Non-surgical therapy
Non-surgical therapy
I- Introduction:
The treatment of MP has long aimed to eliminate the specific lesions of the MP (the pockets)
Recently, the identification of specific anaerobic germs causing PD has led to the preference for etiological therapy aimed at eliminating pathogenic bacteria.
Non-surgical treatments, involving anti-infectious agents (ATB, ATS) show, according to all longitudinal studies, a long-term efficacy equivalent to surgical treatments.
II- Definition:
It is the set of physical and chemical means used to stop the progression of periodontal disease.
III- The objectives of non-surgical treatment:
The goals of non-surgical treatment overlap significantly with those of surgical treatments:
– Reduction in the total number of bacteria
– Reduction in the number of pathogens
– Reduction in the amount of endotoxins
– Restoration of a flora compatible with periodontal health
– Gain of attachment
– Long-term maintenance of results.
VI- Therapeutic modalities:
1- The mechanical approach: see previous course
2- The drug approach:
VII- Chemotherapy: (drug approach to NCT)
It is becoming increasingly clear that the strictly mechanical treatment of periodontitis would be greatly improved if the multiple possibilities of drug treatment were exploited, possibilities which could bring the success rate of treatments (reduction of pockets, gain in clinical attachment) to the level of surgical methods.
(Drisko 2001, Quirynen et al. 2002)
The effectiveness of mechanical treatment varies depending on the periodontal pathogen because:
- Some microorganisms are able to attach to periodontal tissues and invade them. Example: (Aa).
- Some subgingival microorganisms are difficult to eliminate due to their location in hard-to-reach areas such as furcations. Example: (Pg).
- Certain system and function disorders such as stress, promote the resistance of certain pathogens. Example: (Pi) and (Fn).
1- General route:
a- Choice of ATB: focuses on;
– The type of lesion
– The bacterial species concerned
– Pharmacological characteristics of ATB, namely; spectrum of action, diffusion, availability.
b- Monotherapy:
→ Cyclines: Very broad spectrum bacteriostatic ATB, active on AAC, PI, PG.
It offers good tissue and bone diffusion, anticollagenic action, inhibition of the activity of proteolytic enzymes, the most used in periodontology; – Tetracycline hydrochloride 250mg
1g/day for 2 to 3 weeks 1/2 hour before meals
– Doxycycline 200mg the first 2 days and 100mg the following 12 days.
Indicated for localized PCs.
→ Metronidazole: is the antibiotic molecule of choice, bactericidal, very active on anaerobes (bacteroides, PG, spirochetes)
Dosage: 250mg 3xday for 7 to 10 days
Indicated: GUN, PUN.
→ Macrolides: bacteriostatic ATBs, exp; erythromycin, spiramycin, clindamycin, little used in monotherapy.
→ B lactams: broad-spectrum bactericidal ATB, their prescription comes up against the problem of resistance of G- bacteria capable of producing B lactamase, which limits its use in monotherapy.
c- Associations:
→ Their interests:
– Allows to broaden the antimicrobial spectrum of each molecule
– Prescribe lower doses of each ATB
– Take advantage of the resulting synergy
→ The most used associations in periodontology:
* Amoxicillin + Clavulanic Acid: “Augmentin”
– To inhibit the action of B lactamases
– Active on PG, Pi
– Presentation: 250mg, 500mg
– Dosage 500mg every 8 hours for 10 days
– Indication: refractory periodontitis
* Metronidazole + Amoxicillin:
– Synergistic and broad-spectrum action
– Dosage: 250mg 3x/day of metronidazole + 500mg 3x/day of amoxicillin for 7 to 10 days
– Indication: PJG, PPR, P.refractory
* Spiramycin + Metronidazole: “Rodogyl”
– Active on PG, AAC
– Dosage:
– Indicated: periodontal abscess (suppuration)
2- The local route:
a- Rapid release processes:
→ Definition: it is an act which aims to introduce, using a syringe or a water jet, an ATB solution for the disinfection, sterilization and oxygenation of periodontal pockets in order to stabilize the evolution of PD.
→ Objectives:
– Control of PB and disruption of subgingival flora
– Sanitize and oxygenate the bag
– Stabilize bone lysis
– Avoid reinfection
→ Indications: given the cost and time spent, and the fact that mechanical treatment gives equivalent clinical and microbiological results, it is unjustified to use these molecules as first-line therapy during initial therapy.
– Is done after a prior microbiological diagnosis
– Motivated patients
– After drainage of a periodontal abscess
– On sites that need to receive a regeneration technique
– Interradicular lesions
→ Principles and interests:
– Washing the pockets, therefore disinfection or sterilization
– Mechanical action causing disorganization of the subgingival flora
– The intermittently pulsed jet effect oxygenates the flora of the pocket and destroys anaerobic bacteria
→ Operating protocol: irrigation is carried out using a disposable syringe with a plastic tip, the tip is inserted to the bottom of the pocket or using a water flosser.
The product is injected until the pocket is completely filled and overflows.
→ Products:
∙ The ATBs:
– Tetracyclines: Localized Pj; irrigation 3x/week for 3 weeks, has a mordanting effect on the root surface which allows fibrillar reattachment.
– Metronidazole: PPR, PPP, generalized PJ; irrigation 3x/week for 3 weeks.
∙ The ATS:
Antiseptics play an important role in non-surgical periodontal treatments, but they must be carefully chosen and used. There are many antiseptic molecules that are active against periodontal diseases;
– Chlorhexidine: in the form of digluconate, has very significant bactericidal and bacteriostatic effects with good homogeneity of action on all germs and a more specific action on anaerobic periodontal pathogenic germs.
The molecule is also fungicidal, active on Candida Albicans and has a residual power which therefore allows slow release on the surface or in the sites.
– Hydrogen peroxide and sodium bicarbonate: Along with chlorhexidine, these two molecules are the basis of the KEYES method. Their action is anti-inflammatory and anti-plaque.
Hydrogen peroxide is weakly antiseptic, but hemostatic and has an effervescent effect in the presence of hemoglobin, it releases oxygen.
– Hexetidine: the combination of molecules has an anti-plaque and inflammatory effect below that of chlorhexidine.
– Triclosan: little used.
– Sanguinarine: its anti-plaque, antibacterial and anti-inflammatory actions are much lower than those of chlorhexidine.
b- Slow release processes:
→ Principles and interests: ATB local therapy in the treatment of PD aims to establish an in-situ antibacterial reservoir at a sufficient concentration and for a sufficiently long time to eliminate the periodontopathogenic flora.
To meet its requirements, the carrier of the antimicrobial active agent must allow a prolonged and controlled release of the latter at a concentration higher than the minimum inhibitory concentration (MIC)
It should also be biodegradable, easy to apply and pocket-retentive.
→ Side effects: some studies describe a phenomenon of transient resistance after application of tetracycline but which is reversible
– Non-adherence to tissue surfaces of Metronidazole
– Oral candidiasis
– Pains
– An abscess
– Change in taste
The existence of a known allergy to the molecule or its support contraindicates its use.
b- Slow release processes:
→ Principles and interests: ATB local therapy in the treatment of PD aims to establish an in-situ antibacterial reservoir at a sufficient concentration and for a sufficiently long time to eliminate the periodontopathogenic flora.
To meet its requirements, the carrier of the antimicrobial active agent must allow a prolonged and controlled release of the latter at a concentration higher than the minimum inhibitory concentration (MIC)
It should also be biodegradable, easy to apply and pocket-retentive.
→ Products:
∙ Metronidazole gel “ELYZOL”:
It comes in gel form when placed in the periodontal pockets. It slowly releases 25% metronidazole over 36 hours.
The treatment is only undertaken after a significant reduction in the microbial load through hygiene, scaling, root planing and irrigation, and is repeated a second time 8 days after the first application .
∙ Minocycline gel “DENTOMYCINE”: The 2% Minocycline dental gel has the same characteristics as metronidazole gel, namely a prolonged release and a high concentration which decreases after 24 hours.
The work carried out on this product recommends its repeated use in 4 applications spaced 14 days apart.
∙ “ACTISITE” tetracycline fibers: These fibers release a sufficient concentration for 9 days, they have an action on clinical and microbiological parameters equivalent to scaling-surfacing and can improve results when combined with conventional treatment, their main disadvantage is the placement time which is longer than for gels (8 min/tooth)
∙ Periochip: indicated in the treatment of chronic periodontitis in pockets greater than or equal to 5mm, active.
The main agent is chlorhexidine digluconate (2.5mg) which comes in the form of a 5mm high strip which must be cut after adjustment.
The effective concentration of the product is maintained for 12 days compared to 12 hours with any irrigation system.
3- Mixed route:
It is the combination of ATB therapy by general route and local route in order to obtain a potentiation of action.
Non-surgical therapy
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