This review describes the advantages and disadvantages of existing non-surgical methods for treating periodontal diseases: removal of subgingival dental deposits by curettes and ultrasound (using a cavitron / piezon and the like), local delivery of antibiotics to the pocket (arrestin, etc.), systemic antibiotics, immunomodulation.
Comparison of the data obtained from clinical studies showed the following results.
Withdrawal of subgingival scales (Scaling and Root Planing, SRP) is the preferred method of treatment for the majority of patients with moderate to moderate periodontitis and the initial stage of treatment of severe periodontitis. The best results are observed with careful and scrupulous removal of all deposits with the help of both curette and ultrasound.
The use of systemic antibiotics is an effective measure in cases where SRP has not led to significant improvements. Patients with aggressive periodontitis and some patients with chronic periodontitis of severe degree systemic antibiotics may be prescribed as an adjunct to SRP. Also, antibiotics help to relieve inflammation in patients with acute periodontal abscesses. The most studied and well-proven combination of antibiotics is amoxycycline + metronidazole (within 7 days after SRP).
The constant intake of some immunomodulating medications has a small positive effect in the long term after removal of all dental deposits and prescribing to the patient maintenance therapy.
The local delivery of antibiotics to the pocket does not show any noticeable results, and if it makes sense, then only in cases with isolated (individual) pockets, about 5 mm.
The results of the studies confirm that the majority of patients suffering from periodontal disease of medium and mild severity can be helped in a non-surgical way. However, the doctor must understand the limitations and opportunities inherent in each method.
Pathogenesis of periodontitis
Earlier, the cause of parodontitis was considered exclusively pathological microflora in the gingival pockets, which releases destructive enzymes and toxins. Today, experts tend to believe that the microflora of the gingival pockets only gives rise to processes, and their development is largely due to the autoimmune response of the body to the microbial «load». Thus, the pathogenic microflora causes a cascade of autoimmune reactions leading to local production of collagenases and other destructive enzymes by the patient’s body with subsequent loss of bone and formation of gingival pockets.
Garbage pockets deeper than 5 mm are a favorable environment for the development of gram-negative anaerobic microflora, which leads to a vicious circle: microflora caused by dental deposits — inflammation of the gingival tissues — autoimmune response of the organism with the development of destructive enzymes — loss of attachment and bone — formation of deeper pockets — development of more pathogenic microflora in pockets — distribution of dental deposits more apically on the surface of the root — repeat the cycle.
The pathogenesis of periodontitis is very simplified here and will be considered in detail in subsequent publications. It should be noted that gingivitis does not always turn into periodontitis and has no direct relationship to it, but can exist separately, without leading to a loss of attachment and bone.
Microbial associations in subgingival raid. Sokransky and colleagues, Journal of Clinical Parodontology 1998. Orange and especially red complexes are associated with periodontitis and colonize deep periodontal pockets at high concentrations. Aggregatibacter Actinomycetemcommitans serotype B is associated with aggressive forms of periodontitis (juvenile according to the old classification), the remaining serotypes are often observed and normal.
Withdrawal of subgingival scales (Scaling and Root Planing (SRP)
Withdrawal of subgingival dental deposits with the help of curettes and ultrasound is an effective method of treating periodontal disease of mild and moderate severity (loss of attachment level up to 5 mm) and the initial stage of treatment of periodontitis of severe severity. Numerous studies confirm the effectiveness of SRP to reduce the depth of pockets and relieve inflammation of periodontal disease.
Cobb studied a number of studies and calculated the average decrease in probe depth and the improvement in attachment level achieved with SRP in cases where the original depth of the pocket was 4-6 mm and 7 mm or more. According to Cobb’s findings, on average, the depth of the pocket is reduced by 1.29 mm and 2.16 mm, respectively, and the attachment level is displaced more coronally by 0.55 and 1.29 mm respectively (the deeper the pocket initially, the more significant improvements can be expected — S.D.). Reducing the depth of sounding is achieved due to a more coronal displacement of the gingival attachment and recession of the gingival margin in the apical direction. On average, the increment of attachment coronal is equal to half the decrease in the depth of sounding, while the other half is a recession. The healing time after SRP is 4-6 weeks, however, periodontal improvements can occur up to 9 months.
When considering SRP, the doctor should take into account factors such as the effectiveness of removing subgingival deposits, the possibility of bone growth in the presence of vertical bone defects, suppression of microbial load. Numerous studies prove that the possibility of removing subgingival deposits decreases with increasing depth of pockets. For example, Caffesse and his colleagues showed a decrease in the possibility of adequate sanitation with a pocket depth of more than 5 mm. In such conditions, deposits are completely removed only in 32% of cases. (Success largely depends on the manual skills of the periodontist, which is also the basis for the surgical stage with residual deep pockets after SRP, as open access during surgery facilitates the removal of dental deposits — note SD).
According to Cobb’s findings, in the treatment of angular bone defects after removal of subgingival dental deposits (SRP), there is a small increase in bone tissue or an increase in bone density, as indicated by other studies.
Non-surgical therapy also proved ineffective in suppressing the activity of Actinobacillus actinomycetemcomitans, since this bacterium not only lives in pockets, but also penetrates into periodontal tissues. Therefore, in case of suspected invasion of A. actinomycetemcomitans (aggressive periodontitis) it makes sense to use antibiotics.
Mechanical therapy is effective in most cases, when the severity of periodontitis is mild and moderate. In cases of severe periodontitis, SRP is the initial stage of treatment. After the healing phase (at least 6 weeks), it will be necessary to decide on the need for a surgical stage of treatment in cases where the depth of the pockets remains more than 5-6 mm and there is a suspicion that not all subgingival deposits were removed at the SRP stage.
Сообщение Non-surgical methods of treatment of periodontitis появились сначала на Имплантация зубов.