Non-surgical

Periodontal
Therapy
CONTENTS
• Introduction.
• Hyperbaric Oxygen Therapy.
• Phases of periodontal therapy.
• Photodynamic Therapy.
• Nonsurgical phase.
• Nanotechnology.
• Effects of Nonsurgical
• Gene therapy.
Therapy on the Periodontal
• Periodontal Vaccine.
Tissues.
• Studies Showing the Effect of
• Chemotherapeutic Agents.
Nonsurgical Periodontal Therapy on
• Keyes Technique.
Periodontitis.
• Antibiotics in Periodontics.
• Various Studies Comparing Surgical and
• Lasers in Nonsurgical
Nonsurgical Periodontal Therapy.
Periodontal Therapy.
• Conclusion.
INTRODUCTION

• Periodontal diseases are biofilm-mediated, chronic infectious

diseases and the most lead to periodontal attachment apparatus
loss.
• Periodontitis involves a complex interaction between environmental
(such as specific bacteria) and host (genetic and immunological)
factors that leads to loss of periodontal attachment apparatus.
• Ideally, periodontal therapy should eliminate inflammation, arrest
the progression of periodontal disease, improve esthetics, and
create an environment conducive to maintenance of health
• Nonsurgical Periodontal Therapy (Nspt) Is The
Cornerstone Of Periodontal Therapy And The First
Recommended Approach To The Control Of
Periodontal Infections. It Is Also Known As
“Cause‑related therapy,” & “phase I therapy or
etiotrophic phase,” and “initial therapy.”
Non‐surgical therapy involves various means to
Control the infection causing pathologic lesions in the
• .
periodontal tissues. Pocket/root instrumentation
(scaling and root planing), combined with effective
self‐performed supragingival plaque control measures,
serves this purpose by altering the subgingival
ecology through disruption of the microbial biofilm,
Goal of non‐surgical pocket/root
instrumentation
PHASES OF PERIODONTAL THERAPY

Periodontal treatment is divided into the

following phases

1. Emergency phase.
2. Etiotropic phase.
3. Maintenance phase.
4. Surgical phase.
5. Restorative phase.
PHASE 1 THERAPY:-
AIMS OF NON-SURGICAL TREATMENT:

o DECONTAMINATION BY REMOVAL OF ENDOTOXINS FROM THE ROOT

SURFACE.

o DISRUPTION AND ELIMINATION OF BIOFILM FROM THE ROOT SURFACE.

o REMOVAL OF SUBGINGIVAL CALCULUS FROM THE ROOT SURFACE.

PLAQUE AND BIOFILM CONTROL
• PLAQUE OR BIOFILM CONTROL IS AN ESSENTIAL COMPONENT OF SUCCESSFUL
PERIODONTAL THERAPY, AND INSTRUCTION SHOULD BEGIN AT THE FIRST TREATMENT
APPOINTMENT.
• BEFORE ORAL HYGIENE INSTRUCTION, THE PATIENT MUST UNDERSTAND THE REASON
THAT HE OR SHE MUST ACTIVELY PARTICIPATE IN THERAPY.
• THE PATIENT MUST BE INSTRUCTED ON THE CORRECT TECHNIQUE TO REMOVE THE
PLAQUE OR BIOFILM; THIS MEANS FOCUSING ON APPLYING THE BRISTLES AT THE
GINGIVAL THIRD OF THE CLINICAL CROWNS, WHERE THE TOOTH MEETS THE GINGIVAL
MARGIN. THIS TECHNIQUE IS REFERRED TO AS TARGETED ORAL HYGIENE.
• INSTRUCTIONS ARE ALSO INITIATED FOR INTERDENTAL CLEANING WITH DENTAL FLOSS
AND INTERDENTAL BRUSHES.
• THE USE OF THE MULTIPLE APPOINTMENT APPROACH TO PHASE I THERAPY PERMITS THE
USE OF NUMEROUS APPOINTMENTS TO EVALUATE, REINFORCE, AND IMPROVE THE
PATIENT’S ORAL HYGIENE SKILLS.
SCALING AND ROOT PLANING:

• THE PRIMARY OBJECTIVE OF (SRP) IS TO REGAIN GINGIVAL

HEALTH BY COMPLETELY REMOVING ELEMENTS THAT ARE
RESPONSIBLE FOR GINGIVAL INFLAMMATION (I.E., PLAQUE,
CALCULUS, AND ENDOTOXINS) IN THE ORAL
ENVIRONMENT.

• BOTH HAND INSTRUMENTS AND ULTRASONIC

INSTRUMENTS ARE CAPABLE OF DRAMATICALLY
REDUCING THE NUMBER OF SUBGINGIVAL
MICROORGANISMS.

• THE OUTCOME OF ANY TREATMENT METHOD IS

DETERMINED BY COMPLETE AND ADEQUATE ACCESS TO
POCKET AREAS, THE TIME DEVOTED BY THE OPERATOR TO
THE PROCEDURE, AND THE THOROUGHNESS OF THE
PROCEDURE.
• BUSSLINGER ET AL. REPORTED MORE TIME CONSUMPTION BY MANUAL
INSTRUMENTATION THAN THE PIEZOELECTRIC ULTRASONIC SCALER
AND THE MAGNETOSTRICTIVE ULTRASONIC SCALER. ALTHOUGH THE
PIEZOELECTRIC SCALER WAS MORE EFFICIENT THAN THE
MAGNETOSTRICTIVE SCALER IN REMOVING CALCULUS, THE
INSTRUMENTED AREA WAS FOUND TO BE ROUGHER.

• SCHWARZ JP (1958) DEMONSTRATED THAT ULTRASONIC SCALING

CAUSES NO INJURY TO THE PERIODONTAL MEMBRANE, ALVEOLAR
BONE, AND GINGIVA.
 SYSTEMATIC REVIEWS FOR MECHANICAL NONSURGICAL PERIODONTAL THERAPY
Systematic No. of Treatment modalities Tested clinical Conclusion
review studies parameters
Tunkel et al, 27 Machine driven vs Tooth loss, CAL, PPD, No difference between ultrasonic/sonic
subgingival debridement BOP and manual debridement in the treatment
of chronic periodontitis for single-rooted
teeth. Ultrasonic/sonic subgingival
debridement requires less time than hand
instrumentation

Van der 26 Subginigval debridement + BOP, PPD, CAL Improvement in PPD and CAL by
Weijden et supragingival plaque subgingival debridement (with
al control supragingival plaque control)
Slots et al 15 Vector® ultrasonic scaler Calculus removal, time of Comparable clinical and microbiological
vs conventional ultrasonic instrumentation, root effect of all 3 modalities. Vector®
instruments and/or hand surface aspects, patients' ultrasonic system is more time
instrumentation perception, BOP, PPD, consuming
CAL and microbiological
effects
EFFECTS OF NONSURGICAL THERAPY ON THE PERIODONTAL TISSUES

• CHANGES IN GINGIVAL INFLAMMATION:

SEVERAL INVESTIGATORS HAVE DEMONSTRATED A HIGHER PROBABILITY OF A PERIODONTAL
BREAKDOWN AND THE RANGE OF REDUCTION OF THE OCCURRENCE OF BLEEDING AFTER PROBING
AFTER THE 1ST MONTH WAS 6–64%, 12–80% AT 3 MONTHS POSTTREATMENT, 12–87% AT 6 MONTHS,
AND 37–87% AT 12 MONTHS AFTER COMPLETION OF THE NON-SURGICAL PERIODONTAL TREATMENT.
• IT WAS CONCLUDED THAT SUPRAGINGIVAL PLAQUE CONTROL CAN HELP RESOLVE SIGNS OF
INFLAMMATION ASSOCIATED WITH GINGIVITIS BUT DOES NOT PREDICTABLY ALTER THE
BACTERIAL COMPOSITION IN POCKETS >5 MM. THEREFORE, SUBGINGIVAL DEBRIDEMENT IS
NECESSARY IN ADDITION TO PERSONAL ORAL HYGIENE TO ACHIEVE PERIODONTAL HEALTH.

• REDUCED EFFICACY IN MOLAR FURCATION DEFECTS:

NORDLAND ET AL. REPORTED SIMILAR POCKET REDUCTION AND GAIN OF CLINICAL ATTACHMENT
IN THE MOLAR OR NON MOLAR SITES, BUT THERE WAS A TENDENCY TO RECUR IN FURCATION
DEFECTS WITHIN A YEAR. IN ADDITION, THE REDUCTION OF ANAEROBES WAS ONLY 2‑FOLD AT
FURCATION DEFECTS, WHEREAS THERE WAS A 100‑FOLD REDUCTION AT OTHER SITES.
• CHANGES IN PROBING POCKET DEPTH AND CLINICAL ATTACHMENT LEVEL:
FOR NON-MOLAR SITES, WITH INITIAL PD BETWEEN 1 AND 3 MM, THE AMOUNT OF GINGIVAL
RECESSION WAS APPROXIMATELY 1 MM, AND WITH MODERATELY DEEP (4–6 MM) OR DEEP (7
MM OR MORE) PD AT BASELINE, THE GINGIVAL RECESSION WERE 1.2 MM AND 1.9 MM,
RESPECTIVELY.
THERE WAS A SIGNIFICANTLY LESS GINGIVAL RECESSION AT THE MOLAR FURCATION SITES
THAN NON-MOLAR SITES.
NO SIGNIFICANT CHANGES WERE SEEN WHEN HAND INSTRUMENTS OR ULTRASONIC
INSTRUMENTS WERE USED.
PROYE ET AL. REPORTED REDUCTION IN RECESSION AFTER 1 WEEK AND A GAIN OF CLINICAL
ATTACHMENT BY 3 WEEKS AFTER A SINGLE EPISODE OF SRP.
IT WAS CONCLUDED THE MAGNITUDE OF THE RECESSION WAS RELATED TO INITIAL PDS AND
INFLAMMATORY STATUS OF THE TISSUES. THE MOST GINGIVAL SHRINKAGE OCCURRED
INTERPROXIMALLY. THE GREATEST GAIN OF CLINICAL ATTACHMENT OCCURRED AT SITES
THAT INITIALLY HAD DEEP POCKETS.
• CHANGES IN ALVEOLAR BONE STRUCTURES:
RENVERT AND EGELBERG REPORTED THAT PROBING BONE LEVELS INCREASED BY 0.6
MM AFTER SURGERY AND THERE WAS VIRTUALLY NO BONE FILL AFTER ROOT PLANING.
ISIDOR ET AL. FOUND THAT SURGERY RESULTED IN 0.5 MM CORONAL GROWTH OF
BONE IN ANGULAR DEFECTS AND NO CHANGES FOLLOWING ROOT PLANING. ISIDOR ET
AL. OBSERVED NO CHANGES IN THE BONE HEIGHT WITH HORIZONTAL BONE LOSS WHEN
TREATED WITH NSPT.
IT WAS CONCLUDED INTRAOSSEOUS DEFECTS TREATED WITH NSPT SHOWED AN
INCREASE IN BONE PROBING LEVELS OF 0.2 MM AT 6 MONTHS, 0.3 MM AT 12 MONTHS,
AND 0.5 MM AT 24 MONTHS AFTER THERAPY.
AFTER 3 YEARS, THE GAIN IN BONE PROBING LEVELS AFTER NSPT WAS GRADUALLY
LOST, MOST PROBABLY DUE TO THE ABSENCE OF ANY ADDITIONAL PROFESSIONAL
SUBGINGIVAL INSTRUMENTATION DURING THE 5‑YEAR FOLLOW‑UP IN THESE STUDIES.
• .
• SINGLE VERSUS REPEATED INSTRUMENTATION:
BADERSTEN ET AL. REPORTED A REDUCTION OF APPROXIMATELY 2 MM IN MEAN PDS
WITH SINGLE INSTRUMENTATION AND NO FURTHER IMPROVEMENT WAS ACHIEVED
WITH REPEATED INSTRUMENTATION.

IT WAS CONCLUDED THE EFFICACY OF A SINGLE COURSE OF SRP WILL BE AFFECTED BY

THE SKILL OF THE CLINICIAN, TIME ALLOCATED FOR PROCEDURES, THE INFLAMMATORY
STATUS OF TISSUES, ANATOMY OF ROOTS, ETC. IN GENERAL, AFTER SINGLE
INSTRUMENTATION, TREATED AREAS NEED TO BE RE‑EVALUATED FOR FURTHER
TREATMENT.
CORRECTION OF PROSTHETIC AND RESTORATIVE IRRITATIONAL FACTORS

• OVERHANGING MARGINS CONTRIBUTE TO PERIODONTAL

DISEASE BY:

(1) PROVIDING IDEAL LOCATIONS FOR THE ACCUMULATION OF

PLAQUE AND

(2) CHANGING THE ECOLOGIC BALANCE OF THE GINGIVAL

SULCUS AREA TO ONE THAT FAVORS THE GROWTH OF DISEASE-
ASSOCIATED ORGANISMS (GRAM-NEGATIVE ANAEROBIC
SPECIES) AT THE EXPENSE OF THE HEALTHY STATE ORGANISMS
(GRAM-POSITIVE FACULTATIVE SPECIES).
• GILMORE & SHEIHAM (1971) ILLUSTRATED INTERPROXIMAL RADIOGRAPHIC BONE
LOSS ADJACENT TO POSTERIOR TEETH WITH OVERHANGING RESTORATIONS.
• JEFFCOAT AND HOWELL (1980) DEMONSTRATED A LINK TO THE SEVERITY OF THE
OVERHANG AND THE AMOUNT OF PERIODONTAL DESTRUCTION.
• BASED UPON RADIOGRAPHIC EVALUATIONS OF 100 TEETH WITH OVERHANGS AND
100 WITHOUT, THEY REPORTED GREATER BONE LOSS AROUND TEETH WITH LARGE
OVERHANGS. THE SEVERITY OF BONE LOSS WAS DIRECTLY PROPORTIONAL TO THE
SEVERITY OF THE OVERHANG.
• RENGGLI & REGOLATI (1972) DEMONSTRATED THAT GINGIVITIS AND PLAQUE
ACCUMULATION WAS MORE PRONOUNCED IN INTERDENTAL AREAS WITH WELL-
ADAPTED SUBGINGIVAL AMALGAM FILLINGS COMPARED TO SOUND TOOTH
STRUCTURE.
• THE FIRST STEP, IN USING SULCUS DEPTH AS A GUIDE IN MARGIN
GUIDELINES FOR RESTORATIVE MARGIN
PLACEMENT, IS TO MANAGE GINGIVAL HEALTH. ONCE THE TISSUE IS
PLACEMENT:
HEALTHY, THE FOLLOWING THREE RULES CAN BE USED TO PLACE
INTRACREVICULAR MARGINS.
RULE I - IF THE SULCUS PROBES 1.5 MM OR LESS, PLACE THE
RESTORATION MARGIN 0.5 MM BELOW THE GINGIVAL TISSUE CREST. THIS
IS ESPECIALLY IMPORTANT ON THE FACIAL ASPECT AND PREVENTS A
BIOLOGIC WIDTH VIOLATION IN A PATIENT WHO IS AT HIGH RISK IN THAT
REGARD.
RULE II - IF THE SULCUS PROBES >1.5 MM, PLACE THE MARGIN ONE-HALF
THE DEPTH OF THE SULCUS BELOW THE TISSUE CREST. THIS PLACES THE
MARGIN FOR ENOUGH BELOW TISSUE SO THAT IT IS STILL COVERED IF
THE PATIENT IS AT HIGHER RISK OF RECESSION.
RULE III - IF A SULCUS >2 MM IS FOUND, ESPECIALLY ON THE FACIAL
ASPECT OF THE TOOTH, THEN EVALUATE TO SEE WHETHER A
GINGIVECTOMY COULD BE PERFORMED TO LENGTHEN THE TEETH AND
CREATE A 1.5 MM SULCUS. THEN THE PATIENT CAN BE TREATED AS
CHEMOTHERAPEUTIC APPROACHES IN NON-SURGICAL PERIODONTAL THERAPY

• THE EFFECTS OF MECHANICAL THERAPY MIGHT BE AUGMENTED USING ANTIMICROBIAL AGENTS

WHICH FURTHER SUPPRESS THE REMAINING PATHOGENS.
• MANY CHEMOTHERAPEUTIC AGENTS ARE NOW AVAILABLE LIKE SYSTEMIC ANTI‑INFECTIVE
THERAPY (ORAL ANTIBIOTICS) AND LOCAL ANTI‑INFECTIVE THERAPY (PLACING ANTI‑INFECTIVE
AGENTS DIRECTLY INTO THE PERIODONTAL POCKET) CAN REDUCE THE BACTERIAL CHALLENGE
TO THE PERIODONTIUM.
• FOUR GENERATIONS OF ANTISEPTICS THAT INCLUDES:
• I GENERATION: ANTIBIOTICS, PHENOLS, QUATERNARY AMMONIUM COMPOUNDS, AND
SANGUINARINE
• II GENERATION: BISBIGUANIDES, BIPYRIDINES, QUATERNARY AMMONIUM COMPOUNDS,
PHENOLIC COMPOUNDS, METAL IONS, HALOGENS, ENZYMES, SURFACTANTS, OXYGENATING
AGENTS, NATURAL PRODUCTS, UREA, AMINO ALCOHOLS, SALIFLOUR, AND AGENTS THAT INCREASE
THE REDOX POTENTIALS
• III GENERATION: EFFECTIVE AGAINST SPECIFIC PERIODONTOGENIC ORGANISMS
• IV GENERATION: PROBIOTICS ARE INCORPORATED IN MOUTHWASHES.
KEYES TECHNIQUE
• IN THE LATE 1970S, AN ORAL HYGIENE PROGRAM CALLED THE KEYES TECHNIQUE WAS WIDELY
PROMOTED AS A NON-SURGICAL ALTERNATIVE FOR TREATING ADVANCED PERIODONTAL DISEASE.
THE TECHNIQUE INCLUDES:
1. MICROSCOPIC EXAMINATION OF THE PLAQUE.
2. CLEANING THE TEETH AND GUMS WITH A MIXTURE OF SALT, BAKING SODA AND PEROXIDE.
3. USE OF ANTIBIOTICS.

• IN 1978, KEYE’S METHOD OF ORAL HYGIENE WAS COMPARED TO CONVENTIONAL ORAL HYGIENE IN
PATIENTS WITH NO SRP WHO WERE DIVIDED INTO UNTREATED (NO SURGERY) AND TREATED
(SURGERY) GROUPS BY GREENWELL ET AL.
• THIS COMPARISON SHOWED THAT KEYE’S ANTIMICROBIAL AGENTS WERE MORE EFFECTIVE IN
REDUCING CLINICAL INDICATOR VALUES AND PRODUCING FAVORABLE SUBGINGIVAL PROPORTION
CHANGES THAN WAS CONVENTIONAL ORAL HYGIENE ALONE.
ANTIMICROBIALS
• SYSTEMIC ANTIMICROBIALS THERAPY AS AN ADJUNCT TO MECHANICAL
DEBRIDEMENT HAS BEEN ADVOCATED.
• THE RATIONALE FOR THEIR USE IS THE SUPPRESSION OF PERIODONTAL
PATHOGENS PERSISTING IN BIOFILMS IN DEEP POCKETS, ROOT
FURCATIONS, AND CONCAVITIES OR RESIDING WITHIN THE
PERIODONTAL TISSUES OR OTHER ORAL NICHES WHERE MECHANICAL
THERAPY ALONE MAY PROVE TO BE INEFFECTIVE.
• SINCE PERIODONTITIS IS A POLYMICROBIAL INFECTION, THE
HETEROGENEITY OF PATHOGENIC BACTERIA NECESSITATES THE USE OF
DRUG COMBINATION THERAPIES THAT CAN ALSO BE EFFECTIVE TO
OVERCOME THE DRUG PROTECTIVE EFFECTS OF BIOFILM.
• IN-VITRO EXPERIMENTS HAVE REPORTED THE SYNERGISTIC EFFECT OF
AMOXICILLIN WITH METRONIDAZOLE AND CIPROFLOXACIN WITH
METRONIDAZOLE AGAINST A. ACTINOMYCETEM- COMITANS AND
OTHER PERIODONTAL PATHOGENS.
 SYSTEMATIC REVIEWS ON ADJUNCTIVE CHEMOTHERAPEUTIC AGENTS
(SYSTEMIC ANTIMICROBIAL THERAPY)
Systemat No of Treatment Tested clinical Conclusion
ic review studie modalities parameters
s
Herrera et 25 SRP + systemic PPD, CAL Systemic antimicrobials in
al antibiotics vs SRP conjunction with SRP can offer
alone or SRP + an additional benefit over SRP
placebo alone in the treatment of
periodontitis
Haffajee et 29 SRP + systemic CAL The use of systemically
al antibiotics vs SRP administered adjunctive
alone or SRP+ placebo antibiotics with and without
SRP and/or surgery appeared
to provide a greater clinical
improvement in CAL

Goodson RCT#(1 SRP + systemic CAL, PPD Adjunctive therapies generally

et al 87 antibiotics vs SRP + exhibited improved CAL gain
Patients local antibiotic therapy and/or PPD reduction when
) and/or periodontal compared with SRP alone
surgery
Sgolastra 6 AMX/MET + CAL, PPD, Significant CAL gain and PPD
et al SRP vs full secondary reduction in favor of full mouth
mouth SRP outcomes, and SRP + AMX/MET; no significant risk
alone adverse events difference in the occurrence of
adverse events

Zandbergen 28 Adjuvant CAL, PPD, plaque AMX/MET as an adjunct to SRP can

et al AMX/MET + SRP index, BOP enhance the clinical benefits of non-
surgical periodontal therapy in adults
who are otherwise healthy
Keestra et al 43 Different BOP, CAL, PPD Systemic antibiotics combined with
systemic SRP offer additional clinical
antibiotics +SRP improvements compared to SRP alone.
vs SRP Alone For initially moderate and deep
pockets, MET or MET + AMX, resulted
in clinical improvements that were
more pronounced over doxycycline or
azithromycin. Clinical benefit became
smaller over time (1 yr)
• THE RATIONALE OF USING LAD IN PERIODONTAL DISEASE IS TO
CHEMICALLY KILL OR REDUCE THE PLAQUES WITHIN THE BIOFILM IN
LOCAL ANTIMICROBIAL
THE POCKET THERAPY:- OF AN ANTIBIOTIC
BY PLACING HIGH CONCENTRATIONS
OR ANTISEPTIC IN DIRECT CONTACT WITH THE ROOT SURFACE
WITHOUT NOTICEABLE SYSTEMIC EFFECT.
• VARIOUS NON-RESORBABLE AND RESORBABLE INTRAPOCKET
DELIVERY SYSTEMS HAVE BEEN DEVELOPED. THE FIRST LAD AGENT
DEVELOPED FOR PERIODONTITIS WAS ACTISITE™, SUPPLIED AS
HOLLOW, NON-RESORBABLE FIBERS FILLED WITH TETRACYCLINE (12.7
MG/9 INCH FIBER).
• AMONG THE FIRST ABSORBABLE SYSTEM TO BE DEVELOPED WAS
ATRIDOXTM, WHICH IS A 10% FORMULATION OF DOXYCYCLINE (50 MG
IN A BIORESORBABLE GEL SYSTEM).THE POLYMER GEL FILLS AND
CONFORMS TO POCKET MORPHOLOGY, THEN SOLIDIFIES TO A WAX-LIKE
CONSISTENCY UPON CONTACT WITH GINGIVAL CREVICULAR FLUID.
DOXYCYCLINE IS RELEASED AT EFFECTIVE CONCENTRATIONS OVER 7 D,
AND SIGNIFICANT REDUCTIONS (60%) IN ANAEROBIC PATHOGENS ARE
SUSTAINED FOR UP TO 6 MO POST TREATMENT.
• THE EARLY SUCCESS OF ATRIDOX
LED TO DEVELOPMENT OF OTHER
ABSORBABLE LAD SYSTEMS SUCH
AS MINOCYCLINE MICROSPHERES
(ARESTIN™), CHLORHEXIDINE
GLUCONATE CHIPS (PERIOCHIP™)
AND GEL (CHLOSITE™), AND
METRONIDAZOL GEL (ELYZOL™).
 LOCAL ANTIMICROBIAL THERAPY
Systemat No of Treatment modalities Tested Conclusion
ic Review studi clinical
es parame
ters
Hanes et 32 Local controlled-release PPD, CAL Local anti-infective agents resulted in
al antiinfective drug significant adjunctive PPD reduction or
therapy with or without CAL gain for minocycline gel,
SRP vs SRP alone microencapsulated minocycline, CHX chip
and doxycycline gel during SRP compared
to SRP alone.

Bonito et 3 Local antimicrobials CAL,PPD Only modest improvements in PPD

al with SRP vs SRP alone reductions
• IN A RECENT SYSTEMATIC REVIEW OF 52 STUDIES, MATESANZPÉREZ ET
AL OBSERVED THAT SUBGINGIVAL APPLICATION OF TETRACYCLINE
FIBERS, SUSTAINED RELEASED DOXYCYCLINE AND MINOCYCLINE
RESULTED IN STATISTICALLY SIGNIFICANT BENEFIT IN PPD REDUCTION
(WMD BETWEEN 0.5 AND 0.7 MM) WHILE THAT FOR CHX AND
METRONIDAZOLE SHOWED A MINIMAL EFFECT (WMD BETWEEN 0.1
AND 0.4 MM) WHEN COMPARED WITH PLACEBO.
• THE AUTHORS CONCLUDED THAT THE SCIENTIFIC EVIDENCE SUPPORTS
THE ADJUNCTIVE USE OF LOCAL ANTIMICROBIALS TO DEBRIDEMENT
IN DEEP OR RECURRENT PERIODONTAL SITES, MOSTLY WHEN USING
VEHICLES WITH PROVEN SUSTAINED RELEASE OF THE
ANTIMICROBIALS.
SUBGINGIVAL POCKET IRRIGATION
• SUB GINGIVAL IRRIGATION OF AGENTS SUCH AS CHLORHEXIDINE DIGLUCONATE, 10%
POVIDONE IODINE (PI), AND 0.1% SODIUM HYPOCHLORITE HAS BEEN ADVOCATED IN
PERIODONTAL DISEASE AS THEY SHOW EXCELLENT ANTIBACTERIAL AND ANTIVIRAL
PROPERTIES.
• SYSTEMATIC REVIEWS ANALYSING THE EFFECT OF SUBGINGIVAL IRRIGATION WITH
CHX AND PI OBSERVED NO ADDITIONAL CLINICAL BENEFIT TO MECHANICAL
DEBRIDEMENT FOR CHX IRRIGATION AND A SMALL BUT STATISTICALLY SIGNIFICANT
EFFECT OF PI IN PROBING DEPTH REDUCTION.
• CURRENT EVIDENCE SUGGESTS THAT SUBGINGIVAL IRRIGATION IS NEVER INTENDED
TO BE USED AS A STANDALONE THERAPY; RATHER IT IS MEANT TO BE USED AS AN
ADJUNCT TO PROFESSIONAL DEBRIDEMENT, BUT ONE THAT SIMPLIFIES HOME-CARE
ORAL HYGIENE FOR THE PATIENT.
TOTAL ANTISEPTIC APPLICATION:-
• TOPICAL APPLICATION OF ANTISEPTICS SUCH CHX, POVIDONE IODOINE, PHENOLIC
COMPOUNDS AND SODIUM HYPOCHLORITE, WITH ANTI-PLAQUE OR ANTI-GINGIVITIS
ACTION, HAS BEEN SUGGESTED AS USEFUL ORAL HYGIENE AIDS TO COMPLEMENT
MECHANICAL PERIODONTAL THERAPY.
• A RECENTLY PUBLISHED META-ANALYSIS OF 50 STUDIES, OF ATLEAST 6 MO
DURATION, REPORTED CLINICALLY AND STATISTICALLY SIGNIFICANT ANTIPLAQUE
AND ANTIGINGIVITIS EFFECT OF DENTRIFICES CONTAINING TRICLOSAN/COPOLYMER
FORMULATIONS AND MOUTHRINSES WITH 0.12% CHX AND ESSENTIAL OILS-
CONTAINING FORMULATIONS [MENTHOL (0.042%), THYMOL (0.064%), METHYL
SALICYLATE (0.060%), AND EUCALYPTOL (0.092%)].
• STATISTICALLY AND CLINICALLY SIGNIFICANT ANTIGINGIVITIS EFFECT WAS
REPORTED WITH DENTIFRICES CONTAINING STANNOUS FLUORIDE.
•FULL
THE FULL
MOUTHMOUTH DISINFECTION (FMD) PROTOCOL WAS FIRST PROPOSED
DISINFECTION:
BY QUIRYNEN ET AL IN 1995.
• FULL-MOUTH DISINFECTION INVOLVES REMOVAL OF ALL PLAQUE AND
CALCULUS IN TWO VISITS WITHIN 24 H. IN ADDITION, AT EACH OF THESE
VISITS, THE TONGUE WAS BRUSHED WITH A 1% CHX GEL FOR ONE
MINUTE, CHX SPRAYING ON TONSILS AND THE MOUTH RINSED WITH A
0.2% CHX SOLUTION FOR TWO MINUTES.
• TWO SYSTEMATIC REVIEWS OF 7 STUDIES EACH, COMPARING FULL-
MOUTH SCALING AND ROOT PLANING WITHIN 24 H WITH ANTISEPTICS
(FMD) OR WITHOUT (FMS) THE ADJUNCTIVE USE OF AN ANTISEPTIC
(CHLORHEXIDINE) WITH CONVENTIONAL QUADRANT SCALING AND
ROOT PLANNING AS CONTROL, CONCLUDED THAT IN PATIENTS WITH
CHRONIC PERIODONTITIS, ONLY MINOR DIFFERENCES IN REDUCTION IN
PD AND CAL WERE OBSERVED IN MODERATELY DEEP POCKETS BETWEEN
THE TREATMENT STRATEGIES.
 FULL MOUTH DISINFECTION
Systematic No of Treatment Tested Conclusion
Reveiw studie modalities clinical
s parameter
s

Lang et al 12 FMD with or without BOP, PPD, Despite the significant differences of
antiseptics vs CAL modest magnitude, FMD with or without
conventional staged microbial antiseptics do not provide clinically
debridement changes relevant advantages over conventional
staged debridement.

Eberhard et 7 FMD with or without Tooth loss, Slightly more favourable, but modest
al antiseptics vs BOP, PPD, outcomes were found following FMD in
quadrant scaling CAL moderately deep pockets.
LASERS IN NONSURGICAL PERIODONTAL THERAPY
• LASER IRRADIATION HAS BEEN REPORTED TO EXHIBIT
BACTERICIDAL, AND DETOXIFICATION EFFECTS WITHOUT
PRODUCING A SMEAR LAYER, AND ROOT SURFACE TREATED
WITH A LASER MAY, THEREFORE, PROVIDE FAVORABLE
CONDITIONS FOR THE ATTACHMENT OF PERIODONTAL
TISSUE.
• ALTHOUGH THERE IS NO CLEAR EVIDENCE TO DATE THAT
LASER APPLICATIONS IMPROVE CLINICAL OUTCOMES DUE
TO THE ACTION OF CURETTAGE, LASER TREATMENT HAS A
POTENTIAL ADVANTAGE OF ACCOMPLISHING SOFT TISSUE
WALL TREATMENT EFFECTIVELY ALONG WITH ROOT
SURFACE DEBRIDEMENT AND SHOULD BE FURTHER
INVESTIGATED.
• THE DIFFERENT TYPES OF LASERS USED ARE CO2 ,
NEODYMIUM‑DOPED YTTRIUM ALUMINUM GARNET (ND:YAG),
ERBIUM‑DOPED YTTRIUM ALUMINUM GARNET LASER, DIODE LASER,
ARGON LASER, AN ALEXANDRITE LASER, AND AN EXCIMER LASER.
• MIYAZAKI ET AL. REPORTED DECREASED INFLAMMATION AND PD
AFTER TREATMENT WITH CO2 LASER AND IMPROVEMENTS REGARDING
CLINICAL PARAMETERS AND SUBGINGIVAL MICROFLORA AFTER
ND:YAG, CO2, AND ULTRASONIC TREATMENTS.

• SCHWARZ ET AL. REPORTED THE INEFFECTIVENESS OF LASER FOR

CALCULUS REMOVAL AND CAUSES ALTERATION OF ROOT SURFACES
SUCH AS GROOVES AND CRATER‑LIKE DEFECTS IN VIVO.

• HENRY ET AL. REPORTED THE EFFECTIVENESS OF LOW-DOSE ARGON

LASER IN THE TREATMENT OF CLINICAL INFECTIONS CAUSED BY
BIOFILM‑ASSOCIATED SPECIES OF PREVOTELLA AND PORPHYROMONAS.
 SYSTEMATIC REVIEWS FOR LASER THERAPY
Systematic No of Treatment Tested clinical Conclusion
review studi modalitities parameters
es
Schwarz et 11 Laser monotherapy Clinical data Er:YAG laser monotherapy resulted
al vs mechanical Laser safety in similar clinical outcomes, both in
debridement data the short and long term compared
with mechanical debridement.

Karlsson et 4 Laser therapy + BOP, PPD, CAL No consistent evidence for efficacy
al SRP of laser as an adjunct to NSPT in
adults with chronic periodontitis

Slots et al 8 Nd:YAG Laser Plaque, BOP, No beneficial effect of a pulsed

monotherapy vs gingivitis, PPD, Nd:YAG laser compared to
Laser + SRP CAL, and GR ultrasonics and/or hand
instrumentation in the initial
periodontitis
PHOTODYNAMIC THERAPY

• PHOTODYNAMIC
THERAPY (PDT), IS A FORM
OF PHOTOTHERAPY INVOLVING
LIGHT AND A PHOTOSENSITIZING
CHEMICAL SUBSTANCE, USED IN
CONJUNCTION WITH
MOLECULAR OXYGEN TO ELICIT
CELL DEATH (PHOTOTOXICITY).
PHOTODYNAMIC THERAPY
• ANDERSEN ET AL. FOUND THAT SRP COMBINED WITH PHOTO DISINFECTION
LEADS TO SIGNIFICANT IMPROVEMENTS OF THE INVESTIGATED
PARAMETERS OVER THE USE OF SRP ALONE.

• DE ALMEIDA ET AL. REPORTED THAT PDT MAY BE AN EFFECTIVE

ALTERNATIVE FOR THE CONTROL OF BONE LOSS IN FURCATION AREAS IN
PERIODONTITIS.

• CHRISTODOULIDES ET AL. REPORTED FAILURE IN ADDITIONAL

IMPROVEMENT IN TERMS OF PD REDUCTION AND CLINICAL ATTACHMENT
LEVEL (CAL) GAIN WITH A SINGLE EPISODE OF PDT TO SRP, BUT IT
RESULTED IN A SIGNIFICANTLY HIGHER REDUCTION IN BLEEDING SCORES
COMPARED TO SRP ALONE
 SYSTEMATIC REVIEWS FOR PHOTODYNAMIC THERAPY:
Sytematic No of Treatment Tested clinical conclusion
review studie modalities parameters
s
Azarpazhooh et al 5 Monotherapy or PPD, CAL, GR, Full Routine use of PDT for
adjunctive PDT mouth plaque and clinical management of
bleeding scores periodontitis cannot be
recommended

Sgolastra et al 4 PDT used alone or CAL, PPD, GR PDT adjunctive to

adjunctive to conventional treatment
scaling root provides short-term
planning benefits, but
microbiological outcomes
are contradictory. No
evidence of effectiveness
for the use of PDT as an
alternative to SRP
HOST MODULATION THERAPY
• AS THE ROLE OF HOST IMMUNE REACTIONS TO THE BACTERIAL CHALLENGES IS
BEING ESTABLISHED IN THE ETIOPATHOGENESIS OF PERIODONTAL DISEASE,
MODULATION OF THESE REACTIONS PROVIDES FOR VERY PROMISING AND EXCITING
THERAPEUTIC OPTIONS TO MANAGE PERIODONTAL DISEASE.

• HOST MODULATION THERAPY HAS WITNESSED RAPID ADVANCES IN RECENT YEARS

AND NEWER THERAPEUTIC MODALITIES ARE BEING DEVELOPED TO RESTRAIN OR
INHIBIT THE RELEASE OF PROTEOLYTIC ENZYMES, PRO-INFLAMMATORY
MEDIATORS, AND OSTEOCLAST ACTIVITY THAT OCCUR AS A RESULT OF HOST-
MICROBIAL INTERACTIONS.

• DIFFERENT AGENTS ARE BEING INVESTIGATED AS AN ADJUNCT TO MECHANICAL

NSPT WHICH INCLUDES ANTI-PROTEINASE AGENTS, ANTI-INFLAMMATORY AGENTS,
AND ANTI-RESORPTIVE AGENTS.
ANTI-PROTEINASE AGENTS

• GOLUB ET AL FIRST REPORTED THAT THE SEMISYNTHETIC ANALOGS OF TETRACYCLINES, LIKE

DOXYCYCLINE, WERE MORE EFFECTIVE IN REDUCING EXCESSIVE COLLAGENASE ACTIVITY IN
THE GCF OF ADULT PERIODONTITIS PATIENTS.

• THIS IS ACCOMPLISHED THROUGH THE NON-ANTIMICROBIAL ACTIVITIES OF LOW-DOSE

DOXYCYCLINE VIA THE INHIBITION OF MMP-8 AND 13 PROTEASE MECHANISMS AND
DOWNREGULATION OF KEY INFLAMMATORY CYTOKINES (INTERLEUKIN-1,6; TUMOR NECROSIS
FACTOR-Α).

• DOXYCYCLINE HYCLATE (PERIOSTAT®) IS THE ONLY COLLAGENASE INHIBITOR AVAILABLE FOR

USE SPECIFICALLY IN PERIODONTAL DISEASE, THE RECOMMENDED DOSAGE BEING 20 MG
TABLET TWO TIMES DAILY FOR A MINIMUM OF 3 MO TO ACHIEVE LONG-TERM BENEFIT
WITHOUT A REBOUND.
• A RECENT META-ANALYSIS OF 9 RANDOMIZED CONTROLLED DOUBLE-
BLIND CLINICAL TRIALS REPORTED THAT THE HOST MODULATING
AGENT SUCH AS SDD WAS EFFECTIVE IN IMPROVING CAL AND
REDUCING PPD WHEN ADMINISTERED AS AN ADJUVANT IN THE
NONSURGICAL MANAGEMENT OF CHRONIC AND AGGRESSIVE
PERIODONTITIS.
• ANOTHER META-ANALYSIS OF 3 TRIALS BY SGOLASTRA ET AL
SUPPORTED THE LONG-TERM EFFECTIVENESS OF THE ADJUNCTIVE SDD
TREATMENT.
ANTI-INFLAMMATORY AGENTS
• IN PERIODONTAL INFLAMMATION, SIGNIFICANTLY HIGH LEVELS OF PROSTAGLANDIN
E2 (PGE2) HAS BEEN REPORTED IN GINGIVAL TISSUES AND GCF.

• THE TISSUE DAMAGE RESULTING FROM HOST-MICROBIAL INTERACTIONS ALLOWS THE

PRODUCTION OF FREE ARACHIDONIC ACID (AA) FROM PHOSPHOLIPIDS IN PLASMA
MEMBRANES OF CELLS BY ACTION BY PHOSPHOLIPASE A2 VIA THE CYCLOOXYGENASE
(CO) OR LIPOXYGENASE (LO) PATHWAYS. THE FINAL PRODUCTS OF THE CO PATHWAY
INCLUDE PROSTAGLANDINS, PROSTACYCLIN, AND THROMBOXANE, WHEREAS THE END
RESULTS OF THE LO PATHWAY INCLUDE LEUKOTRIENES AND OTHER
HYDROXYEICOSATETRAENOIC ACIDS.

• NSAIDS HAVE THE ABILITY TO BLOCK THE ENZYME CO AND REDUCE PROSTAGLANDIN
SYNTHESIS AND RATE OF ALVEOLAR BONE RESORPTION.
• TOPICAL APPLICATION OF NSAIDS HAS BEEN ADVOCATED OWING TO THE
LIPOPHILIC PROPERTIES OF THESE DRUGS.

• NSAIDS THAT HAVE BEEN EVALUATED FOR TOPICAL ADMINISTRATION INCLUDE

KETOROLAC TROMETHAMINE, S-KETOPROFEN, AND FLURBIPROFEN.

• THOUGH THESE TRIALS REPORTED REDUCTIONS IN THE RATE OF ALVEOLAR

BONE LOSS, NO SUPERIOR EFFECT WAS OBSERVED FOR OTHER CLINICAL
PARAMETERS WHEN TOPICAL NSAIDS WERE USED IN CONJUNCTION WITH
CONVENTIONAL PERIODONTAL TREATMENT.
• RECENTLY, NEW CLASSES OF PRORESOLVING LIPID MEDIATORS SUCH AS RESOLVINS
(RESOLUTION-PHASE INTERACTION PRODUCTS) AND PROTECTIN HAVE BEEN
IDENTIFIED THAT ARE DERIVED FROM THE OMEGA-3 FATTY ACIDS,
EICOSAPENTANOIC ACID (EPA) AND DOCOSAHEXANOIC ACID (DHA) RATHER THAN
AA.

• RESOLVINS AND PROTECTINS STIMULATE ANTI-INFLAMMATORY AND PRORESOLVING

PATHWAYS SIMILAR TO THE LIPOXINS BUT THEIR BINDING OCCURS TO DISTINCT
SITES ON INFLAMMATORY CELLS.

• IN A P. GINGIVALIS-INDUCED EXPERIMENTAL PERIODONTITIS, TOPICAL APPLICATION

OF RESOLVINS DEMONSTRATED REMARKABLE EFFICACY IN THE REDUCING
ALVEOLAR BONE LOSS WITH COMPLETE RESOLUTION OF INFLAMMATION AND
RESTORATION OF SOFT AND HARD TISSUES OF PERIODONTIUM
ANTI-RESORPTIVE AGENTS:

• BISPHOSPHONATES (BPS) ARE PYROPHOSPHATE ANALOGS THAT

SUPPRESS OSTEOCLASTIC ACTIVITY, PREVENT DISSOLUTION OF
HYDROXYAPATITE CRYSTALS AND PROMOTE OSTEOBLAST
DIFFERENTIATION.
• FEW HUMAN TRIALS HAVE REPORTED SIGNIFICANT REDUCTION IN
ALVEOLAR BONE LOSS, REDUCTION IN PPD, CLINICAL ATTACHMENT
GAIN, REDUCTION IN BLEEDING ON PROBING, AND GAIN IN ALVEOLAR
BONE HEIGHT WHEN BPS ARE USED AS AN ADJUNCTIVE AGENT TO SRP.
 SYSTEMATIC REVIEWS ON HOST MODULATION THERAPY
Systemati No of Treatment Tested clinical Conclusion
c review studies modalities parameters

Reddy et al 7 (SDD), 10 Adjuntive efficacy Bone changes, CAL, Use of SDD+ SRP is statistically
(NSAIDs), 3 of anti- PPD, plaque index, more effective than SRP alone
(BPs) proteinases, anti- gingivitis in reducing PPD and achieving
inflammatory CAL gain. Insufficient data for
agents, and anti- NSAIDs and BPs may have
resorptive potential adjunctive role in
periodontal therapy

Preshaw et 2 SDD + SRP vs SRP CAL, PPD Adjunctive SDD enhances

al + placebo therapeutic outcomes
compared with SRP alone,
resulting in clinical benefit in
both smokers and non-smokers
with chronic periodontitis
PROBIOTICS:-
• FIRST PROBIOTIC SPECIES TO BE INTRODUCED IN RESEARCH WAS LACTOBACILLUS
ACIDOPHILUS BY HULL ET AL. IN 1984.

• THE ABILITY OF PROBIOTICS TO LOWER THE PH IN THE ORAL CAVITY ALONG WITH ITS
ANTIOXIDANT PROPERTIES OF NEUTRALIZING FREE ELECTRONS REQUIRED FOR
MINERAL FORMATION HAVE BEEN SHOWN TO REDUCE PLAQUE AND CALCULUS
FORMATION.

• CLINICAL STUDIES WITH LACTOBACILLUS REUTERI STRAINS BY ADMINISTERING

CHEWING GUMS AND OTHER FORMS TWICE A DAY FOR 2 WEEKS ALONG WITH SCALING
AND ROOT PLANNING SHOWED IMPROVED CLINICAL PARAMETERS IN THE SUBJECTS.
• PROBIOTICS CAN BE IN POWDER
FORM, LIQUID FORM, GEL, PASTE, OR
GRANULES.
• EXAMPLES OF COMMERCIALLY
AVAILABLE PROBIOTICS FOR
PERIODONTAL CONCERNS INCLUDE
- GUM PERIOBALANCE,
- PERIBIOTIC
- ACILACT
- VITANAR AND
-PRO DENTIST.
HYPERBARIC OXYGEN THERAPY:
• HBOT IS A METHOD OF ADMINISTERING PURE OXYGEN AT GREATER
THAN ATMOSPHERIC PRESSURE TO A PATIENT TO IMPROVE OR CORRECT
CONDITIONS. HBOT SHOULD BE USED TO COMPLEMENT CONVENTIONAL
THERAPIES AND TREATMENTS.

• GUO AND ZHU SHOWED THAT HBOT COMBINED WITH SUPRAGINGIVAL

AND SUBGINGIVAL SCALING THERAPY HAD SYNERGISTIC ACTION ON
Chen et al. showed that HBO had
PERIODONTITIS.
good therapeutic effects on human
severe periodontitis, the effects can
keep more than 1 year.
OZONE THERAPY
• OZONE AS A DISINFECTANT IN MEDICINE WAS FIRST USED AND INTRODUCED BY
LANDLER IN 1870 AND IN THE YEAR 1932, DR. E.A.FISCH- A SWISS DENTIST HAD THE
FIRST IDEA TO USE OZONATED WATER OR GAS IN HIS PRACTICE.

• ALONG WITH THE ANTIHYPOXIC EFFECT OF REDUCING INFLAMMATORY PROCESSES,

OZONE CAUSES THE SYNTHESIS OF BIOLOGICALLY ACTIVE SUBSTANCES SUCH AS
INTERLEUKINS, LEUKOTRIENES, AND PROSTAGLANDINS WHICH ARE BENEFICIAL IN
REDUCING INFLAMMATION AND PROMOTING WOUND HEALING.

• OZONE CAN BE USED IN THE FORM OF OZONATED WATER,

GASEOUS OZONE, OR OZONIZED OILS.
• OZONATED WATER IN VARIOUS EXPERIMENTAL
STUDIES HAS BEEN FOUND EFFECTIVE FOR
KILLING GRAM-POSITIVE AND GRAM-
NEGATIVE ORAL MICROORGANISMS AND ORAL
CANDIDA ALBICANS IN PURE CULTURE AS
WELL AS BACTERIA IN PLAQUE BIOFILM AND
THEREFORE MIGHT BE USEFUL AS A MOUTH
RINSE TO CONTROL INFECTIOUS
MICROORGANISMS IN DENTAL PLAQUE

• HEALOZONE®, OZONYTRON®, PROZONE® ARE

SOME COMMERCIALLY AVAILABLE
APPLIANCES USED FOR OZONE PRODUCTION IN
DENTAL TREATMENT.
GENE THERAPY
• APPLICATION OF GROWTH FACTORS OR SOLUBLE
FORMS OF CYTOKINE RECEPTORS BY GENE
TRANSFER PROVIDES GREATER SUSTAINABILITY
THAN THAT OF SINGLE PROTEIN APPLICATION.
• GENE THERAPY MAY ACHIEVE GREATER
BIOAVAILABILITY OF GROWTH FACTORS WITHIN
PERIODONTAL WOUNDS, WHICH MAY PROVIDE
GREATER REGENERATIVE POTENTIAL.
• IT INCLUDES IN-VIVO GENE TRANSFER AND EX-
VIVO GENE DELIVERY. GENE THERAPY STUDIES
UTILIZING BONE MORPHOGENETIC PROTEINS
(BMPS) HAVE BEEN PERFORMED AND BONE
FIBROBLASTS WERE USED TO STIMULATE THE
REPAIR OF ALVEOLAR BONE WOUNDS
• IN THE EARLY 20TH CENTURY, PERIODONTAL
PERIODONTAL
VACCINES WERE VACCINE
EMPLOYED WHICH
INCLUDED PURE CULTURES OF
STREPTOCOCCUS AND OTHER ORGANISMS,
AUTOGENOUS VACCINES, AND STOCK
VACCINES.

• VANCOTT’S VACCINE AND INAVA ENDOCARP

VACCINE ARE EXAMPLES OF PERIO VACCINES
THAT WERE DEVELOPED.

• NASAL SPRAYS, GENE GUNS,

TRANSCUTANEOUS PATCH DELIVERY
SYSTEMS ARE VARIOUS MODES OF
IMMUNIZATION THAT CAN BE USED FOR
PERIODONTAL VACCINATION.
• NANO-MEDICINE WAS FIRST PUT FORWARD BY ROBERT A. FREITAS JR. IN
NANOTECHNOLOGY
1993.
• IT IS THE SCIENCE AND TECHNOLOGY OF DIAGNOSING TREATING AND
PREVENTING DISEASE AND TRAUMATIC INJURY OF RELIEVING PAIN AND
PRESERVING AND IMPROVING HUMAN HEALTH, THROUGH THE USE OF
NANOSCALE STRUCTURED MATERIALS, BIOTECHNOLOGY AND GENETIC
ENGINEERING, AND EVENTUALLY COMPLEX MOLECULAR MACHINE
SYSTEMS AND NANOROBOTS.
• TRICLOSAN NANOPARTICLES HAVE BEEN USED EXPERIMENTALLY AND
SHOWN TO REDUCE INFLAMMATION OF EXPERIMENTAL SITES. THE
TIMED RELEASE OF DRUGS MAY OCCUR FROM BIODEGRADABLE
NANOSPHERES. A GOOD EXAMPLE IS ARESTIN IN WHICH TETRACYCLINE
IS INCORPORATED INTO MICROSPHERES FOR DRUG DELIVERY BY LOCAL
MEANS TO A PERIODONTAL POCKET.
RNA INTERFACE (RNAI)

• RNAI WORKS THROUGH SMALL RNAS OF APPROXIMATELY 20 TO 30

NUCLEOTIDES THAT GUIDE THE DEGRADATION OF COMPLEMENTARY OR
SEMI-COMPLEMENTARY MOLECULES OF MESSENGER RNAS
(POSTTRANSCRIPTIONAL GENE SILENCING) OR INTERFERE WITH THE
EXPRESSION OF CERTAIN GENES AT THE PROMOTER LEVEL
(TRANSCRIPTIONAL GENE SILENCING).
.

• RNAI IN PERIODONTAL REGENERATION THROUGH THE SILENCING OF

GENES THAT NEGATIVELY CONTROL CELL PROLIFERATION AND CELL
DIFFERENTIATION OR GENES THAT INDUCE INFLAMMATION OR
APOPTOSIS, RNAI MAY FAVOR TISSUE REGENERATION.

• TUMOR NECROSIS FACTOR-A-TARGETED SIRNA CAN SUPPRESS

OSTEOLYSIS INDUCED BY METAL PARTICLES IN A MURINE CALVARIA
MODEL, OPENING THE WAY TO THE APPLICATION OF RNAI IN
ORTHOPEDIC AND DENTAL IMPLANT THERAPY.
STUDIES SHOWING THE EFFECT OF NONSURGICAL PERIODONTAL
THERAPY ON PERIODONTITIS

• FROM 1980 TO 1986 A GROUP OF SEVEN STUDIES WAS DONE TO SHOW

THE EFFECT OF SRP ON MODERATELY ADVANCED AND ADVANCED
PERIODONTITIS:

i. A STUDY DONE BY ANITA BADERSTEN ET AL., IN 1981 EVALUATED THE

EFFECT OF NSPT ON MODERATELY ADVANCED PERIODONTITIS WITH
HAND INSTRUMENT AND ULTRASONIC INSTRUMENTATION AND
SHOWED NO DIFFERENCE AT THE TIME OF TREATMENT BUT MORE
REDUCTION IN POCKET DEPTH AND MORE ATTACHMENT GAIN FOR
SURFACES WITH 6–7.5 MM INITIAL DEPTH THAN FOR SURFACES WITH
4–5.5 MM INITIAL DEPTH WAS SEEN.
I. In 1984, they reported marked improvement of gingival conditions not only in
periodontal pockets of moderate depth but also in pockets up to 12 mm deep by non-
surgical therapy

II. In another study in 1984, they compared the effects of single versus repeated
instrumentation and demonstrated no difference in results could and suggest that
recurrence of disease due to subgingival recolonization by microorganisms during
the healing phase may not be a major problem.

III. In 1985 they demonstrated that deep periodontal pockets may be successfully treated
by plaque control with one episode of instrumentation and operator variability may
be limited
V. CONTINUING THE STUDY IN 1985 SHOWED THAT PROBING AND
ATTACHMENT LOSS IN SITES WITH NON-RESPONSIVE TO INITIAL
PERIODONTAL THERAPY FOLLOWS A GRADUAL, LINEAR COURSE, OR
APPROXIMATELY A LINEAR PATTERN FOR THE VAST MAJORITY OF
TREATED SITES
VI. IN 1985, THEY SUGGESTED THAT THE MAJORITY OF SITES WITH
ATTACHMENT LOSS WERE FOUND AMONGST INITIALLY SHALLOW OR
MODERATELY DEEP A LESION WHICH INDICATES THAT THE ATTACHMENT
LOSS IS DUE TO TRAUMA ASSOCIATED WITH THERAPY RATHER THAN
LOSS AS A RESULT OF A CONTINUING INFLAMMATORY DISEASE PROCESS
VII. IN 1986 SHOWED THAT SITES WITH PROBING ATTACHMENT LOSS WERE
MORE FREQUENT FOR SITES WITH HIGH SCORES FOR PLAQUE, BLEEDING,
RESIDUAL PD, AND SUPPURATION THAN IN SITES WITH LOW SCORES.
VARIOUS STUDIES COMPARING SURGICAL AND NONSURGICAL
PERIODONTAL THERAPY

• THESE INCLUDES:-
1. MICHIGAN STUDY
2. SWEDISH STUDIES.
3. MINNESOTA STUDY.
4. DENMARK STUDY.
5. LOMA LINDA STUDY.
6. NEBRASKA STUDY.
7. ARIZONA STUDY.
• MICHIGAN STUDY I WAS DONE BY RAMFJORD ET AL. IN 1973 FOUND
MICHIGAN STUDY:
GREATER GAIN IN PROBING ATTACHMENT LEVEL BY NSPT WITH NO
DIFFERENCE IN PROBING ATTACHMENT LEVEL IN SURGICAL AND
NONSURGICAL TREATMENT AFTER 5 YEARS.
• MICHIGAN STUDY II WAS DONE IN 1975 BY RAMFJORD ET AL. FOUND NO
DIFFERENCE AFTER 1 YEAR IN SURGICAL AND NONSURGICAL THERAPY.
HOWEVER, AFTER 5 YEARS, POCKET DEPTH ≥7 MM TREATED WITH
MODIFIED WIDMAN FLAP HAD GREATER ATTACHMENT GAIN THAN NSPT.
• MICHIGAN STUDY III WAS DONE BY MORRISON, RAMFJORD, HILL IN 1980
FOUND A GREATER REDUCTION IN PD BY SURGERY WHEN COMPARED
TO NSPT AND WHEN POCKET DEPTH WAS 4–6 MM THERE WAS LESS LOSS
(GREATER GAIN) WITH NSPT AND PD ≥7 MM SHOWED NO DIFFERENCE BY
SURGICAL AND NONSURGICAL THERAPY.
• AFTER 5 YEARS, PD REDUCTION WAS GREATER BY SURGERY WHEN
POCKET DEPTH WAS 4–6 MM BEFORE SURGERY. HOWEVER, WHEN
POCKET DEPTH WAS ≥7 MM THERE WAS NO DIFFERENCE IN PD
REDUCTION BY SURGICAL AND NSPT.
SWEDISH STUDIES:

• SWEDEN STUDY I WAS DONE BY ROSLING ET AL. IN 1976 FOUND NO DIFFERENCE IN PD

REDUCTION BY FLAP SURGERY WITH OSSEOUS AND WITHOUT OSSEOUS RESECTION.

• SWEDEN STUDY II WAS DONE BY LINDHE ET AL. IN 1982 FOUND GREATER PD REDUCTION
AND MORE ATTACHMENT LEVEL GAIN WITH SURGICAL THERAPY THAN NONSURGICAL
THERAPY AND NO DIFFERENCE IN SURGICAL AND NSPT WITH POCKET DEPTH ≥4 MM.

• SWEDEN STUDY III WAS DONE BY LINDHE AND NYMAN IN 1985 FOUND NO DIFFERENCE
IN SURGICAL AND NSPT IN PD REDUCTION AND ATTACHMENT LEVEL GAIN.

• SWEDEN STUDY IV AND V WAS DONE BY WESTFELT ET AL. IN 1985 FOUND MORE
ATTACHMENT GAIN IN POCKET ≥7 MM WITH SURGERY AND AFTER 1 YEAR NO
DIFFERENCE WAS NOTICED WITH SURGICAL AND NSPT IN PD REDUCTION AND
ATTACHMENT LEVEL GAIN.
• THIS STUDY WAS DONE BY PIHLSTROM
MINNESOTA STUDY:
ET AL. FOUND A GREATER REDUCTION IN
PD WITH SURGICAL THERAPY AS
COMPARED TO NONSURGICAL THERAPY.
WHEN INITIAL PD WAS 1–3, NO
DIFFERENCE WAS FOUND IN SURGICAL
AND NSPT. AFTER 5 YEARS, NO
DIFFERENCE IN SURGICAL AND NSPT
WAS FOUND WITH PD 1–6 MM, AND WITH
PD ≥7 MM GREATER REDUCTION IN
PROBING WAS FOUND BY SURGICAL
THERAPY. IN CASE OF ATTACHMENT
LEVEL GAIN AFTER 1 YEAR AND 5 YEARS
DURATION, POCKET WITH 4–6 MM THERE
WAS GREATER GAIN IN ATTACHMENT IN
NSPT AND POCKET WITH >7 MM THERE
WAS NO DIFFERENCE IN SURGICAL AND
NONSURGICAL THERAPY.
DENMARK STUDY:

• THE DENMARK STUDY WAS DONE BY ISIDOR F, KARRING ET AL. FOUND

THAT THERE WAS GREATER PD REDUCTION AFTER 1-YEAR DURATION,
BUT THERE WAS NO DIFFERENCE AFTER 5 YEARS. IN CASE OF
ATTACHMENT LEVEL GAIN, THERE WAS GREATER ATTACHMENT GAIN
BY NSPT BUT AFTER 5 YEARS THERE WAS NO DIFFERENCE.
LOMA LINDA STUDY:

• THIS STUDY WAS DONE BY DURWIN ET AL. FOUND GREATER GAIN IN

ATTACHMENT LEVEL BY SURGICAL THERAPY AFTER 1 YEAR. HOWEVER,
AFTER ≥5 YEARS DURATION THERE WAS NO DIFFERENCE IN SURGICAL
AND NSPT.
NEBRASKA STUDY:-

• THE NEBRASKA STUDY WAS DONE BY KALKWARF ET AL. IN 1988 FOUND

GREATER PD REDUCTION BY SURGICAL PROCEDURES AFTER 1 YEAR.
HOWEVER, IN THE CASE OF ATTACHMENT LEVEL GAIN, THERE WAS
MORE GAIN WITH NSPT WHEN PD WAS 5–6 MM AFTER 1 YEAR AND WITH
PD ≥ 7 MM THERE WAS NO DIFFERENCE IN SURGICAL AND NSPT.
ARIZONA STUDY:-

• THIS STUDY WAS DONE BY BECKER ET AL. IN 1988 FOUND GREATER PD

REDUCTION WITH SURGICAL THERAPY AFTER 1 YEAR AND NO
DIFFERENCE IN ATTACHMENT LEVEL GAIN.
CONCEPT OF CRITICAL PROBING DEPTH:
• CRITICAL PROBING DEPTH INDICATES THE PROBING POCKET DEPTH
BELOW WHICH CLINICAL ATTACHMENT WOULD BE LOST AS A RESULT OF
THE RESPECTIVE TREATMENT PROCEDURE AND ABOVE IT WOULD
RESULT IN A CLINICAL GAIN OF ATTACHMENT.
• A CRITICAL PROBING DEPTH OF 2.9 MM. FOR NONSURGICAL THERAPY
AND 4.2 MM FOR THE SURGICAL APPROACH WAS GIVEN BY LINDHE ET
AL.
• HEITZ-MAYIELD AND LANG PUT FORWARD THE CONCEPT OF CRITICAL
PROBING DEPTH OF 5.4 MM. IT MEANS THAT A PROBING DEPTH OF ABOUT
5.5 MM WOULD BENEFIT FROM ADDITIONAL SURGICAL THERAPY.
CONCLUSION
• PLAQUE IS THE PRIMARY ETIOLOGICAL FACTOR FOR GINGIVITIS AND PERIODONTITIS. SO FAR
NO HOME CARE PRODUCTS OR DEVICES CURRENTLY AVAILABLE CAN COMPLETELY CONTROL
OR ELIMINATE THE PATHOGENIC PLAQUES ASSOCIATED WITH PERIODONTAL DISEASES FOR
EXTENDED PERIODS OF TIME. DAILY HOME CARE AND FREQUENT RECALL ARE STILL
PARAMOUNT FOR LONG-TERM SUCCESS.

• NONSURGICAL THERAPY REMAINS THE CORNERSTONE OF PERIODONTAL TREATMENT. AND IT

STILL CONSTITUTES THE FIRST STEP IN CONTROLLING PERIODONTAL INFECTIONS. CHANGING
CONCEPTS IN PERIODONTAL MICROBIOLOGY MIGHT MODIFY THE APPROACH TO MECHANICAL
THERAPY, AND TECHNOLOGICAL ADVANCES MIGHT HELP US TO UNDERSTAND THE EXACT
NATURE OF PERIODONTAL INFECTIONS AND TO PERFORM THE TREATMENT MORE
EFFECTIVELY AND EASILY.
• CURRENT BEST EVIDENCE SUGGEST THAT:
(1) NSPT RESULTS IN SUPERIOR CLINICAL OUTCOMES AS COMPARED TO
SURGICAL THERAPY IN PERIODONTITIS PATIENTS WITH MODERATE
POCKET DEPTH (≤ 5 MM).
(2) THOROUGH MECHANICAL PERIODONTAL THERAPY REMAINS A GOLD
STANDARD RESULTING IN SIGNIFICANT RESOLUTION OF PERIODONTAL
INFLAMMATION LEADING TO IMPROVEMENT IN THE CLINICAL SIGNS
AND SYMPTOMS OF ACTIVE DISEASE.
(3) ADJUNCTIVE USE OF LASERS OR PHOTODYNAMIC THERAPY IN THE
TREATMENT OF PERIODONTITIS DOES NOT RESULT IN SUPERIOR
CLINICAL EFFECTS COMPARED TO THAT ACHIEVED BY CONVENTIONAL
MECHANICAL THERAPY ALONE.
(4) SYSTEMIC AND LOCAL ANTIMICROBIALS USED IN CONJUNCTION WITH
SRP OFFER ADDITIONAL BENEFITS IN TERMS OF CAL AND PPD CHANGE,
ESPECIALLY IN PATIENTS WITH DEEP PERIODONTAL POCKETS, AND
AGGRESSIVE OR REFRACTORY PERIODONTITIS. THE CLINICAL EFFECTS
ARE MODEST WITH LAD.
(5) FULL MOUTH DISINFECTION RESULT IN CLINICAL BENEFITS
COMPARABLE TO THAT ACHIEVED BY FULL MOUTH SCALING WITHOUT
ANTISEPTICS AND CONVENTIONAL STAGED DEBRIDEMENT.
(6) HOST MODULATION THERAPY SPECIFICALLY WITH SDD RESULTS IN
BETTER CLINICAL EFFECTS WHEN USED AS AN ADJUNCT TO MECHANICAL
THERAPY. AND
(7) DAILY ORAL HYGIENE MAINTENANCE COUPLED WITH FREQUENT
RECALL VISITS BY PATIENTS IS VITAL FOR THE LONG-TERM SUCCESS OF
NSPT.
REFERENCES
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• BHANSALI RS. NON-SURGICAL PERIODONTAL THERAPY: AN UPDATE ON
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