Original Article
Nonsurgical Treatment of Periodontitis

https://doi.org/10.1016/S1532-3382(12)70019-2Get rights and content

Abstract

Context. Scaling and root planing (SRP) is the gold standard treatment for most patients with chronic periodontitis. Nevertheless, in the last years, different therapeutic strategies have been proposed to improve the results of SRP and hence to avoid the need of periodontal surgical interventions in some patients with advanced periodontitis. They are based on modifications of standard therapies (such as enhancement of instrument tip designs), on development of new technologies (such as lasers), or development of alternative treatment protocols (eg, full-mouth disinfection). The purpose of this review is, therefore, to update the scientific evidence based on randomized clinical trials (RCT) evaluating these advanced nonsurgical therapies that have been published between January 2010 and March 2012.

Evidence Acquisition. RCTs published between January 2010 and March 2012 have been selected. Previous systematic reviews were used as a start point. Three distinct aspects were evaluated independently: the modification of conventional instruments, the advent of new technologies, and the development of new treatment protocols.

Evidence Synthesis. Twenty-two publications were selected: 4 were related to modifications of standard therapies (new tip designs and local anesthetics), 14 to new technologies (new ultrasonic devices, air abrasive systems, endoscope and lasers), and 4 to new treatment protocols.

Conclusions. These technological advances and the development of new protocols may improve patient-related outcomes and cost-effectiveness, although they have not shown significant differences in efficacy when compared with conventional SRP.

Introduction

The primary goal of periodontal therapy is to preserve the natural dentition, by arresting the chronic inflammatory process, that results in loss of periodontal attachment and alveolar bone and formation of periodontal pockets. The current understanding on the etiology and pathogenesis of periodontitis acknowledges that this disease is the result of a complex interplay of bacterial aggression and host response, modified by behavioral and systemic risk factors. The pathogens are organized in communities (biofilms) adhered to the root surface in the subgingival environment, which are usually resistant to both the natural antibacterial defense mechanisms present in the oral cavity and to any chemical antibacterial medication.1 Only therapies achieving the mechanical disruption of subgingival biofilms have proven successful and, hence, periodontal health can be maintained only provided there is adequate plaque control by the patient and frequent professional prophylaxis.2

Mechanical root debridement is the cornerstone of cause-related periodontal therapy and it is aimed at removal of subgingival biofilm and calculus, which together with the patient's oral hygiene practices will prevent bacterial recolonization and formation of supragingival biofilms. This debridement is usually carried out with hand instruments (curettes and scalers) and staged in different sessions (by quadrants or sextants). This conventional protocol is termed scaling and root planning (SRP) and it has proven to be the gold standard of periodontal therapy for most patients with chronic periodontitis. Its efficacy is well documented in systematic3, 4, 5 and narrative reviews6, 7, 8 by the demonstration of gains in clinical attachment levels (CAL), reductions in probing pocket depths (PPD), and in the frequency of bleeding on probing (BOP). SRP is able to significantly improve CAL levels between 0.55 and 1.29 mm and to reduce PPD between 1.29 and 2.16 mm, these results being mostly dependent on the extent and severity of disease.2 These results are, however, not dependent on the mode of debridement, as power-driven instrumentation has demonstrated similar outcomes when compared with hand instrumentation.9, 10 The results are dependent rather on the presence of local factors, such as deep and tortuous pockets, furcations, and angular bony lesions, which may limit the reach of nonsurgical debridement,11 as well as on patient's related factors, such as tobacco smoking and the compliance with plaque control.12

In the past years different therapeutic strategies have been proposed to improve the results of SRP and hence to avoid the need of periodontal surgical interventions. These additional therapies are based on modifications of standard therapies (such as enhancement of instrument tip designs), on development of new technologies (such as lasers), or development of alternative treatment protocols (eg, full-mouth disinfection). The purpose of this review is, therefore, to update the scientific evidence based on randomized clinical trials (RCTs) evaluating these advanced nonsurgical therapies that have been published between January 2010 and March 2012.

Section snippets

Modification of Standard Therapies

Traditionally, SRP has been performed with curettes, which have been modified by changing the shape of the instrument or the active tip (eg, After Five and Mini-Five curettes) to optimize their instrumentation efficacy in areas of difficult access.13 Similarly, power-driven instrument devices using sonic or ultrasonic technologies have improved their outcome performance and modified their application tips so as to improve their capacity of subgingival plaque and calculus removal. Moreover,

New Technologies

New technologies are being developed with the aim of outperforming the classical hand- and power-driven root instrumentation systems in the nonsurgical treatment of chronic periodontitis.

New Treatment Protocols in the Nonsurgical Therapy of Periodontitis

Traditionally, initial periodontal treatment was rendered in scheduled sessions (usually at weekly intervals) of SRP with either hand or ultrasonic instruments.3 In 1995, researchers from the University of Leuven proposed the therapeutic concept of full-mouth disinfection (FMD).59 This mode of periodontal therapy consisted of SRP of all pockets combined with the topical application of chlorhexidine, within 24 hours (usually in 2 sessions on 2 consecutive days). This therapy aimed to avoid

Discussion

Despite significant advancements in our knowledge of periodontal disease pathogenesis and the factors affecting the outcome of periodontal therapy, the traditional approach of biofilm and calculus removal by root surface instrumentation continues to be the standard mode of periodontal therapy. In fact, our improved knowledge, mainly derived from biofilm research, has emphasized the importance of mechanical debridement of biofilm and calculus in the attainment of significant clinical and

Conclusions

Nonsurgical periodontal therapy is an efficacious mode of therapy for patients with periodontitis, irrespective of the instrument used or the treatment protocol performed. Many new technologies are available in the market and most have not been properly tested in clinical research, but all in general have demonstrated similar clinical outcomes to conventional SRP, with either curettes or power-driven instruments. All these new protocols and technologies, however, have shown improved

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