Etiological therapy in periodontology

Etiological therapy in periodontology

• Periodontal diseases (gingivitis and periodontitis) are very complex multifactorial diseases in which different factors are involved.
• This etiological complexity requires complex treatment, which must encompass the majority of these factors.
• Etiological therapy is an essential step in the treatment plan that aims to stop periodontal disease.

Definition:

Etiological therapy, also called initial therapy or preparation or basic therapy, is considered the most important phase of periodontal therapy.

It is an etiological treatment in the truest sense of the word since it consists of eliminating the causes of the condition.

It includes:

• informing the patient about plaque control techniques adapted to their case,
• scaling and root planing (RSP),
• the administration of antibacterials
• and any dental procedure aimed at reducing the bacterial load or limiting the recolonization of oral surfaces (extractions, removal of iatrogenic restorations, polishing of fillings, caries treatment, etc.)

Place of initial therapy in the treatment plan:

The periodontal treatment plan includes the following phases:

1. Emergency treatment
2. General treatment (control of risk factors, infectious or hemorrhagic)
3. Initial therapy
4. The re-evaluation phase
5. The corrective phase (complementary periodontal treatments)
6. The maintenance phase (periodontal monitoring)

The steps of basic therapy:

It includes the following steps:

• Motivation for oral hygiene
• Mechanical treatment: supra and subgingival scaling and/or root planing and polishing.
• Chemical treatment: antiseptics (chlorhexidine is the antiseptic of choice) and (antibiotics if necessary)
• Complementary care (elimination of plaque retention factors).

1. Plaque Control: (Motivation for Oral Hygiene):
   • Supragingival plaque control is a patient-specific responsibility. Improving plaque control is an essential step in any periodontal treatment, which determines its success.
   • This step involves teaching the patient how to individually control the level of dental biofilm.
2. Brushing: This is the mechanical removal of food residue and bacterial biofilm from all surfaces of the teeth.
   • Its effectiveness is based on:

(1) the suitability of the brushing equipment and the patient,

2. the latter’s manual skill,
3. the frequency and duration of use.
   • It is done using a toothbrush which can be manual or electric.
   • It should be used twice a day (2 times a day) for an average of 2 minutes. For manual toothbrushes, there are 5 types:
   • Extra-soft brush reserved for infants.
   • Soft brush reserved for thin gums or sensitive teeth, exposed teeth or post-operative teeth.
   • Medium brush most recommended for thick gums.
   • Hard and extra-hard brush exclusively for dentures.

Rules to follow when choosing a manual toothbrush:

Brushing techniques:

• Many of our patients use a toothbrush frequently, but use it incorrectly.
• It is therefore appropriate to show them the deficiencies in their brushing technique which does not allow the complete elimination of dental biofilm.
• Horizontal technique
• Leonardo’s technique (vertical)
• Phones or circulatory technique
• Bass Technique
• Modified Bass Technique
• Stillman Technique
• Modified Stillman Technique
• Charters Technique
• Solo Technique.
• Roller Technique

Currently, the recommended methods are:

• Roller Method,
• Modified Bass Method,
• Modified Stillman Method.
  • The methods not recommended are:
• Horizontal method and vertical method
  • methods not recommended:
• Charters method.

Roll Method:

• The toothbrush filaments are inclined 45° towards the apex at the level of the JGD.
• Moderate pressure is applied and the brush head then rotates, i.e. sweeps vertically from the gum towards the occlusal surface of the tooth.
• This simple technique, which is a bit like brushing your teeth, can be recommended as a first-line treatment.

Roll method:

Brushing aids:

• Good oral hygiene involves using a penetrating instrument between two adjacent teeth:
• Interdental floss;
• Interdental sticks;
• Interdental brushes;
• Single-tuft brushes;
• Water flossers;
• Tongue brushes and scrapers…etc.

Contraindications to brushing: (temporary):

• Acute phase of GUN.
• Inflammatory reaction in irradiated patients.
• Immediately after surgery or tooth extraction.
• Within the first few days following a traumatic injury.

Chemical adjuvants:

Toothpastes:

• Toothpastes are chemical additives that help clean and polish the surface of teeth. They come in paste, powder, or gel form.

Plaque disclosing agents:

• These are also chemical adjuvants based on solutions applied with a cotton ball or tablets that are kept in the mouth for 1 minute.

• the fuchsia that colors the PB pink
• erythrosine which colors PB pale pink
• the two-color system of BLACK et al. which colors old PB blue and yellow PB pink.

Regarding food:

• It’s necessary:
• reduce the intake of sugars and especially sticky foods and
• maintain a balanced diet. (Firm and hard foods).
• More recently, authors have highlighted the importance of consuming antioxidants, vitamin D and calcium in the treatment of periodontal disease.
• It seems that supplementation is less important than the deficiency itself.

2. Mechanical treatment: scaling-root planing:

1. Definitions:
   • Scaling is a procedure that involves removing deposits of plaque, tartar and various discolorations from dental surfaces.
   • Depending on the location of the deposits, scaling will be supra- or subgingival.
   • Root planing removes microbial flora adhering to root surfaces or evolving freely within the pocket, residual tartar

as well as softened cementum and dentin contaminated by bacteria and their product.

• When these terms are used together (scaling-root planing), they define non-surgical procedures performed blindly without flap reclination,

the root surface then not being accessible for visual inspection.

• In recent years, another term has been preferred: periodontal debridement.
• DSR consists of tissue debridement, under local anesthesia, associated with mechanical disruption of the subgingival biofilm and the elimination of deposits.
• The action therefore consists of removing the tartar (scaling) and “smoothing” the root surface (surfacing) by removing the layer of cement infiltrated by bacterial toxins.
• Its objective will be to obtain the reattachment of soft tissues to the root surface by making the surfaces histocompatible

Instruments and techniques of use:

• Classically, the technique is either manual or mechanized; sonic or ultrasonic.
• The basic technical platform includes manual and sonic/ultrasonic instrumentation because the two are complementary
• Alternative techniques such as laser are now proposed to limit the effects on the root surface and improve patient comfort.

• Hand instruments are mainly represented by sickles and curettes.
• The sickles are intended to dislodge tartaric concretions by performing repeated apico-coronary traction.
• The curettes are intended for surface treatment of the root. The vertical apicocoronary movement is repeated until a smooth surface is perceived digitally.

2. Grâcey curettes:
   • This is a very widely used set of curettes that can be found as a single or double instrument.
   • These instruments are angled at 70° and have a single useful cutting edge.

Technique of use (scaling and surfacing technique):

• Local anesthesia in case of significant hypersensitivity.
• First, supragingival scaling is carried out to facilitate access to the subgingival area.
• The support point must be close to the area to be scaled to ensure stability of the movement.
• The instrument is held by a so-called “stylo-modified” grip with a support point provided by the ring finger or middle finger;

Modified pen holder:

Correct positioning of the instrument will be achieved when the last third, close to the tip of the instrument, comes into contact with the tooth.

As soon as the sharp edge is at the bottom of the pocket, we search during the

descaling, an angle between 45° and 90° and as close to 90° as possible.

• The instrument is inserted to the base of the pocket, it is turned into the working position and then a pulling movement is performed in the apico-coronal direction while maintaining an angle of 60° to 80° with the root,
• This movement is repeated until a smooth, hard surface is obtained, controlled using the probe.

2. Surfacing technique:
   • Using the curette, the root planing is carried out by inserting the instrument subgingivally, its flat face will be held gently against the tooth.
   • Each action will have removed a thin layer of cementum or dentin, thus gradually eliminating irregularities until a hard, clean and smooth surface is obtained.

• At the end of the scaling (with or without root planing), the practitioner must complete his work with hemostasis by soaking compresses or cotton balls with hydrogen peroxide.

2. The mechanized DSR:
   • Its basic principle is the mechanical oscillation of a small insert.
   • Ultrasonic inserts are electric.
   • Ultrasonic scalers convert electrical current into vibration
   • The movement described by the insert is elliptical, which allows it to be active on all sides.

Technique for using piezoelectric ultrasonic scalers:

• The use of ultrasonic scalers automatically involves the use of surgical suction, wearing a mask and goggles (septic aerosol).

• The power of the instrument must be modulated according to the work to be performed. Maximum power should be used with caution to avoid surface cavitations.
• The instrument vibrates unidirectionally, with a variable amplitude depending on the power, from 0.006 to 0.1 mm. Care should always be taken to direct the instrument by placing the vibration plane tangentially to the dental surface.
• Perpendicular use would cause damage.!!!!
• Too much pressure from the instrument on the root surface should be avoided because it limits effectiveness and risks causing lesions to appear.
• This work must be carried out methodically and meticulously. NB:
• There is no significant difference in terms of effectiveness between the reference, which is manual DSR, and new technologies.
• Ultrasounds are:
• easier to use,
• faster,
• less tiring and facilitate access to certain areas such as furcations with very suitable inserts.
• They use the cavitational effect of water which increases the cleaning action and promotes the elimination of debris.
• On the other hand:

• Ultrasound is still sometimes painful on sensitive teeth, particularly when it comes to temperature variations;
• the tactile sensation is less fine and the creation of an associated bacterial aerosol is more polluting for the environment and the practitioner.

Polishing:

• Polishing of root surfaces is essential after use with manual or mechanized instruments.
• For mechanical polishing, a polishing paste mounted on a brush or rubber cup is most often used. Pumice-based polishing paste contains fluoride.

3. Chemical treatment:

1. Antiseptics:
   • Chlorhexidine: The main molecule used, mainly in the form of a solution for mouthwashes or for subgingival irrigations, is chlorhexidine.
   • It has a direct and persistent bactericidal action on the germs of the oral bacterial flora.
   • Two mouthwashes per day with CHX for 15 to 30 seconds, morning and evening, 30 minutes before brushing, with a 0.12% solution are sufficient to obtain an antiplaque effect.
2. Antibiotics:
   • Apart from prophylactic use in at-risk patients, the administration of ATBs in patients with periodontal disease should be limited.
   • They are used by local application or systemically, either following microbiological analysis or probabilistically.
   • Their aim is to potentiate the effects of mechanical treatment and to reduce the quantity of periodontopathogenic bacteria located in the subgingival spaces and insufficiently eliminated by mechanical treatment.
   • In periodontology, the most commonly used molecules or associations are the association:
   • amoxicillin-metronidazole,
     • metronidazole,
     • azithromycin
     • and doxycycline
   • The recommendations for this antibiotic therapy are:
     • Aggressive periodontitis;
     • Necrotic periodontal diseases;
     • Active (purulent) periodontitis;
     • Congestive and purulent pericoronitis.
     • Refractory periodontitis.
   • Doxycycline (200 mg once daily for 14 days) or a combination of amoxicillin (2 g/day) and metronidazole (1.5 g/day) for 10 days may be indicated systemically in addition to mechanical treatment in cases of severe aggressive forms.

Global disinfection (FULL MOUTH THERAPY):

• If the DSR procedure is classically carried out in several sessions per quadrant or per sextant, spaced approximately one week apart, a new method of

realization was described in the 1990s by Quyrinen, allowing the act to be performed in a shorter period of time in order to avoid the

recolonization of treated sites by untreated sites; this is “global disinfection”.

• The protocol consists of carrying out the DSR in one to two sessions over a period of 24 hours and combining it with the application of antiseptics (chlorhexidine).

Classic approach or global disinfection:???

• The 2008 European Consensus Conference concluded that one approach was not superior to the other.
• The choice of one technique cannot be made on the basis of potential clinical results, but on the patient’s preferences, the operator’s personal experience, and the cost/effectiveness ratio.

4. Complementary care: (Elimination of plaque retention factors):
   • Avulsion (Extraction) of irrecoverable teeth (with an initially unfavorable prognosis);
   • Care of decayed teeth;
   • Endodontic treatments
   • Reconstruction of poorly made prostheses and overflowing fillings; (removal of unsuitable restorations)
   • Temporary prosthesis:

Temporary dentures restore decayed teeth, replace missing teeth, and also allow for the preservation of effective chewing.

• Contention:

Loose teeth are consolidated during the first phase of periodontal treatment using temporary retaining devices (steel wire, composite splint, molded plastic splint).

• Gutter:

Treating bruxism with a splint can also be a part of initial therapy.

Conclusion:

• Initial therapy constitutes the keystone of all periodontal therapy .
• Its aim is to stop the disease and return to a healthy periodontium.
• In some cases, it remains insufficient and requires other complementary and corrective treatments.

Etiological therapy in periodontology

  Deep cavities may require root canal treatment to save the tooth.
Dental veneers can correct stained or malformed teeth.
Misaligned teeth can cause speech problems.
Dental implants prevent bone loss in the jaw.
Antiseptic mouthwashes reduce bacteria that cause infections.
Decayed baby teeth must be treated to avoid complications.
An electric toothbrush cleans more effectively than a manual one.
 

Etiological therapy in periodontology