Aetiological phase

The periodontal treatment plan starts with the aetiological phase whose purpose is to stop disease progression by controlling pathogenic oral biofilm, eradicate systemic and local aetiological factors and restore oral microbiota that is consistent with health.

The following steps are essential for controlling periodontal infection:

Patient information and motivation

Patients need to be completely aware of the type of disease they have, because long-term treatment success depends on their compliance. They need to know the aetiopathogenesis of periodontitis to therefore become motivated to actively participate in the treatment process.

Systemic control phase

There is scientific evidence proving an association between periodontal disease and systemic level involvement. Systemic diseases must be identified and controlled, and any medication the patient may be taking must be known, as these may affect periodontal disease progression and treatment.

These factors must be controlled, and if necessary, the patient’s specialist treating physician should be contacted.

Controlling risk factors, such as smoking, is also essential during this phase.

Controlling other oral infections

Prior to initiating periodontal treatment, it is important to eradicate active oral infections, acute periodontal disease, active caries and pulpal lesions that require endodontic treatment.

Oral hygiene instruction

Adequate control of bacterial plaque by the patient is crucial for healing and for maintaining gingival health. Therefore, teaching patients personalised oral hygiene methods is essential.

Poor hygiene habits should be corrected, for example: observing a patient’s brushing performance to observe weak points that may cause injury to teeth and gums, in order to instruct him on the proper technique. Different supragingival plaque removing tools and their proper use should also be shown to patients.

Elimination of retention factors

This involves the removal of factors that retain pathogenic oral biofilm and hinder patient hygiene. Natural factors such as: developing pockets, enamel projections or iatrogenic anomalies.

Supragingival prophylaxis

Prophylaxis forms part of both the baseline, or initial, periodontal treatment, and the maintenance phase. It involves the removal of calculus, plaque and tooth stains.

Supragingival plaque control by the professional and the patient, is the most important preventive measure for maintaining periodontal health, and in a treated patient, it is the primary measure for preventing periodontal disease recurrence.

Occlusal stabilisation

A patient’s occlusion must be stabilised by controlling occlusal trauma through adjustments, splints and/or orthodontic treatment.

Scaling and root planing

This is the basic mechanical treatment of periodontitis.

Scaling: is the procedure by which plaque, calculus and surface tooth stains are removed, both supra- and subgingivally.

Root planing: is the procedure whose aim is to remove residual calculus and cementum or dentin that is impregnated with calculus or contaminated with microorganisms, to obtain a smooth and hard root surface.

The objectives of scaling and root planing include:

• Disruption of subgingival biofilm
• Decontamination of root surface
• Reduction or elimination of gingival inflammation
• Periodontal pocket reduction
• Used as a step prior to gum surgery
• Stop disease progression

The clinical and microbiological results obtained with this procedure are:

• Reduced plaque index
• Reduced gingival inflammation and bleeding index
• Reduced probing depth
• Clinical attachment gain
• Reduced total bacterial count
• Microbial shift to less pathogenic subgingival microbiota
• Reduction of periodontal pathogens such as P. gingivalis (P.g.), A. Actinomycetemcomitans (A.a.), T. Forsythia (T.f.).

Scaling and root planing is very effective in the vast majority of patients, but there are certain limitations that can compromise its success.

• Probing depth and pocket shape: the amount of calculus and the type of pockets (deep and/or narrow) may affect the difficulty in removing calculus.
• Type of tooth and tooth surface: posterior teeth, interproximal surfaces, multiradicular teeth and furcations are areas that are more difficult to access.
• Root anatomy and furcations: more difficult in concavities, grooves, irregularities, etc.
• Bony defects: May hinder access with conventional instrumentation.
• Operator’s experience.
• Instrumentation type (manual vs automatic): both equally effective in removing plaque, although neither by itself performs the action thoroughly.
• Difficulty in removing certain pathogens: some specific pathogens that are associated with periodontitis.
• Negative consequences: recession, hypersensitivity, etc.

Adjunctive treatment with antiseptics

Supragingival plaque control is achieved mainly through mechanical methods – conventional toothbrush and interproximal oral hygiene techniques. However, despite using these methods, many people are far from achieving optimum plaque control. At-home chemical control with antiseptics is particularly important because it can:

• Make up for deficiencies in mechanical plaque control.
• Successfully control periodontal disease.
• Possibly play an important role in preventing the progression of periodontitis and its recurrence.

An antiseptic is a product used for fighting and preventing infection, as it attacks pathogenic bacterial microbiota and provides effective control of bacterial plaque.

Those used most frequently in clinical practice include:

Chlorhexidine

Chlorhexidine (CHX) is a cationic bisguanidine with a very broad antibacterial activity against gram-positive and gram-negative bacteria, viruses and fungi.

It is the antiseptic of choice, and is considered to be the gold standard. It acts by binding to molecules of the outer and inner membranes, altering the permeability and achieving a bacteriostatic effect at low concentrations, and a fast-acting bactericidal effect at high concentrations. Its antibacterial effect is useful in the oral cavity due to its high substantivity; it is actively released and keeps working for 12 hours.

Chlorhexidine is commonly available in concentrations of 0.12% and 0.20%. Numerous studies have proven the benefits of both formulations, but particularly of the formulation containing 0.12% CHX and 0.05% Cetylpyridinium chloride, as it proves to be just as effective but with fewer side effects.

Cetylpyridinium chloride (CPC)

Cetylpyridinium chloride is a quaternary ammonium compound that has a plaque inhibitory effect. Its mechanism of action seems to be due to the increase in permeability of the bacterial wall, favouring lysis and decreasing the capacity of bacteria to bind to the tooth surface. It is normally formulated in concentrations of 0.05% or 0.07% and shows good adsorption in oral pH conditions, with a substantivity of 3 hours.

Very effective formulations exist combining CPC with other active agents such as chlorhexidine, which exert a synergistic effect that increases the efficacy of the formulation. The addition of active substances to a certain formulation can increase or decrease the product’s efficacy. CHX and CPC are molecules that are cationic in nature, and there is therefore no negative interaction between them, but rather on the contrary, both act synergistically if used together in the same formulation, increasing the formulation’s antimicrobial activity, and therefore, its efficacy.

Phenols and essential oils

This category includes products such as thymol, hexylresorcinol and eucalyptol. They are formulated with a combination of essential oils dissolved in a hydroalcoholic vehicle. Their mechanism of action is based on their ability to disrupt the cell wall and inhibit bacterial enzymes, causing a significant reduction in the levels of plaque and gingivitis. Their side effects are related to the amount of alcohol present in the formulation.

Triclosan

It is a chlorinated bisphenol antiseptic. At concentrations of 0.02% it has a moderate plaque inhibitory effect and antimicrobial substantivity of about 5 hours. Its action is enhanced by the addition of zinc citrate or polyvinyl-methyl ether maleic acid copolymer in the same formulation. Its anti-inflammatory action seems to be more important than its plaque control effect.

Other substances such as enzymes, fluorides, oxidising agents, etc., are also used for chemically suppressing oral biofilm.

Adjunctive treatment with antibiotics

Mechanical treatment is directed to a complex group of bacteria, and it cannot completely remove certain periodontal pathogens that are commonly associated with periodontitis. The areas treated may be recolonised by periodontal bacteria that reside in other sites.

In order to effectively administer an antibiotic, it is necessary to make a previous microbiological diagnosis.

Antibiotics can be administered locally or systemically.

• Local antibiotics following the disruption of the subgingival biofilm, for controlling isolated sites.
• Systemic antibiotics as an adjunct to mechanical therapy, after scaling and root planing for the best results.

Although they can be given to all patients, it is not necessary to prescribe an adjunctive antibiotic therapy to all periodontitis patients. The ones who will reap the greatest benefits will be those patients with:

• Advanced periodontitis (deep pockets).
• Aggressive periodontitis.
• Periodontitis that does not respond to standard therapy.
• Periodontitis with certain microbiological profiles (Presence of A.a and P.g)
• Periodontitis associated with systemic disease.

Antiseptics are also recommended to be used along with antibiotic therapy.