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Perio Reports Trisha E. O'Hehir, RDH, BS Editorial Director, Hygienetown Magazine

More by this author (282)
Perio Reports  Vol. 21 No. 1
Perio Reports provides easy-to-read research summaries on topics of specific interest to clinicians.
Perio Reports research summaries will be included in each issue to keep you on the cutting edge
of dental hygiene science.
Effects of full-mouth debridement

Since periodontal pockets are reservoirs for pathogens and untreated sites can potentially transmit pathogens that re-infect treated sites, full-mouth debridement within 24 hours was introduced in 1995 by researchers in Belgium. Their concept of full mouth debridement also included full-mouth disinfection with an antiseptic, chlorhexidine.

Conventional quadrant scheduling of mechanical debridement of periodontal pockets has shown probing depth reductions of 1mm for pockets initially 5-6mm and 2.2mm reductions in pockets 7mm or deeper. Full-mouth debridement needs to show significantly better probing depth reductions before it can replace conventional quadrant treatment.

Since 1995, researchers have compared three approaches to non-surgical therapy: full-mouth debridement within one day, full-mouth debridement within one day with antiseptics and conventional quadrant visits over several weeks. Although some differences were noted between treatment approaches, the changes were not clinically significant in the long term. Some studies reported microbial changes in the pockets, but the methods for measuring these differences varied between studies and cannot be compared.

Based on research to date, all three approaches can be recommended for non-surgical therapy. Deciding which treatment approach is best for a patient must consider needs and preferences of the patient, skills and experience of the clinician, travel time to the dental practice and the cost effectiveness of the treatment.

Editor's Note: This is one of 24 reviews taken from the Sixth European World Workshop on Periodontics.

Clinical Implications: Three comparable options are available to patients: full-mouth debridement, full-mouth debridement with antiseptics, and conventional quadrant visits. The long-term clinical outcomes from these three treatment approaches are similar.

Lang, N., Tan, W., Krähenmann, M., Zwahlen, M.: A Systemic Review of the Effects of Full-Mouth Debridement with and without Antiseptics in Patients with Chronic Periodontitis. J of Clin Perio 35:(Supplement 8) 8-21, 2008.
Advances in power scalers

Hand instruments used to remove subgingival deposits have sharp blades to break the bond between calculus and the tooth surface. Hand instrumentation requires specific skills, is time consuming, physically demanding and depends on the clinician's direct tactile sense to achieve a deposit-free surface. Power scalers have relatively blunt tips and rely on tip vibration to break the bond of deposits to the tooth surface and fluid lavage to flush out the deposits.

Comparing research studies continues to be difficult since study design varies so much and power scalers include a wide variety of technologies: sonic, ultrasonic and piezoelectric. In reviewing the research, power scalers demonstrate similar clinical outcomes when compared to hand instruments. Adding antiseptics to the fluid lavage provides no added benefit for healing when compared to water.

Thinner tip and insert designs have been introduced to provide easier access to deep pockets and less potential tissue trauma. However, the smaller tip size reduces the effectiveness of the tip for calculus removal. Studies report no added clinical benefit of newer tip designs over traditional tips and inserts for non-surgical therapy.

Cavitation and microstreaming caused by an ultrasonic scaler show potential benefits in laboratory studies, but no clinical benefits have been demonstrated. Laboratory studies also show variations in performance between power scalers, however, these findings have not yet been shown to impact clinical outcomes.

Editor's Note: This is one of 24 reviews taken from the Sixth European World Workshop on Periodontics.

Clinical Implications: According to the research, power scalers are as effective as hand instruments, and slimmer power scaler tip designs provide no added benefit over standard power scaler tips used for non-surgical periodontal therapy.

Walmsley, A., Lea, S., Landini, G., Moses, A.: Advances in Power Driven Pocket/Root Instrumentation. J of Clin Perio 35:(Supplement 8) 22-28, 2008.
Lasers for non-surgical periodontal therapy

Several lasers have been introduced for application in periodontics, Er:YAG, Nd:YAG, CO2, and Nd:YAP. The team assigned the topic of lasers screened more than 1,000 titles and found only 11 studies that met the inclusion criteria for evaluation: randomized, controlled or comparative study of chronic periodontitis treatment, with at least 10 patients, including clinical and or microbiological data.
The studies needed to compare mechanical instrumentation to the use of the laser. Many published studies didn't meet these criteria or other factors disqualified them from consideration: patients had periodontal treatment or systemic antibiotics within the previous six months, or insufficient information was included about the laser device and energy settings.

The Er:YAG was used as a mono therapy and compared to traditional instrumentation with a two-year follow up that demonstrated significant differences in bleeding and attachment levels in favor of the laser.

Only one study compared the effects of two different lasers, the CO2 and the Nd:YAG. Most studies used different energy settings, periods of observation, and modes of application, making comparisons difficult. Only the Er:YAG was found to provide added benefit over traditional root surface instrumentation. No added benefit was measured for the other lasers when combined with traditional subgingival instrumentation. Editor's Note: This is one of 24 reviews taken from the Sixth European World Workshop on Periodontics.

Clinical Implications: Many clinicians are currently using lasers for non-surgical periodontal therapy based on published case studies, anecdotal evidence and personal experience. It will be a while yet before enough randomized, controlled clinical trials are published to add significantly to a systematic review on the topic.

Schwarz, F., Aoki, A., Becker, J., Sculean, A.: Laser Application in Non-surgical Periodontal Therapy: A Systematic Review. J of Clin Perio 35:(Supplement 8) 29-44, 2008
Systemic antibiotics to control subgingival biofilm

If the decision is made to use systemic antibiotics for treatment of periodontitis, they should only be given in conjunction with mechanical therapy, as biofilm penetration of the antibiotic is unlikely. Mechanical removal of the biofilm is essential. There isn't enough evidence to suggest that routine use of systemic antibiotics provides benefits when combined with periodontal surgery.

Evidence doesn't support one particular protocol for combining antibiotics with non-surgical therapy, but findings suggest the systemic antibiotic should be given to the patient on the last day of debridement therapy, a therapy that shouldn't be extended past one week. The removal of subgingival bacterial biofilm should be completed prior to antibiotic therapy for the antibiotic to be effective.

Systemic antibiotics should be prescribed on a case-by-case basis for a select and very small group of patients – those whose deep pockets, aggressive periodontitis and progressing disease may benefit from systemic antibiotics. To achieve the best results possible, thorough subgingival debridement must be accomplished and effective daily oral hygiene must be part of the patient's daily routine. Systemic antibiotic dosage and daily oral hygiene can strongly influence the outcome of studies evaluating the effects of systemic antibiotics on clinical indices.

Editor's Note: This is one of 24 reviews taken from the Sixth European World Workshop on Periodontics.

Clinical Implications: When used, systemic antibiotics should be given in conjunction with subgingival debridement and begin on the last day of instrumentation. Debridement should be completed within one week.

Herrera, D., Alonso, B., Leon, R., Roldan, S., Sanz, M.: Antimicrobial Therapy in Periodontitis: The Use of Systemic Antimicrobials Against the Subgingival Biofilm. J of Clin Perio 35:(Supplement 8) 45-66, 2008
Fluoridated salt reduces caries prevalence

Fluoridated salt has been tested in both Switzerland and Hungary as an alternative to water fluoridation. In Hungary, villages were compared for caries incidence while receiving either fluoridated salt or fluoridated water. Fluoridated salt was used from 1966 to 1985 with cariostatic effects similar to fluoridated water, 50-60 percent reduction in DMFT rates for children five-to-14 years of age.

Researchers returned to the villages in 1991 to reevaluate caries prevalence. Residents currently between the ages of 18 and 47 were evaluated. A control group was also included that had no access to fluoride.

Those in the water-fluoridated areas demonstrated less caries than the fluoridated salt subjects. Those 18-27 years old, receiving fluoridated water had DMFT scores of 6 compared to 8 for those receiving fluoridated salt.
Scores for those of the same age not receiving any fluoride were 14. Scores for 28-37-year-olds were 10, 13 and 17 respectively. For those 38-47 years old, scores were 13, 15, and 19. Those who began using fluoridated salt at an early age, benefited most. Those who were adults when the study began received some benefit, but not as great as the younger residents. No fluorosis was reported for those receiving fluoridated salt.

At the time of the fluoridated salt study, prepackaged foods were not used by families in the village. Families used salt for curing meats, making preserves and pickles, etc. Each person consumed approximately 3.3 grams of salt per day compared to others in Western Europe who reportedly consumed 1.5 to 2 grams of salt/day.

Clinical Implications: Fluoridated salt is not currently available, but the study results are interesting.

Radnai, M., Fazekas, A.: Caries Prevalence in Adults Seven Years After Previous Exposure to Fluoride in Domestic Salt. Acta Med Dent
Helv 4: 163-166, 1999.
Potential harm from oral hygiene products

Oral hygiene products, when properly used, provide much more benefit than harm. However, some harmful effects have been reported for toothbrushes, toothpastes, mouthrinses and interdental aids.

Toothbrushes used without toothpaste cause little or no damage to either enamel or dentin. Toothbrush bristle filament hardness appears to be softer than enamel or dentin, explaining the lack of damage. If the enamel or dentin are softened by acid erosion, the toothbrush alone can cause damage. Depending on bristle stiffness, tissue trauma can occur. Toothbrushing, as well as eating, can cause bacteremia. However, toothbrushing contributes to improved oral health, which might reduce the frequency and magnitude of the bacteremia.

Toothpastes contain abrasives that can cause damage to both enamel and dentin. Soft, multitufted toothbrushes hold the abrasive toothpaste on the tooth surface longer, thus causing more damage than hard bristle brushes that allow the toothpaste to pass through the tufts and not be held against the tooth surfaces.

The evidence of harm due to interdental cleaning aids is extremely limited and is most often a rare, anecdotal report. With normal, correct use of interdental brushes, floss, wooden/ plastic sticks, damage is unlikely as these products are all softer than dentin. Damage to the gingiva from improper flossing creating “flossing clefts” in the tissue has been reported, but is rare and can be corrected with proper flossing technique.

Mouthrinses have the potential for harm due to a variety of ingredients. Rinses that are highly acidic can soften the dentin, but compared to soft drink controls, they are less damaging. Some ingredients cause staining, calculus formation and tissue irritation.

Clinical Implications: The benefits of oral hygiene products far outweigh the potential for harm.

Addy, M.: Oral Hygiene Products: Potential for Harm to Oral and Systemic Health. Perio 2000 48: 54-65, 2008.
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