9. General principles of generalized periodontitis treatment. The local therapeutic intervention on patients with generalized periodontitis. The methods and tools of dental plaque removing: manual (mechanical), chemical and combined methods.
Periodontitis is a set of inflammatory diseases affecting the periodontium — that is, the tissues that surround and support the teeth. Periodontitis involves progressive loss of the alveolar bone around the teeth, and if left untreated, can lead to the loosening and subsequent loss of teeth. Periodontitis is caused by microorganisms that adhere to and grow on the tooth’s surfaces, along with an overly aggressive immune response against these microorganisms. A diagnosis of periodontitis is established by inspecting the soft gum tissues around the teeth with a probe (i.e. a clinical exam) and by evaluating the patient’s x-ray films (i.e. a radiographic exam), to determine the amount of bone loss around the teeth. Specialists in the treatment of periodontitis are periodontists; their field is known as “periodontology” or “periodontics”.
The word “periodontitis” comes from peri (“around”), odont (“tooth”) and –itis (“inflammation”).
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Signs and symptoms
Visualizing the mineralized accumulation originating at the gingival margin readily identifies calculus deposition. Calculus is most commonly found on the canines, incisors, and buccal aspect of the cheek teeth. The removal of calculus is easily facilitated by the use of a sickle scaler, ultrasonic scaler, or air abrasion. The most common sequela to calculus accumulation on the incisors is the recession of the attached gingiva. Although clinically significant, this condition rarely results in severe periodontitis or tooth loss. Despite the large amounts of calculus that can accumulate on the canines, mild gingivitis is the most common finding postscaling. The authors believe that the potential for tooth loss, as a result of calculus accumulation, is highest when the premolars and molars are involved. The removal of calculus from the cheek teeth requires the use of extended length instruments and care should be given to prevent excessive soft-tissue trauma.
The presence of a diastema, enabling feed to be- come impacted between the teeth, identifies horses at risk of tooth loss due to periodontal disease. This condition results in inflammation, gingival regression, and the formation of periodontal pockets. Further tissue erosion enables more feed to pack in the pockets and the cycle perpetuates itself. A periodontal probe should be used to measure the depth of the pocket and enable the practitioner to evaluate the effectiveness of the treatment regimen.
Quality dental care, appropriate crown reductions, and necessary extractions should be the first phase in treating a horse with periodontal disease. The removal of severely diseased teeth eliminates periodontal pockets and potential sources of sepsis. Pulling a tooth out of occlusion will eliminate the abnormal forces acting upon it. Many mild cases of periodontal disease caused by feed impaction will resolve after the diastema is cleaned and an appropriate crown reduction is performed. In these cases, the tooth will move back into its normal position and the interproximal space will resolve.
The removal of the impacted feed is necessary to arrest the destructive cycle. The use of: a hand scaler or dental probe, flushing with 60-ml syringe using 0.1% chlorhexidine solution, and an elongated water pick has been described.
The authors have modified a portable dental system that incorporates an extended length “prophy handpiece.” This handpiece uses water and med- ical grade baking soda, under pressure, to produce powerful slurry that removes the feed material and debris from the interproximal spaces and periodontal pockets. In cases without significant periodontal pockets, this may be all the treatment necessary. Severe cases appear to benefit from the placement of a barrier to prevent immediate reimpaction of feed. In these cases, dental impression material has been used to create a mechanical barrier to prevent feed impactions and protect the subgingival periodontium. The placement of a perioceutic within a deep socket is an appropriate way to manage area specific infection and potentiate the reparative process. Surgical resection has also been described. As the periodontal ligament is capable of regenerating, the authors believe that the disease may be reversible if diagnosed early and treated appropriately. Extraction may be the only option in cases where long-standing periodontitis has resulted in severe periodontal destruction. Questions remain as to the hypsodont’s ability to repair its periodontal tissues, to reestablish intraalveolar attachment, and to repair vs. rejuvenate tissue.
The inflammatory periodontal diseases are widely accepted as being caused by bacteria associated with dental plaque. However, the nature of the periodontal disease resulting from dental plaque appears to depend to a large extent on the interaction among the bacterial agent, the environment, and the response of the host’s defense mechanisms to the bacterial assault.
Since the early 1970’s, the quest to identify bacterial specificity in periodontal disease became the prominent area of investigation. It lead Loesche (1976) to promulgate the specific plaque hypothesis, suggesting that specific bacteria caused specific forms of periodontal diseases. Increasing knowledge of anaerobic bacteria as predominant agents in the development of periodontal disease has led to new treatment strategies, aiming primarily at suppression or elimination of specific periodontal diseases. Non-surgical and surgical therapy is both applicable in the treatment of periodontal disease. However, mechanical therapy itself may not always reduce or eliminate the anaerobic infection at the base of pocket, with in the gingival tissues and in both structures inaccessible to periodontal instruments . Moreover, recolonization of disease associated bacteria occurs from the residual bacterial reservoir in dentinal tubules causing renewal of the inflammatory state. To overcome this, addition of antimicrobials both systemic and locally would enhance a treatment protocol and serve as adjuncts to mechanical therapy. Systemic antimicrobial agents may reduce or eliminate bacteria that cannot be removed by scaling and root planning. However, adverse effects such as drug toxicity, acquired bacterial resistance, drug interaction and patient’s compliance limit the use of systemic antimicrobials.
Treatment
The goal of treating periodontal disease is to:
• Reverse or repair the damaging effects of periodontal disease
• Reduce systemic health risks
• Implement an oral health routine to remove the bacteria to prevent recurrence
• Reduce the risk of tooth loss
Treatment plans can vary by person. Only by working closely with their dental team can patients decide what treatment or combination of treatments may best fit their unique situation.
Treatment Strategies
In order to determine the appropriate treatment or combination of treatments that best fit their unique situation, patients must work closely with their dental professionals.
Treatments for periodontal disease may include:
• Professional cleaning to remove tartar and plaque buildup
• Scaling and root planing to the depth of the pockets, sometimes with local anesthesia
• Use of a locally or systemically applied antibiotic drug to reduce the bacterial load in the pockets and help lead to reduction of the inflammation
• A daily oral hygiene treatment plan for between professional visits
• Surgical repair of the diseased tissues
• Removal of the damaged tooth
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• Therefore to override these short comings, local deliveries of antibacterial agents into periodontal pockets have been extensively studied. It was Dr. Max Goodson in 1979 that championed and developed local delivery of therapeutic agents into a viable concept.
• This modem of drug delivery avoids most of the problems associated with systemic therapy, limiting the drug to its target site and hence achieving a much higher concentration. For local delivery in the subgingival areas, various antimicrobials have been tried e.g. tetracycline, chlorhexidine and metronidazole. Similarly, various studies have been conducted on the different modes of local delivery of the antimicrobials subgingivally. Local antimicrobial therapy in periodontitis involves direct placement of an antimicrobial agent(s) into subgingival sites, minimizing the impact of the agent(s) oon oral body sites. Local antimicrobial agents may be personally applied as a part of home oral hygiene regimens, and professionally applied as part of office-based treatment procedures.
Local antimicrobial delivery into periodontal pockets may be further classified as providing either nonsustained or sustained subgingival drug delivery. Nonsustained subgingival drug delivery provides high pocket concentrations of the antimicrobial agent for only short time periods. Subgingival irrigation with antiseptic agents lacking substantivity for oral tissues (povidone-iodine) is examples of nonsustained subgingival drug delivery. Sustained subgingival drug delivery provides retention of the within periodontal pockets. Controlled drug release can be provided with subgingival irrigation of agents intrinsically substantive for tooth root surfaces (aqueous tetracycline) or pocket placement of commercial antimicrobial fibers, gel or films.
Locally applied antimicrobial agents should be safe, stable, substantive, efficaceous, cost effective, patient compliant, achieve effective concentrations. Factors affecting the bio-availability of an antimicrobial agent are solubility, pH and ion-binding capacity, delivery vehicle-drug interaction and metabolism.
SUPRAGINGIVAL IRRIGATION
Home irrigation devices allow the patient to deliver medicaments into the periodontal pocket at home on more frequent basis than is practical with professional gingival irrigation,,the ability of the device to gain a access to the depth of periodontal pocket and the manual dexterity of the patients are the limiting factors . The mechanism of action of irrigation occurs through the direct application of a pulsed or steady stream of water or other solution. Studies by (Bhasker and Selting et al) have found pulsation and pressure to be critical components of an irrigation device. The pulsation creates two zones of hydrokinetic activity. The impact zone is where solution initially contacts the surface and flushing zone is where solution reaches into the subgingival sulcus. The outcome of hydrokinetic activity is subgingival penetration . Home irrigation devicees include supragingival and subgingival devics. Irrigation with a standard jet tip is generally called supragingival irrigation. Tip is placed coronal to gingival margin. Oral irrigation devices with traditional jet tip results in greater access of medicament to periodontal pocket when compared with rinsing alone. A 90 degree angle of application to the tooth surface provides 71% penetration in shallow pockets. These devices may be useful in delivering of medicaments in cases of gingivitis with shallow pocket depths, they are less useful in delivering medicaments in periodontitis patients with deeper pockets. They are mainly used for full mouth irrigation.
SUBGINGIVAL IRRIGATION
Irrigation with the soft, site specific tip is often called subgingival irrigation. This also refers to placement of tip, which is placed slightly below the gingival margin. These devices generally include blunt end metal cannula that the patient inserts into the periodontal pocket, this increases the depth of penetration of fluid but has the potential for injury owing to the metal tip (Greenstein 1992). The subgingival tip is generally used for the localized irrigation of specific site, such as a deep pocket, furcation, implant, or crown and bridge. Studies have shown that it can deliver solution into a pocket of 6mm or less up to 90%of its depth. In pockets greater than 6mm, the depth of penetration has been shown to 64%. Professional subgingival irrigation device include a wide range of powered and manually operated irrigations. Irrigation using a syringe with blunt end cannula attached to an oral irrigator can penetrate to 71.5% of the pocket depth in pocket 3.5to 6 mm deep (Hollander 1989). Vehicles tested for sustained periodontal pocket delivery of antimicrobial agents include solution pastes, hollow fibre, acrylic strips, monolithic fibres, resorbable cellulose, collagen and biodegradable gel
LOCAL ANTIMICROBIAL AGENTS
A local route of drug delivery can attain 100-fold higher concentrations of an antimicrobial agent in subgingival sites compared with a systemic drug regimen. For example, local placement of a tetracycline- releasing ethylene vinyl acetate monolithic fiber can yield tetracycline concentrations in excess of 1300 Fg/ml in gingival crevicular fluid over 10 days. In comparison, repeated systemic doses of tetracycline- HCl can only provide tetracycline levels of 4-8 pg/ml in gingival crevicular fluid. Disadvantages of local antimicrobial treatment of periodontitis include difficulty in placing therapeutic concentrations of the antimicrobial agent into deeper parts of periodontal pockets and furcation lesions. Personal application of antimicrobial agents by patients as a part of their home self-care procedures is frequently compromised by the patient’s lack of adequate manual dexterity, limited understanding of periodontal anatomy, and poor compliance and performance with recommended procedures.
The task of professionally applying local antimicrobial agents in periodontitis patients with numerous advanced lesions distributed throughout their mouth is time-consuming and labor-intensive. Nonsustained subgingival drug delivery is limited by a only brief exposure of the target microorganisms to the applied antimicrobial agent. Antimicrobial agents locally applied into periodontal pockets do not markedly affect periodontal pathogens residing within adjacent gingival connective tissues and on extra-pocket oral surfaces (tongue, tonsils and buccal mucosa), which increases the risk of later reinfection and disease recurrence in treated areas. Local agents used for irrigation includes chlorhexidine, povidine iodine, stannous fluoride ,hydrogen peroxide.
The first locally administered antibiotic for periodontal disease was Actisite®, made up of nonabsorbable fibers filled with tetracycline. Although Actisite was found to be effective in many cases, placement and patient follow-up for fiber removal were challenging issues.1 A bioabsorbable local delivery device called PerioChip® was then deve- loped. It was comprised of 34% chlorhexidine gluconate, about 5mm round and 1mm thick. It is the only LAA that is not an antibiotic.
Antibiotics
The physical removal of biofilm has proven to be the most effective method for treating periodontal disease. The use of adjunctive antibiotic therapy, either systemic or topical, is controversial. Some studies show superior results with antibiotic use while others show no clinical difference. There is a general consensus that antibiotics should not be used as a monotherapy in the treatment of periodontal disease. Antibiotics as a stand-alone treatment are ineffective at diminishing intact subgingival biofilms.
The American Academy of Periodontology has offered guidelines for systemic and topical antibiotic use in treating periodontal disease. These guidelines suggest that aggressive types of periodontitis and acute periodontal infections should be treated with systemic antibiotics while chronic infections should be treated with topical therapy. Antibiotic therapy is generally used as a follow up treatment after conventional mechanical therapy. Aggressive periodontitis may use systemic antibiotics as an adjunctive therapy.
There are many systemic antibiotics on the market. The most commonly used include tetracycline, ciprofloxacin, metronidazole and the penicillins, including amoxicillin and amoxicillin/clavulanate acid (Augmentin®). Tetracycline is bacteriostatic, targets both gram positive and gram negative organisms, and has become bacterial resistant. Ciprofloxacin is bactericidal, targets gramnegative rods, and may cause gastrointestinal discomfort. Amoxicillin and Augmentin are both bactericidal, with Augmentin targeting a more narrow spectrum than amoxicillin. Augmentin was developed due to amoxicillin’s bacterial resistance from penicillinase enzyme sensitivity.
Of the many systemic antibiotics available, there is no consensus as to an ideal dose and duration. The choice of antibiotic should be made on an individual basis. In addition to serious adverse effects, like anaphylactic shock, microbial resistance is a growing concern. Other issues with oral antibiotic administration are patient adherence and adequate absorption from the gastrointestinal tract.
Understanding that the periodontal disease process may be initiated by bacteria but the individual’s host response was critical to the progression of this disease led to the FDA approval of doxycycline at a sub-antimicrobial dose (20mg twice daily). When administered at this low dose, doxycycline does not cause the long term side effects seen with other systemic antibiotics. Randomized double blind placebo controlled trials demonstrated reduction in probing depths, improvement in clinical attachment levels and decreased bleeding on probing when used as an adjunct with scaling and root planing.
A recent review evaluating non-surgical chemotherapeutic strategies for the management of periodontal disease determined that “systemic antibiotics reach the periodontal tissues by transuduction across serum, then cross the crevicular and junctional epithelia to enter the gingival sulcus.” By the time the systemic antibiotic reaches the gingival sulcus it no longer has an adequate concentration to achieve the desired antimicrobial effect. This supports the fact that the mechanical disruption of biofilm must be included in the treatment of periodontal disease.
Atridox® is a 10% doxycyline hyclate gel and is prepared by mixing powder and liquid from two syringes. The antibiotic is administered into the gingival sulcus through a cannula. Absorption lasts up to 21 days, while therapeutic drug levels in the gingival crevicular fluid start to decline at 7 days. The most notable drawback is the high level of clinician skill needed to deliver this therapy as the material tends to come out of the pocket as the syringe is being pulled out of the sulcus. The majority of the time, more than one site can be treated depending on the depth and size of the pockets.
Arestin® is comprised of spheres embedded with 2% minocycline HCl that is slowly released and holds the therapeutic dose in the gingival crivicular fluid for 14-21 days. The most notable drawback for Arestin is the delivery dose. The syringe holds pre-set doses that may not
be sufficient for every site. This results in the need to reapply in the same pocket.
Currently, resorbable antibiotics such as Atridox® and Arestin® are the topical antibiotics of choice.The American Academy of Periodontology (AAP) supports that local adjuncts, when compared with scaling and root planning alone, provide limited improvement. Locally administered antibiotics still require a strict health history review to verify there are no known allergies. Even though these medications are applied topically, as opposed to oral administration, the same precautions apply.
Antiseptics
Unlike topical controlled-released antibiotics, oral rinses do not penetrate deep into the gingival sulcus. Despite this limitation they do show benefit when used adjunctively for gingival inflammation. Oral rinses are also of great value in post surgical healing. Substantivity is a crucial component when considering the effectiveness of a mouthrinse. This term refers to the adherent qualities of a mouthwash and its ability to be retained. Saliva has a natural flushing property making it difficult to maintain an antimicrobial effect. Research shows a significant antibacterial effect up to 7 hours after mouthrinses with high a substantivity property.
First generation antimicrobials include phenolic, sanguinarine, qua- ternary compounds. Listerine® and its generics are phenolics, which possess the only ADA Seal of Acceptance among the first generation antimicrobials. Listerine contains 26.9% alcohol, alters the bacterial cell wall, and has 36% gingivitis reduction. Cepacol® and Scope®, quaternary ammonium compounds, contain 14% and 18.9% alcohol respectively, increase bacterial cell wall permeability causing cell lysis, and reduces gingivitis approximately 15%.1
Second generation antimicrobials include cetylpyridinium chloride (CPC) and chlorhexidine (CHX). A commercial name for CPC is Crest® Pro-Health®, which contains 0.07% CPC. Bacteria cells are killed by cellular pressure, resulting in a similar efficacy as Listerine. Chlorhexi- dine has many commercial products including the availability of a nonalcoholic version by Sunstar Americas, Inc. Peridex® by 3M Espe and Periogard® by Colgate® Professional are two examples of popular chlorhexidine-based products. Their active ingredient is 0.12% chlorhexidine. Cell death results from altered osmotic equilibrium. CHX efficacy in the reduction of certain aerobic and anaerobic bacteria has been shown to be as high as 97% after 6 months of use. CHX has 29% gingivitis reduction. The gingivitis reduction percents listed above for both first and second generation antimicrobials are based on efficacy data published by manufacturers.
Other antimicrobials include oxygenating, chlorine dioxide, and zinc chloride agents. Peroxyl® is an oxygenating agent with the active ingredient of hydrogen peroxide. It has anti-inflammatory properties as well as a bubbling action to clean and alleviate discomfort. Short term studies have produced controversial findings. Oxyfresh®, a 1% chlorine dioxide agent, has minimal plaque reduction. It is a stable, free radical and an oxidant with algicidal, bactericidal, cysticidal, fungicidal, sporicidal, and viricidal properties. Oxyfresh is primarily used for the treatment of halitosis. Breath Rx® is a zinc chloride agent designed to odorize sulfhydryl groups with zinc ions. It claims to be a scientific bad breath treatment specifically designed to help treat the causes of bad breath and the symptoms.
Antimicrobial mouth rinses have been linked to several side effects; some more serious than others. First generation compounds like Listerine can cause a burning sensation and bitter taste. Chlorhexidine can cause supragingival calculus build-up and staining. Research
has demonstrated permanent damage to enamel through erosive pH levels and abrasive antimicrobial toothpastes.1 Carcinogenic changes have been linked to the use of oxygenating agents and mouth rinses containing alcohol.
Nutraceuticals
As antibiotic resistance becomes more of a concern, health care pro- viders looking for alternate adjunctive periodontal therapies for their patients. Some examples of nutraceuticals include herbal and nutri- tional supplements and the future of this type of therapy is promising. There are approximately 500,000 plant species, with only 1% having been photochemically investigated. Herbal plant extracts have been shown to reduce the level of biofilms influencing the level of bacterial adhesion. This has shown results with the reduction of periodontal disease. Some herbs such as Coptidis rhizome extract and Hamamelis virginiana, are used as bactericidal agents against oral bacteria while others such as cranberry, Polygonum cuspidatum and Mikania are used to inhibit adhesion.
The use of probiotics in the control of periodontal pathogens is emerging. Probiotics are “live microorganisms, which when administered in adequate amounts confer a health benefit on the host.” Simply put, they are healthy bacteria that displace unhealthy or pathogenic bacteria. A reduction in gingivitis and dental plaque has been shown with the administration of L. reuteri Prodentis® gum chewed twice daily in patients with moderate to severe gingivitis.14 GUM® Perio Balance®, marketed by Sunstar Americas, is a once daily lozenge with L. reuteri Prodentis® that claims a reduction in moderate to severe plaque and bad breath. EvoraPlusTM from Oragenics, Inc. is another new probiotic for oral health and is used once daily. This supplement contains a combination of three bacterial strains Streptococcus uberis KJ2, S. oralis KJ3, and S. rattus JH145, and claims a reduction in periopathogens within the periodontal pocket.
INHIBITION OF PERIODONTAL DISEASE PROGRESSION
There are conflicting data with respect to the efficacy of minocycline gel (applied two times) in deep pockets (7mm). Timmerman et al (1996) reported that there was no benefit of employing 2% minocycline gel as an adjunct to SRP to reduce probing depths at deep sites, whereas van Steenberghe et al (1999) noted that combined therapy provided a better result than SRP alone at sites 7 mm deep. When Michalowicz et al (1995) monitored the number of sites manifesting a loss of clinical attachment (a 1-mm threshold) after placement of tetracycline fibers plus SRP versus SRP alone, they reported less disease progression after combined therapy (4% versus 9% of all the treated sites; N>200 sites per group; 9-month monitoring period). In another study that compared doxycycline gel versus SRP, there was no statistically significant benefit regarding inhibition of disease progression associated with drug therapy (Garrett et al 1999) . After employing chlorhexidine chips plus SRP, Jeffcoat et al noted that these sites achieved a mean 0.1 mm gain of bone, whereas 15% of the sites administered SRP alone lost bone (0.04mm) during a 9-month clinical trial . Overall, it is difficult to project outcomes regarding the ability of local drug delivery to inhibit disease progression because a limited number of studies, diverse study protocols, and different thresholds for disease progression were used.
Bacterial and antibiotic sensitivity testing may be necessary to determine putative pathogens and their susceptibility to specific antimicrobial agents. Local drug delivery often appears to be as effective as scaling and root planing with regards to reducing signs of periodontal inflammatory disease : redness, bleeding upon probing, probing depth, and loss of clinical attachment .Local drug delivery systems usually do not provide a benefit beyond what is achievable with conventional scaling and root planing in the treatment of adult periodontitis. Therefore, their routine utilization is unnecessary.
Local delivery may be an adjunct to the conventional therapy. The sites most likely to be responsive to this adjunctive treatment method may have refractory or recurrent periodontitis, or specific locations where it is difficult to instrument root surfaces. However, the data are limited to support this concept. At present, there are insufficient data to indicate that one local drug delivery device is clearly superior to all the other systems. However, desired characteristics include ease of placement, controlled release of drugs and resorbability. In conjunction with conventional treatment, systemically administered drugs appear to be as effective as local drug delivery.
To date, results from studies assessing local drug delivery systems have not justified extending the time interval between supportive periodontal maintenance visits. There are preliminary, but very limited data, regarding the ability of local delivery to help suppress future disease progression. There are insufficient data to indicate that local drug delivery induces bacterial resistance to antimicrobial agents. Long term studies are needed to address this important issue.
Prudent administration of antimicrobial agents following judicious pharmacologic principles will preclude the abuse of chemotherapeutic agents and reduce the potential of developing or selecting drug resistant bacterial strains. Local drug delivery systems with controlled release properties have the potential to be used as a therapeutic component in the management of periodontal diseases. However, additional randomized, controlled studies are needed to help delineate the types of lesions, periodontal diseases, or specific situations where local delivery systems would be most beneficial.
Advances in Technology and Periodontal Therapy
Treatment of periodontal disease has changed tremendously in the last 60 years. The basic principles of periodontal surgery as described by Shluger in 1949 called on periodontists to eliminate the periodontal pocket, create a harmonious gingival form and recontour the alveolar bone in order to pre- vent the progression or recurrence of periodontal pocketing. The traditional treatment modalities were based on the repair model of care. The clinician’s goal was to diagnose the disease and provide treatment without any consideration of risk factors or host susceptibility. Hygienists who practiced in the 1960’s and 70’s will remember referring most patients with 5 to 6 millimeter pockets to the periodontist for evaluation and surgery. It was not until the 1980’s when well-designed clinical trials compared scaling and root planing therapy, to periodontal surgery, that the outcomes of the various treatments were systematically reviewed.
Clinical trials carried out over a period of five years demonstrated that thorough debridement was often as effective as periodontal surgery in preventing the progression of alveolar bone loss in patients with chronic periodontitis. These results led to a paradigm shift in the treatment of periodontal disease still practiced today and periodontal research continues to focus oon-surgical methods to prevent attachment loss. The new frontier in periodontal research is in the application of new technologies including lasers, gene therapy, growth factors, drug delivery systems and implants to restore lost tissue and function. While the role of periodontal therapy in the prevention or reduction of systemic disease has not been proven by randomized controlled trials, new research with improved study designs is ongoing.
Dental hygienists today have a variety of tests available to identify patient’s risk factors and to treat and manage disease tissues. When evaluating any new technique or technology, remember to make decisions based on the best evidence supporting the treatment or technology along with clinical experience and the specific needs of the patient.
DIAGNOdent® Perio Probe
KaVo Dental Corporation This periodontal probe utilizes the laser fluorescence properties of subgingival calculus to quantify the amount of residual calculus on the root surfaces following scaling and root planing.The device utilizes the DIAGNOdent caries detection classic or pen model handpiece. The thin, perio tip insert attaches to the handpiece and detects calculus, elicits an audible tone and gives a measurable value in pocket depths up to 9 mm.The unit has been shown to register readings in areas where only slight amounts of residual calculus remain or in difficult access areas such as furcations and deep line angles.The audible tone and detection values can also prove beneficial in patient acceptance and compliance with periodontal treatment recommendations.
The NV MicrolaserTM delivers full power and the capabilities of the larger, desktop soft tissue diode lasers in a light-weight pen-sized package. Formerly known as the Styla MicroLaser, the NV microlaser is completely wireless. Controlled by a foot pedal, a rechargeable lithium ion battery powers the micro diode laser in continuous wave or pulsed modes. Custom features include preset procedure settings, pre-threaded disposable tips and a combination charger/sensor holder. Incorporation of the disposable tips eliminates the need for fiber management and enhances the portability of the device.
Now marketed as water flossers, Water Pik® offers a full line of products that feature state of the art dental water jet technology. Units vary from countertop models to completely portable models with self- contained water reservoirs. The units come with a variety of tips and intraoral devices designed for oral irrigation. Added product benefits include ease of use and the capability of adding oral medicaments to the irrigating solution.
The Sonicare FlexCare+ is specifically designed to help motivate patients to achieve consistency with their home brushing habits. The FlexCare+ offers advanced features including 1,2 and 3 minute cycles and 3 speeds or intensities. The brush head attachment slides on and off the lightweight handle making it easy to clean. The FlexCare+ features a UV light sanitizing chamber that kills 99% of selected pathogens including: E.coli, S. mutans, and Herpes simplex virus
Periodontitis are manifesting as painful, red, swollen gums, with abundant plaque.
In the early stages, periodontitis has very few symptoms and in many individuals the disease has progressed significantly before they seek treatment. Symptoms may include the following:
• Redness or bleeding of gums while brushing teeth, using dental floss or biting into hard food (e.g. apples) (though this may occur even in gingivitis, where there is no attachment loss)
• Gum swelling that recurs
• Halitosis, or bad breath, and a persistent metallic taste in the mouth
• Gingival recession, resulting in apparent lengthening of teeth. (This may also be caused by heavy handed brushing or with a stiff tooth brush.)
• Deep pockets between the teeth and the gums (pockets are sites where the attachment has been gradually destroyed by collagen-destroying enzymes, known as collagenases)
• Loose teeth, in the later stages (though this may occur for other reasons as well)
Patients should realize that the gingival inflammation and bone destruction are largely painless. Hence, people may wrongly assume that painless bleeding after teeth cleaning is insignificant, although this may be a symptom of progressing periodontitis in that patient.
Effects outside the mouth
Periodontitis has been linked to increased inflammation in the body such as indicated by raised levels of C-reactive protein and Interleukin-6.[3] It is through this linked to increased risk of stroke,[4][5] myocardial infarction,[6] and atherosclerosis.[7] It also linked in those over 60 years of age to impairments in delayed memory and calculation abilities.[8]
