Design and organization of periodontal treatment
Patients, once diagnosed, should be treated according to a pre-established sequential approach which, depending on the stage of the disease, will be incremental, with each stage including different interventions.
The treatment plan in periodontology consists of four stages, adaptable to each case:
Etiological therapy followed by re-evaluation, then corrective therapy and finally supportive therapy.
The main goal of periodontal treatment is to restore periodontal health and maintain it over the long term.
- Reminder on the periodontal pocket:
The periodontal pocket is defined as the pathological deepening of the sulcus either by loss of attachment (true pocket) or by gingival growth (false pocket).
It consists of a hard (dental) and soft (gingival) prey, a base and a content including bacteria and their products, dental plaque and gingival fluid.
Depending on the position of its base in relation to the resorbed bone crest, there are two types of pockets: infra- and supra-osseous.
- Etiological therapy:
This step aims to establish a change in behavior by motivating the patient to undertake effective elimination of supragingival dental biofilm and to control their risk factors.
It also aims to control biofilm and subgingival tartar.
- Bacterial factor control: Personal :
Oral hygiene instructions and patient motivation to implement them should be an integral part of patient care at all stages of treatment.
Supragingival dental biofilm control can be achieved by both mechanical and chemical means. Mechanical plaque control is primarily achieved by toothbrushing, either with a manual or electric toothbrush, and by the complementary use of interdental cleaning tools such as interdental floss, brushes, and jets.
dental…etc.
Antiseptic agents, administered in various forms, such as toothpaste or mouthwash, are recommended as an adjuvant to mechanical plaque control.
Professional :
It involves the professional removal of dental biofilm and supragingival calcified deposits. It also involves the removal of plaque-retaining factors, whether related to the anatomy of the tooth or, more frequently, to unsuitable restoration margins.
Indeed, performing supragingival debridement before subgingival debridement reduces the need for subgingival treatment and maintains periodontal stability over time. In addition, supragingival debridement can induce favorable changes to the subgingival microbiota.
- Risk factor control: Tobacco:
Periodontal patients may benefit from smoking cessation assistance to improve periodontal treatment outcomes and maintain periodontal stability.
This care consists of short counseling sessions; the patient may also be referred to other professionals for more in-depth advice and drug therapy.
Diabetes:
Patients with periodontal disease may benefit from interventions aimed at controlling diabetes with the aim of improving the outcome of periodontal therapy and maintaining periodontal stability.
This care consists of patient education sessions, supplemented by nutritional advice and, in cases of hyperglycemia, the patient is referred to a specialist.
- Mechanical treatment:
This step aims to eliminate subgingival biofilm and tartar and may be associated with
the removal of the root surface (cementum). In the literature, it has several names: scaling and root planing (SRP), mechanical debridement, subgingival instrumentation, etc.
It is a non-surgical procedure and can be performed manually using curettes or motorized with sonic or ultrasonic devices.
It aims to reduce soft tissue inflammation by removing hard and soft deposits from the tooth surface.
The criterion for treatment success is clinical closure of the pocket, defined by a probing depth ≤ 4 mm and the absence of bleeding on probing.
It can be carried out using the quadrant method, which involves scaling each quadrant in several sessions spaced approximately one week apart. Or using the global disinfection method, which involves global scaling in two sessions spaced approximately one week apart.
24h. No significant difference was observed between the two treatment modalities.
- Chemical treatment: Antiseptics:
In periodontology, local antiseptics can be used by the patient in addition to brushing, for individual control of supragingival plaque, or by the practitioner during therapy.
The main molecule used, mainly in the form of a solution for mouthwashes or for subgingival irrigations, is Chlorhexidine, which is the only one to be of interest in the management of infections of the oral cavity and post-operative care in dentistry and stomatology. It has a direct and persistent bactericidal action on the germs of the oral bacterial flora.
Antibiotics:
The aim of using antibiotics in addition to DSR is to potentiate the effects of mechanical treatment and to reduce the amount of periodontopathogenic bacteria located in the subgingival spaces and insufficiently eliminated by mechanical treatment (Porphyromonas gingivalis, Treponema denticola, Tannerella forsythius, agreggatibacter actinomycetemcommitans). They are used by local application or systemically, either following microbiological analysis or probabilistically. Adverse effects are the risk of developing bacterial resistance, potential allergic reactions or drug interactions, as well as the suppression of the oral microflora with the risk of selection of opportunistic pathogens.
- By local means:
It consists of applying antibiotics to periodontal pockets during a DSR in the form of prolonged-release materials (strips, fibers), by subgingival irrigation, in the form of gels or microspheres. The support used must be biodegradable and allow for the slowest possible release kinetics. The advantages are the delivery of the molecule
directly at the site to be treated at a high concentration, and to avoid side effects,
drug resistance or interactions of systemic administration. The disadvantages are the rapid elimination of the antibiotic if an adequate carrier is not used and the molecule is administered for a prolonged period, the possibility of taste disturbance, gingival recession and oral mycosis.
Given the weakness of the available studies and due to problematic safety of use, due to the risk of selection of resistant mutants, local antibiotic therapy, with release
immediate or controlled, is not indicated in dentistry and stomatology in the treatment of periodontitis
- Orally:
Oral probabilistic antibiotic therapy may be prescribed in addition to mechanical debridement. Indeed, the treatment of periodontitis essentially comes from the disruption of the biofilm. Only certain forms of periodontitis require antibiotic prescription. We find aggressive periodontitis (localized and generalized) and severe chronic periodontitis.
Not all periodontal emergencies require antibiotics. Local treatment is usually sufficient unless the patient’s general condition deteriorates. In contrast, necrotizing periodontal disease requires systemic administration of metronidazole.
Antibiotic prophylaxis may be prescribed in patients at risk of infection such as those with heart disease at risk of Oslerian heart disease.
Table: Oslerian risk prophylaxis.
| First-line treatment | Second-line treatment | |
| General case | Amoxicillin: 2g/day in two dosesClarithromycin: 1000 mg/day in two dosesSpiramycin: 9MIU/day in three dosesClindamycin: 1200 mg/day in two doses | Amoxicillin-clavulanic acid: 80 mg/kg/day in three doses. Amoxicillin 50 to 100 mg/kg/day in two to three doses and metronidazole: 30 mg/kg/day in two to three doses. Metronidazole: 30 mg/kg/day in two or three doses and azithromycin: 20 mg/kg/day in one dose. Or clarithromycin: 15 mg/kg/day in two doses. Or spiramycin: 300,000 IU/kg/day in three doses. |
| Necrotizing periodontal disease | Metronidazole: 1500 mg/day in two or three doses | |
| Localized aggressive periodontitis | Doxycycline: 200 mg/day in one dose | |
| Generalized aggressive periodontitis | Amoxicillin: 1.5 g/day in three doses or 2 g/day in two doses and metronidazole: 1500 mg/day in two or three doses. In case of allergy to pennicillins: Metronidazole: 1500 mg/day in three doses. |
Table: recommended administration schedules for adults according to the ANSM.
- Re-evaluation:
Reassessment is a key step in periodontal treatment. It allows you to measure the results obtained by the initial treatment and decide on a possible treatment.
complementary. It is generally at this stage that the provisional treatment plan, established during the first consultation, is finalized.
The reassessment is performed 6 to 8 weeks after the etiological therapy. This arbitrary period corresponds to the time required for the periodontal tissues to return to a near-optimal state of health.
This session is therefore devoted to a careful clinical examination based on measurements and leading to a decision. So that the measurements taken can be
If interpreted correctly, they must be compared with those carried out at the time of the initial examination.
The clinical parameters to be measured are:
- Plaque index.
- Bleeding index
- Probing depth
- Attachment level
- Gum recession
- Microbiology
- Gingival defects (thin periodontium): gingival reinforcement may be necessary.
- Bone defects (by probing and radiographic examination)
- Dental mobility: occlusal correction or retention may be indicated.
- Corrective therapy:
Or also called multidisciplinary, it is divided into two categories, surgical therapy and occlusal-functional therapy:
Surgical therapy:
The use of surgery is justified by one or more of the following objectives:
- Improve access to root surfaces (access surgery);
- Treat intraosseous lesions (resective or regenerative surgery);
- Treat interradicular lesions (resective or regenerative surgery)
- Modify the morphology of the deep periodontium (resective surgery, plastic surgery)
- Modify the morphology of the superficial periodontium (plastic surgery) The surgical decision must meet one or more of these objectives.
It includes all treatments aimed at restoring a balanced occlusion: prosthesis, orthodontics , occlusal adjustment, etc.
- Supportive therapy:
Periodontal health is the result of a balance, a homeostasis, between the factors of aggression, mainly bacterial, and the individual’s resistance to this aggression.
The objective of supportive periodontal care will be to maintain this balance, or even to restore it if it has been disrupted, in order to avoid the appearance of pathology or to stop any tendency towards relapse after the active phase of treatment.
The frequency of supportive care sessions varies depending on the initial periodontal disease. Generally, however, it ranges from every 2 to 12 months.
- Decision tree:
- Conclusion :
The design of periodontal treatment and its organization are based on the periodontal disease.
Informing the patient and their cooperation and consent are key elements in the success of treatment.
Bibliographic references:
- Aldebert Louise, Lafon Arnaud, antibiotics in oral surgery, dental information, n°35/36, October 17, 2018.
- Bouchard Philippe, Periodontology and Implant Dentistry, Volume 1, Lavoisier, 2015.
- Bercy, Tenenbaum, periodontology from diagnosis to practice, de boek, 2000.
- Mariano Sanz, David Herrera et al., Treatment of Stage I-III Periodontitis – EFP S3 Recommendations in Clinical Practice.
Design and organization of periodontal treatment
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