Using evidence-based science to advance periodontal therapy

Disease management

When pathogenic biofilm causes disease (gingivitis, periodontal disease, peri-implant disease) in a susceptible host, the oral health care provider must develop a treatment plan framework that includes debridement approaches, individualized care recommendations based on individual risk factors, and long-term monitoring of patient’s response to treatment. This is the act of practice periodontal medicine as described in the 2018 classification system: taking into account all the individual needs of the patient, complementary biological characteristics, assessment of the rate and possible progression of the disease during diagnosis, strategy and treatment planning.¹

Providers should use the staging and scoring framework from the classification system to plan disease treatment and maintenance recommendations:

• Stages I and II: Patients have a good prognosis with easily understood complications.^8,9 Non-surgical periodontal therapy should be performed as the first line of recommended treatment with the goal of resolving inflammation and returning to oral symbiosis.³
• Stages III and IV: Patients have an increased risk of future tooth loss or teething.^8,9 These patients have increased complexity in disease management and a worse prognosis. They may require both non-surgical and surgical interventions.
• Grade A: Patients have slowly progressive periodontal disease and a good prognosis with nonsurgical periodontal treatment and maintenance recalls of three to six months.^3,8,9
• Classes B and C: Patients have moderately (B) and rapidly (C) progressing periodontal disease.^8,9 They require more frequent maintenance recalls (every one to three months) and will likely benefit from non-mechanical cleaning treatments to control their disease.^3.10

Systemic antibiotics

Systemic antibiotics are no longer used as a standard of care in the management of periodontal and peri-implant disease.³ While planktonic bacterial cells are affected by antibiotics, a stomatal biofilm provides a shield over individual bacterial cells with its extracellular polysaccharide matrix.¹¹ The dose of antibiotic needed to penetrate the shield to reach individual cells would have to be 1,000-1,500 times its normal dose, which is enough to kill the patient before killing the bacteria in the biofilm.^3.11 Decades of evidence-based research have shown that periodontal and peri-implant diseases respond favorably to non-surgical interventions and rarely require antibiotics to gain control of disease pathogenesis.³

Chemical agents

Chemical agents are often used as part of a comprehensive treatment plan for patients with active disease. They are typically used as an adjunct to non-surgical treatments and may be useful in deep periodontal pockets, unresolved inflammation, and overall biofilm reduction and control.¹² According to the American Academy of Periodontology (AAP),¹² For a chemical agent to be effective, it must meet three criteria:

• Reach the base of the periodontal pocket
• They have bacteriostatic or bactericidal properties
• Stay in place long enough for it to take effect

Controlled clinical trial data and long-term maintenance studies demonstrate the benefits of reducing gingival inflammation by providing low-dose (1.7%) hydrogen peroxide gel (Perio Gel, QNT Anderson) in an FDA-cleared, lab- , specially made. tray (Perio Tray, Perio Protect LLC) for use by the patient at home.^13-18 According to the Food and Drug Administration (FDA), the Perio Tray is a custom-fit tray that requires an impression by a licensed dentist that is used to place solutions into gingival fissures or periodontal pockets and allows solutions to be placed deeper into the fissure/pocket than is possible. with traditional fluoride trays.”¹⁹

Hydrogen peroxide (H₂THE₂) is one of the oldest, purest, and most versatile antimicrobial agents on the planet. It is produced naturally by humans as a by-product of the biochemical metabolism of many different cells.²⁰ It is present in the lungs, gastrointestinal tract and bloodstream.²⁰ Even oral bacteria produce hydrogen peroxide that becomes part of the air exhaled by humans.²⁰

H₂THE₂ it is broken down into water and oxygen by organisms that contain specific enzymes (catalase, peroxidase) that break it down, such as human cells, aerobic bacteria, and facultative anaerobic bacteria.^20,21 Obligate anaerobic bacteria lack these enzymes and when exposed to hydrogen peroxide, have a toxic effect through damage to their cellular lipids, nucleic acids and cell membranes.^20,21 This makes X₂THE₂ a useful chemical agent in combating inflammation induced by a host-mediated immune response in oral biofilm.

Perio Gel is placed inside a Perio tray (image 4) for an average of 15 minutes per session. Through simple diffusion, the gel will reach the base of the periodontal pocket, be maintained at high levels for a long time, and exert both bactericidal and bacteriostatic action (figure 5). Perio Gel alters the microbiological state of the subgingival environment by increasing subgingival oxygen saturation, which makes it more difficult for obligate anaerobes to grow. A study published in Journal of Clinical Dentistry confirmed the bactericidal ability of Perio Gel in 2011.²² Optional anaerobic Streptococcus mutans exposed to Perio Gel for 10 min and almost all cells died as shown by the color change from green (S. mutans, untreated control. figure 6a) to red (dead cells; figure 6b).²² This same study also confirmed that Perio Gel delivered in a Perio tray was able to diffuse to pocket depths of 9 mm.