Non-surgical therapies

Non-surgical therapies

Non-surgical periodontal treatment is a key component of periodontal disease management. It is primarily based on mechanical removal of tartar and subgingival microbial biofilm combined with chemical therapy using antiseptics and/or antibiotics to allow a return to a symbiotic microflora. A large number of longitudinal studies demonstrate long-term efficacy equivalent to surgical treatments.

The objectives:

Stopping the progression of periodontal disease.
Reduction of gingival inflammation (reduction of bleeding and swelling).
Removal of plaque and tartar deposits from dental and root surfaces.
The replacement of pathogenic flora with flora more compatible with periodontal health.
Obtaining a root surface biologically compatible with soft tissues.
Reducing the pocket depth to a shallow, healthy sulcus.

The means
1. Mechanical treatment Individual plaque control

-Patient information and motivation

-Brushing teeth

The effectiveness of plaque control is based on:

the suitability of the brushing equipment and the patient,
the patient’s manual dexterity,
the frequency and duration of use.
The quality criteria of a toothbrush

have a size adapted to the patient’s age and dexterity,
have a size adapted to the patient’s mouth,

*The size of the handle must correspond to the size of the hand,

*The size of the brush head must be adapted to the size of the teeth (maximum the length of 2 mandibular molars), to the mouth opening.

have nylon or polyester bristles with rounded tips and a diameter of 20/100 millimeters maximum,
The flexibility of the bristles will be chosen according to the gingival biotype:

flexible for a fine biotype
medium for a thick biotype

have bristle tips that promote the removal of plaque in the proximal spaces and along the marginal gingiva.
However, it seems that multidirectional implantation of the bristles allows for better plaque removal.
Brushing techniques

The modified Bass method:

*bristles inclined at 45°, towards the apex, at the gingivodental junction.

*moderate pressure, anteroposterior movement without moving the handle (back and forth without clearing the hairs from the sulcular area). *Then rotation (roll) = vertical sweep of the gum towards the occlusal surface of the tooth.

*simple method, the most widespread.

Interdental hygiene:

Dental floss,
Interdental brushes
Sticks
Gingival stimulators
Water flossers

The prescription of the material must be adapted to each clinical situation:

width of space,
tooth shape,
presence or absence of gingival recession…).

Dental floss

This is the best known and most widely used interdental cleaning material; when combined with brushing, the amount of plaque removed is much greater than when brushing alone. Recommended for the maintenance of the proximal surfaces of teeth in the presence of healthy periodontium, gingivitis or periodontitis in patients without open embrasures (gingival papilla fills the entire embrasure); as well as in cases of dental malposition.

When used correctly, it can remove up to 80% of interdental plaque and promotes effective prevention of gingivitis and a reduction in the plaque index.

The effectiveness appears to be very patient-dependent because the difficulty of using the thread, especially in the posterior areas, requires training.

Using a wire holder allows you to reach the posterior areas.

It can be presented in the form of a ribbon or with a rigid part allowing it to be used by wearers of plural joint prostheses, the rigid part allowing it to pass under the prosthetic intermediaries.

-The stretched floss is guided so that it crosses the interdental contact point. Once the contact point is passed, the floss is slid along one of the surfaces to be cleaned.

-A few vertical back-and-forth movements are required. The thread is then raised to the level of the top of the papilla and the technique is repeated on the other side of the embrasure.

Interdental sticks :

Triangular in section, it is the sides of the triangle that are used for cleaning.

Soft wood, or plastic.
Cleaning areas where the gingival papilla is retracted.

Interdental brushes:

*Conical or cylindrical shapes;

*Different diameters (from 0.6 to 4 mm);

*Diameter must be adapted to the embrasure in order to freely occupy the space between the teeth.

Single-tuft brush:

Their more specific use concerns areas that are difficult to access: open interradicular furcations,
the distal surfaces of the last molars
the lingual surfaces of the mandibular molars.

Gingival stimulators:

These are rubber tips that are supposed to “massage” the spaces between the teeth and stimulate interdental vascularization.

Water flossers : Allows the elimination of food debris thanks to the mechanical action of a pulsed jet of water.

Tongue Brushing *Tongue scrapers are more effective at cleaning the tongue than a traditional brush.

Professional license plate check

Individual supragingival plaque control is necessary for the treatment of periodontal diseases but is insufficient on its own to reduce pocket depth, i.e., to treat periodontitis. Periodontal pockets are the habitat of subgingival plaque microorganisms and the main reservoirs of periodontopathogens. Returning to periodontal health with a compatible flora requires the elimination of all pathogen reservoirs, particularly by eliminating periodontal pockets, i.e., a return to a probing depth ≤ 3 mm. Scaling and root planing (SRP) largely meets this objective and constitutes the gold standard for the treatment of periodontal diseases.

Justification
- Remove endotoxins from the deep layers of cementum and dentin.
- Ensure the smoothest surface condition to avoid endotoxin adhesion.
- Invasion of cementum by periodontopathogens justifying the elimination of infected cementum.
- Scaling is the basic approach to treating gingivitis and periodontitis.
The indications

*Scaling is the only treatment in the simplest cases of gingivitis in which there is no loss of attachment.

*Associated with root planing, “DSR” is indicated for all types of periodontitis, whether or not it is associated with antibiotic treatment or surgical treatment.

* DSR is also indicated for gingival recessions.

Contraindications
- Locally : none; as long as the prognosis for dental preservation is not hopeless.
- general “relative” related to bacteremia and bleeding caused by the procedure.

Infectious risk: prophylactic antibiotic treatment.
Hemorrhagic risk: biological assessment + local means of hemostasis.
Instrumentation

DSR can be performed using various types of instruments:

Manual instrumentation,
sonic and ultrasonic instrumentation
laser devices.

Manual DSR Operating protocol :

Descaling: The instrument is held with a modified pen grip:

*The middle finger placed on the arm of the instrument, as close as possible to the working end.

*Index finger on the handle, on the same side.

*As for the thumb, it is held opposite the index finger. This grip must be fixed; it is the rotation of the wrist and the muscular contraction of the forearm that activate the instrument. A stable digital support is sought: A stable support point, ensured by the ring finger, will prevent slipping and lacerating the gum. In some cases, an extra-oral support point will be necessary. The correct working end is chosen (the working end to choose is the one that curves towards the surface to be scaled). The end is positioned on the tooth, the working part parallel to the surface. The end is inserted apically.

*Identify tartar,

*Go around it and eliminate it with a rapid vertical pulling movement under pressure, in the coronal direction.

*Root planing is performed with slow, repeated pulling movements using less pressure than scaling.

Ultrasonic systems : Transform electric current into vibration through a quartz crystal (piezoelectric instruments) or lamellae (magnetostrictive instruments)

Frequencies ranging from 25,000 to 50,000 Hz (20,000 to 40,000 cycles per second).

The movement described by the insert is circular.

Method of use

The insert should oscillate under spray before any contact with the tooth wall to avoid the “hammering” sensation.
The insert therefore penetrates “in action”, gently and progressively to the bottom of the periodontal pocket, in contact with the root surface.
Elliptical or vertical back-and-forth movements with as light pressure as possible.
The movement is repeated at least 4 to 5 times or more if necessary.

Advantages and disadvantages

Working time: manual > ultrasonic
Tactile sensation: manual > ultrasonic
Temperature: manual < ultrasonic
Contamination (aerosol): ultrasonic+++
Post-op sensitivity: manual < ultrasonic
Per-op sensitivity: manual < ultrasonic.

Processing methods

Classic approach (several sessions)

The organization of the sessions is closely linked to the segmentation of the oral cavity:

6 “sextant” parts.
4 “quadrant” parts

Classic Non-Surgical Treatment (NST) for moderate to severe periodontitis usually takes place over four appointments of approximately one hour, spaced one to two weeks apart (quadrant approach).

A sextant approach has also been suggested for severe periodontitis.
The treatment is meticulous and time-consuming. In fact, the recommended working time is 2 minutes per side for each tooth.

Full mouth disinfection:

FMD = chemical and mechanical disinfection of the oral cavity within 24 hours.

Theoretical interest : limit contamination of instrumented sites by non-instrumented sites.

Clinical results

Non-surgical treatment always results in a reduction in pocket depth and even minimal gum recession;
in a patient without periodontitis, planing is iatrogenic because it causes loss of attachment;
in the case of inter-radicular lesions, it is of limited effectiveness at the level of molar furcations.

Polishing

*Using an air polisher

The Air Polisher uses the projection by an air spray of powder based on sodium bicarbonate = suspension of hot air based on hot water and sodium bicarbonate.

Side effects :

Consequences of the abrasive effect of powder air polishing devices using sodium bicarbonate:

*Possible significant loss of tooth substance (cementum and dentin).

* Transient lesions of the gingival tissue (clinically insignificant).

*Amalgam restorations, composite resins, cements and other non-metallic materials may be roughened.

Contraindications:

Any polishing system using a powder air spray:
- History of respiratory illnesses
- Hemodialysis patient
- Communicable infectious diseases (creation of large quantities of aerosol)
Powders containing sodium bicarbonate:
- Hypertension
- Low-sodium diets
- Drugs affecting electrolyte balance.

*Mechanical polishing : we use:

A contra-angle
A stiff-bristled brush = use limited to the crown to avoid damaging the cementum and gum
A rubber cup
A polishing paste: available in fine, medium or coarse grains, made from pumice stone, contains fluoride, sometimes zirconium silicate.

*Dental strip: with a polishing paste allows you to polish proximal surfaces inaccessible to other polishing instruments.

New technologies

LASER = Light Amplification by Stimulated Emission of Radiation.

The laser has been proposed to replace manual and/or ultrasonic instrumentation (therapeutic alternative, innovative approach).

The bactericidal action (bacterial decontamination) is controversial
It has the ability to eliminate granulation tissue.

*The elimination of tartaric deposits with the laser results from the vaporization of the water contained in the tartar + increase in pressure which causes micro-explosions of the deposits.

*The wavelength used must coincide with the absorption peak of water to avoid any thermal damage (on peripheral tissues: cementum and pulp).

*The laser that gave the best results is the Erbium Yag (Er:Yag) laser,

The others (CO2 laser, Nd Yag laser) cause damage to the root or bone surfaces without additional benefit compared to a classic DSR. Er:Yag laser Gives similar results and not superior to DSR alone in terms of:
amount of tartar removed,
bleeding index,
attachment gain,
bone gain.
preservation of the root surface.
- Advantage:

Shortened operating time

Superior patient comfort with less pain, therefore less anesthesia

Disadvantages:

High cost of the device (not efficient in terms of cost/benefit ratio).

2-2-CHEMICAL THERAPEUTICS

ANTISEPTICS:
Prevention of periodontal disease requires inhibition of plaque accumulation. Therefore, the use of anti-plaque agents designed to potentiate mechanical plaque control is justified.

Definition :

Antiseptics are “antimicrobial” agents with antibacterial, antifungal and antiviral activity against microorganisms present on damaged skin and mucous membranes.

Properties :

Antimicrobial (bacteriostatic and bactericidal),
Anti-pathogenic (inhibitor of virulence factors),
Anti-plaque (suppressor of established biofilm).

Chemical control of bacterial plaque can be:

Individual, i.e. supragingival (toothpastes, mouthwash, etc.),
or professional, that is to say subgingival (subgingival irrigations, varnish, etc.).

Supragingival plaque control:

Chemical control of supragingival plaque is based on the personal or professional use of antiseptics in different media: mouthwashes, sprays, toothpastes, gels, varnishes, or irrigations.

Mouthwashes and toothpastes are the most common carriers.

Subgingival plaque control

In order to transport the antiseptic inside the periodontal pockets, two types of approach have been proposed: subgingival irrigations and slow-release materials.

Chlorhexidine

Chemical form used: chlorhexidine digluconate (chlorinated biguanide)
Would be bacteriostatic at low doses and bactericidal at high doses, has anti-plaque properties.
Optimal efficacy: concentrations 0.1% and 0.2%.
12-hour persistence (adhesion and retention power on dental surfaces); its effectiveness would remain stable for 8 to 12 hours. The most effective agent in plaque control, its action is superior to all other molecules, it is the antiseptic of choice in “gold standard” periodontics.
Rapidly inactivated subgingivally: inactivated by pus, blood .
Inhibited by anionic derivatives, soaps and detergents (toothpastes); a delay of at least 30 minutes between the use of toothpaste and chlorhexidine is necessary.
May sometimes cause hypersensitivity reactions.
Its long-term use leads to numerous side effects: brown discoloration of the tongue, teeth and composites, changes in commensal microflora, taste disturbances.

Chlorhexidine can come in the form of:

*Mouthwashes: Paroex®, Eludril®, Cariax®.

Gel, spray, toothpaste (Elgydium®), varnish, slow-release system (Periochip®)

Povidone iodine:

Iodine complex with polyvinylpyrrolidone: Betadine®.
In vitro, iodine is bactericidal, sporicidal, fungicidal and virucidal.
Optimal concentration 0.1% iodine
Not inhibited by organic compounds: Activity persists even in the presence of blood = reference antiseptic in subgingival areas.
Prolonged use: possibility of thyroid dysfunction, transient discoloration of teeth, tongue and skin
Excellent results in subgingival irrigation alone, in spray in conjunction with ultrasonic scalers.
Can be used as a mouthwash.
Contraindicated in: pregnant women after the first trimester, breastfeeding women, iodine intolerance.
The authors recommend this antiseptic during periodontal treatment and not for prophylaxis.

Oxidizing agents

Hydrogen peroxide or “oxygenated water” H2O2,
antiseptic properties by oxygen release,
Usual concentration 3% = at 10 volumes.
Hydrogen peroxide is inactivated by organic matter (proteins, blood, pus) . Interesting results in association:

*Hydrogen peroxide + sodium chloride + baking soda = Keyes mixture.

* Povidone iodine + hydrogen peroxide reduction of oral bacterial load in acute pathologies such as necrotizing periodontal diseases.

Use and methods of application of antiseptics:

Antiseptics come in the form of:

Toothpaste.

Helps improve the mechanical action of brushing
Active ingredient:
- Triclosan+ copolymer: significant reduction of gingival bleeding, plaque and tartar formation (Colgate Total®).
- * Amine fluoride + stannous fluoride: Effective prevention of gingivitis (Meridol®)

Mouthwash: for b-1 ) Gargling

Efficacy only affects the supragingival and marginal areas of the sulcus/pocket (the active product cannot penetrate beyond 3 mm)

Access: interproximal spaces, back of the tongue, cheeks, tonsils
Used secondarily after brushing except in special cases: disability, post-operatively
Can be used pure or diluted.
Gargle for 30 seconds to 1 minute.
Do not swallow.
Do not rinse after use (for long-lasting microbicidal action).
2 or 3 times a day after each meal
Duration: not to exceed 15 days

Interest

Essentially preventative
BDB for therapeutic purposes: supplement professional mechanical control with scaling, root planing and prophylactic polishing in healthy subjects with periodontitis.
BDB for prophylactic purposes (quaternary ammonium, fluorides, oxygenating agents, phenols)

= recommended use to supplement brushing deficiencies:

primary prevention (healthy subjects),
secondary prevention (subjects at periodontal risk),
tertiary prevention (subjects who have already had periodontitis and are in the follow-up phase).

b-2) Subgingival irrigation:

Definition :

It is a therapy that aims to introduce an antibacterial solution using a syringe for the disinfection, sterilization and oxygenation of periodontal pockets.

Principles:

-Washing pockets;

-Mechanical action (disorganization of the subgingival flora);

-Pulsed jet effect oxygenates the bottom of the pocket and destroys anaerobic bacteria.

Slow-release processes

During irrigation the product reaches a certain concentration in the pocket, but as soon as the operation is stopped it is diluted and in a few minutes its antibacterial action declines, hence the slow release devices which are supports which, introduced into the

pouch releases an antimicrobial agent for a sufficient duration and concentration

,exp. (the periochip).

Keyes Paste : mainly consists of hydrogen peroxide + baking soda + chlorhexidine
Sprays
- Several advantages:

*Amount of antiseptic used much less than mouthwashes.

*Advantageous support for people with disabilities.

Gels
- the necessary amount of antiseptic is applied tooth by tooth.
- Useful post-surgery: brushing is difficult, avoid “gargling” which is detrimental to quality healing (mechanical disturbance).
- The results depend heavily on the patient’s ability = support not recommended for disabled people.
Varnish
- Application on the chair for long periods to be effective (numerous sessions).

The most commonly used antibiotics in periodontics :

B-Lactams:

-Inhibit the synthesis of the bacterial wall.

-Bactericides.

Mainly used: Amoxicillin,

Augmentin (Amoxicillin + Clavulanic Acid)

The Cyclines:

-Bacteriostatic.

-Act on protein synthesis.

-Action on the Aa.

-Anticollagenases.

-Inhibit bone resorption.

– Contraindication: pregnancy, breastfeeding, child < 8 years old.

The most used molecules: Minocycline, Doxycycline, Tetracycline.

Metronidazole:

-Antiparasitic activity.

-Bactericide.

-Inhibits the synthesis of nucleic acids.

-Acts on anaerobic germs, very effective on Porphyromonas-gingivalis and spirochetes.

Macrolides . Lincosamides. Synergistins:

Azithromycin (macrolide family): increasingly documented in periodontology.
Has interesting characteristics: – Excellent distribution in periodontal tissues. Very slow half-life: 500 mg/day, 1 dose, 3 days.

6-2-2 Administrative channels:

a) General route : a-1) monotherapy :

-Cyclines :

Indicated in the case of (localized aggressive periodontitis), we use: Tetracycline (250mg), 1g/day for 3 weeks.

Doxycycline (100mg), 200mg the first day, then 100mg for 14 days. Minoxyclines (100mg), 200mg/day for 15 days.

-Metronidazole :

indicated in the case of GUN, PUN, severe chronic periodontitis with persistence of purulent pockets after DSR.

Dosages: dosed at 500mg, (1.5g)/day for 10 days. Specialty: Flagyl, Rodogyl.

-Amoxicillin 2g/day Pd One week in case of periodontal abscess not collected or associated with a deterioration in the general condition (fever and asthenia).

a-2) Associations:

a-2-1) interest :

-presence of bacteria with different sensitivity to ATB.

-Expand the spectrum of action of each ATB.

-Prescribe in low doses.

-Exploit the resulting synergy.

a-2-2)-Most used associations :

Metronidazole (dosed at 250mg) 750mg/day + Amoxicillin dosed at (500mg) 1.5g/day

Bi-rodogyl: a single medication which is a combination of spiramycin and metronidazole.

Indication: localized and generalized aggressive periodontitis Augmentin+Metronidazole as second line.

Prescription terms:

Local antibiotic therapy Classification

Unsupported local application = without support Subgingival irrigation of ATB in the treatment of periodontitis is not recommended (Afssaps 2001).
Sustained local application = with support: ATB incorporated into slow-release devices:

Extended-release systems; release of active agent for up to 24 hours.
Controlled release systems; release of effective concentrations for more than 24 hours.

Slow release devices:

Non-absorbable supports: irritation, interfere with healing. Placement + removal. Fibers, acrylic strips.
Absorbable supports: preferred. Gel, biodegradable polymer powder.

Different presentations

Tetracycline:

Actisite® fiber soaked in 25% tetracycline hydrochloride (1st device).

Doxycycline:
- Resorbable gel (Atridox®) extended-release system containing 10% doxycycline.
Minocycline:
- Resorbable gel (Parocline® and Arestin®) controlled-release device containing 2% minocycline.
- Applications are repeated, after root planing, 4 times every 2 weeks.
Metronidazole:
- Gel (Elyzol®) 25% metronidazole extended-release system.
- Duration of action 24 to 36 hours.
- 1 application per week for two weeks.

Indications:

Local antibiotic therapy alone has no proven benefit in the treatment of periodontitis.
Could only be considered as a complement to mechanical debridement after mechanical disruption of the subgingival biofilm: improvement of the clinical response. Interest: Therefore, it is justified in the one-off treatment of sites losing attachment and not in the overall treatment of a patient suffering from periodontitis.
Not indicated as a first-line treatment for periodontal diseases. Its indication is limited:

* for non-surgical treatment of a localized deep pocket.

*or during periodontal monitoring in the event of localized recurrence.

Among recent therapies:

Photodynamic therapy (PDT),

Also called antimicrobial photochemotherapy, it has been proposed as a therapeutic adjuvant to DSR as an alternative to antibacterials, particularly antibiotics. In the presence of photosensitizing dyes (toluidine blue, methylene blue, aniline green), oral bacteria become sensitive to infrared laser.

During processing, the bacteria located in the pocket are brought into contact with the dye.
The dye is then rinsed off.
The periodontal pockets are then irradiated with laser light whose wavelength corresponds to the maximum absorption of the dye.

The extremely modest clinical outcome and the cost of the device make it difficult to recommend this approach today as a replacement for traditional antibacterials.

Probiotics

Live microorganisms that stimulate the growth of bacteria that may have a beneficial effect on health.

Conclusion

“Non-surgical” periodontal treatments have long been considered an initial step and therefore an incomplete treatment if they are not followed by surgical therapy (respective or regenerative).

Recent literature tends to demonstrate that a non-surgical approach alone can achieve the objectives of attachment gains even in cases of severe periodontitis . Mechanical therapy is carried out with an increasingly minimally invasive approach (mechanized instrumentation, advent of the laser).