 8-day antibiotic regimen.

He continued in a maintenance program every 3 months with erythritol-based air polishing for biofilm and stain removal. Oral hygiene techniques were reinforced and prescription fluoride toothpaste was provided to reduce the incidence of root caries and sensitivity. Despite the severity of his initial presentation, he was no longer in pain, more confident in his smile, and healthier overall.

Summary and Conclusions

Treatment modalities should evolve with new evidence in the pathogenesis of periodontal and peri-implant diseases. Air polishing, salivary testing, antibiotic use, and laser therapy may benefit certain oral and systemic conditions more than others. Choosing the right materials and techniques for each patient will improve not only the chairside experience, but also treatment outcomes.

References

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From Decisions in Dentistry. June/July 2024; 10(4):28-31