3. Periodontal Treatment BSP Roadshows 2008/9 Home care Core Values for Treating Patients in Practice 3. Periodontal Treatment Phil Ower www.periocourses.co.uk • Why is it so important? • Oral hygiene methods – what’s best? • Improving adherence Professional care • Root surface contamination (to plane or not to plane?) • Rational use of antimicrobials • New treatments Home care Why is it so important? 5th Edition 2008 ...with NS or S treatment, can control periodontitis (Lindhe & Nyman 1975, Axelsson & Lindhe 75 Contributors from 12 countries 1981, Pihlstrom et al 1983, Isidor et al 1984, Renvert et al 1990, et al et al) ...but poor supra PC following therapy results in continued attachment loss (Nyman et al 1975, Axelsson & Lindhe 1981, Westfelt et al 1983, Lindhe & Nyman 1984) Home care Why is it so important? “A high standard of OH is a critical part in the success of all forms of periodontal therapy ” (Jan Wennstrom June 2006) “... plaque control is the name of the game!” game!” (Success in Periodontics – What is it?) (Klaus Lang BSP Nov 2007) Home care Why is it so important? “It should be noted that the performance of optimal oral hygiene practices is an inseparable principle to be observed with any protocol of mechanical debridement ” Sanz M & Teughels W, Consensus Report of the 6th European Workshop on Periodontology, 2008 1 Home care Biofilms deserve respect! Home care Biofilms deserve respect! QuickTime™ and a GIF decompressor are needed to see this picture. “…plaque “…plaque represents a classic example of both a biofilm and a microbial community… community… displaying properties that are more than the sum of its constituent members.” members.” (Marsh 2004) ...the significance of microbial communities in biofilms: • Quorum sensing – bacterial communication • Outer organisms protect more vulnerable organisms • Strength in numbers – enhanced ability to cause disease • Resistance to host defences and antimicrobials Home care What’ What’s best? CounterCounter-rotational powered brushes offer additional benefits (4th EWP 2002, Cochrane review 2003, updated 2005) “Flossing is the most universally applicable method ...” ...” Home care Home care Improving adherence “The lack of patient compliance in home care is the key problem in the prevention of periodontal disease” disease” Schü Schüz et al 2006, Widstrom 2004, Cianco 2003 Baseline Improving adherence • Explain disease process in detail • Make concrete plans with patient (esp when) • Develop selfself-efficacy (withhold treatment initially?) • EventEvent-based recall •Verbal and written info Lynn Myers, BSP Cambridge 2008 6 weeks 2 Baseline 6 weeks Baseline 6 weeks Baseline Baseline 6 weeks 15 weeks 6 weeks Professional care Relevance of calculus? “...evident that subgingival calculus represents a secondary product of infection and not a primary cause of periodontitis. periodontitis.” “...represents mineralised bacterial plaque.” plaque.” “...clinical studies have shown that the removal of subgingival plaque on top of subgingival calculus will result in healing of periodontal lesions...provided that the supragingival deposits are meticulously removed on a regular basis.” basis.” “Plaque removal is more important for healing than calculus removal” removal” (Kocher et al 2001) Professional care Relevance of calculus? • “...evident that subgingival calculus represents a secondary product of infection and not a primary cause of periodontitis. periodontitis.” • “...represents mineralised bacterial plaque.” plaque.” “If you think calculus is important, I suggest you leave the room now.” now.” “I am more interested in living bacteria than petrified ones.” ones.” (Andrea Mombelli June 2006) 3 Professional care To plane or not to plane? “...it was thought necessary to remove not only calculus but also underlying cementum...later evidence suggested that removal of tooth substance was not necessary.” necessary.” Washing Moore et al 1986 Polishing 39.52% 59.73% Root planing 0.75% Professional care To plane or not to plane? Professional care To plane or not to plane? “...it was thought necessary to remove not only calculus but also underlying cementum...later evidence suggested that removal of tooth substance was not necessary.” necessary.” “Aggressive RP to remove cementum does not appear to be warranted” warranted” (WWP 1996) “...should ...should be aimed especially at the removal of subgingival plaque rather than ‘diseased’ diseased’ cementum. This may require a more differentiated approach ... the use of ultrasonics may have to be rere-evaluated. evaluated.” Professional care FM or QxQ? • Questioned the traditional “per quadrant” quadrant” treatment approach (Bollen et al 1998) • Statistically and clinically significant improvements in the FMD groups, when SRP used (Bollen et al 1998, Mongardini et al 1999, Quirynen et al 1999) • Same result if UD only used (FMUD vs QUD) Q. What about FMUD vs QSRP? A. No differences in treatment outcomes Professional care FM or QxQ? Periodontal debridement as a therapeutic approach for severe chronic periodontitis: a clinical, microbiological and immunological study Ribeiro et al 2008 • Compared FMUD (max 45 mins) with conventional QQ-SRP (no time limit) • 25 subjects with severe periodontitis (PPD > 7mm) • assessed at 3/12 and 6/12 for clinical (VPI, GBI, BOP, RAL, PPD), microbiological (Pg, Aa, Tf) and immunological change (PGE2, ILIL-1β, IFNIFN-γ, ILIL-10) (Wennstrom et al 2005, Zanatta et al 2006, Ribeiro et al 2008) 4 Professional care FM or QxQ? FMUD Periodontal debridement as a therapeutic approach for severe chronic periodontitis: a clinical, microbiological and immunological study Ribeiro et al 2008 Baseline “ Periodontal debridement resulted in similar clinical, microbiological and immunological outcome when compared with standard scaling and root planing and therefore may be assumed as a viable approach to deal with severe chronic periodontitis.” periodontitis.” 8 months 4 years 1 year 2 years 8 months Baseline 6 months later 8 months Professional care FMUD 2002 2002 2003 2007 Baseline 2 Years 5 Professional care Systemic antimicrobials Systemic AntiAnti-infective Periodontal Therapy. A Systematic Review (in : 2003 Workshop on Contemporary Science in Clinical Periodontics • Sys abs uniformly beneficial in providing an improvement in AL when used as adjuncts to SRP • Improvements in mean AL were consistent for both chronic and aggressive periodontitis subjects although the aggressive periodontitis patients benefited more from the antibiotics Baseline Baseline 1 year 6 months 18 months Baseline 2 months 3 months 6 9 months Professional care New treatments? The use of a linear oscillating device in periodontal treatment: a review (Guentsch & Preshaw 2008) “...disruption of the subgingival biofilm ...remains the cornerstone of periodontal therapy.” therapy.” Professional care New treatments? “...photodisinfection warrants further investigation....” investigation....” (Anderson et al 2007) QuickTime™ and a Motion JPEG OpenDML decompressor are needed to see this picture. QuickTime™ and a Motion JPEG OpenDML decompressor are needed to see this picture. “...Vector is an effective method of treatment for periodontitis and results in similar clinical improvements to those achieved by other methods of periodontal therapy.” therapy.” BSP Roadshows 2008/9 Core Values for Treating Patients in Practice Phil Ower www.periocourses.co.uk 7