Non-surgical therapy
Introduction:
periodontal diseases are multifactorial infectious diseases whose main cause remains bacterial plaque. treatment is therefore based on the principle of controlling bacterial accumulation and colonization on dental surfaces well before focusing on the consequences of the disease. faced with the real pocket, the therapist has two therapeutic methods; surgical or non-surgical for the elimination of accumulated plaque, particularly on root surfaces. each method meets distinct indications with similar results as long as the root surfaces are treated and cleaned of all bacterial accumulation.
Definition :
It is the set of mechanical and chemical means aimed at gradually perfecting the root surfaces over time in order to make them clean, smooth and able to receive a new gingival attachment and possibly encourage the regeneration of periodontal tissues. It is an act that is done without anesthesia and without detachment of a gingival flap.
Objectives of non-surgical therapy:
- reduction in the total number of plaque bacteria, particularly periodontopathogenic bacteria
- preparation of a cement surface compatible with periodontal health (polished and free of any accumulation of bacterial plaque and tartar)
- sanitation of the contents of the periodontal pocket
- maintenance of the results of the sanitation of periodontal pockets as part of maintenance therapy.
Indications and limitations of non-surgical therapy:
Indication:
- suprabony periodontal pocket equal to or less than 5 mm in depth without bone deformation or gingival hyperplasia or any true pocket whose hard surface is accessible to manual debridement without resorting to the detachment of a gingival flap.
- This therapy is also intended for patients whose general condition contraindicates complex surgical procedures involving long work sessions.
- Similarly, the acute phases of periodontal diseases (periodontal abscess) require scaling and root planing, which will not only relieve the pain but also initiate the healing process.
- Represents the only treatment in unmotivated patients
- as a means of maintenance therapy
Limit:
Non-surgical therapy has no contraindications but it is ineffective on pockets of 6 mm or more or any pocket whose bottom is inaccessible to scaling and root planing methods. The presence of anatomical obstacles such as furcations, longitudinal grooves and other particularities that constitute retentive traps for plaque and tartar makes “blind” debridement a therapy without satisfactory effect.
Non-surgical therapy procedures:
The mechanical means:
- scaling and root planing
Definition: Scaling is the removal of plaque and tartar from the surface of the tooth. It is supragingival for deposits located on the enamel and subgingival for those located on the cementum…
Root planing: the removal of rough cementum infiltrated with toxins or microorganisms, with the aim of creating a biologically acceptable root surface condition so that reattachment can occur.
Instrumentation and Techniques
- Manual instrumentation: – scrapers, curettes, scissors, and files…
- Ultrasound instrumentation: – the cavitron, operating at 25,000
Vibrations / S allows the detachment of the
Tartar by fragmentation.
Chemotherapy:
The action of plaque control by mechanical means can be potentiated by the use of antibiotics and antiseptics, the choice of which depends on the quality of the bacterial plaque, namely polymorphic plaque which is treated more effectively using antiseptics or specific plaque which is neutralized using antibiotics.
A- antibiotics
1- General route:
Indicated during the active phase of the disease in case of general disease (where there is the risk of infection; RAA, heart disease, unbalanced diabetes) and during active periodontal treatment after bacteriological confirmation (bacterial specificity)
→Monotherapy:
– Cyclines: tetracycline hydrochloride, Doxycycline, Minocycline (localized PJ)
– Metronidazole: Flagyl (GUN, PUN)
– Macrolides: Erythromycin, Rovamycin.
– B-lactams: Amoxicillin.
→Associations:
– Amoxicillin + Clavulanic acid: Augmentin (GUN, refractory periodontitis)
– Metronidazole + Amoxicillin (generalized PJ, PPP, PPR)
– Spiramycin + Metronidazole (Rodogyl).
Non-surgical therapy
2-The local route:
a- Rapid release processes:
Definition: This 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 progression of periodontal disease.
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 in 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 jet.
The product is injected until the pocket is completely filled and overflowing.
Frequency and choice of antibiotic
– 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.
b- Slow release processes:
→ Principles and interests: local ATB therapy in the treatment of periodontal disease 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 active antimicrobial 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 stable in the pocket.
→ Products:
∙ Metronidazole gel “ELYZOL”:
Comes in gel form when placed in periodontal pockets. It slowly releases 25% metronidazole over 36 hours.
Treatment is only undertaken after significant reduction of the microbial load through hygiene, scaling, root planing and irrigation, and is repeated a second time 8 days after the first implementation .
∙ Minocycline gel “DENTOMYCINE”: Minocycline dental gel at 2% 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: initially the support used (hollow fibers) was only effective for 24 hours, which led to the development of second generation support (EVA) containing tetracycline hydrochloride crystals.
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 the results when combined with conventional treatment, their main disadvantage is the implementation time which is longer than for gels (8min/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 will need to be cut after adjustment.
The effective concentration of the product is maintained for 12 days compared to 12 hours with any irrigation system.
Non-surgical therapy
3- Mixed route:
It is the combination of ATB therapy by general route and local route in order to obtain a potentiation of action.
B- antiseptics:
Antiseptics have an important place in non-surgical periodontal treatments, but they must be chosen and used carefully. There are many antiseptic molecules that are active on 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 particular action on anaerobic periodontal pathogenic germs.
The molecule is also fungicidal, active on Candida Albicans and has a residual power which therefore allows slow expansion on the surface or in the sites.
– Hydrogen peroxide and sodium bicarbonate: 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 haemostatic and has an effervescent effect in the presence of haemoglobin, it releases oxygen.
– Hexetidine: the combination of molecules has an anti-plaque and inflammatory effect below that of chlorhexidine.
– Triclosan: from the phenol family, when incorporated into toothpaste (Colgate total®) triclosan inhibits the colonization of dental surfaces by bacteria.
– Sanguinarine: its anti-plaque, antibacterial and anti-inflammatory actions are much lower than those of chlorhexidine.
Antiseptics are indicated in the treatment of periodontal diseases with polymorphic microbial flora, such as gingivitis of simple and local etiology with severe inflammation and adult periodontitis.
Antiseptics are used in the form of mouthwashes, gels or incorporated into toothpastes. Their application by irrigation of periodontal pockets is also beneficial to potentiate the action of mechanical debridement.
Non-surgical therapy
CONCLUSION:
Opting for surgical or non-surgical therapy depends on the anatomical characteristics of the periodontal pockets without forgetting to take into consideration the motivation and general condition of the patient. Both therapies are part of the same important stage of the periodontal treatment plan, which is the stage of cleaning up the periodontal pockets. Both therapies have given comparable results when carried out correctly in the cases in which they are indicated. It is also interesting to note that the procedures and objectives of non-surgical therapy are the same as those of surgical therapy, with the exception of manipulation of the soft wall, surgical removal of the residual epithelial attachment and possibly manipulation of the alveolar bone; gestures that are carried out during surgical periodontal cleaning.
Non-surgical therapy
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