Regular home care by the patient in addition to professional removal of subgingival plaque is generally very effective in controlling most inflammatory
periodontal diseases. When disease does recur, despite frequent recall, it can usually be attributed to lack of sufficient supragingival and subgingival plaque control or to other risk factors that influence host response, such as diabetes or smoking. Causative factors contributing to recurrent disease include deep inaccessible pockets, overhangs, poor crown margins and plaque-retentive
calculus. In most cases, simply performing a thorough
periodontal debridement under
local anesthesia will stop
disease progression and result in improvement in the clinical signs and symptoms of active disease. If however, clinical signs of disease activity persist following thorough mechanical
therapy, such as increased pocket depths, loss of attachment and
bleeding on probing, other pharmacotherapeutic
therapies should be considered. Augmenting scaling and
root planing or maintenance visits with adjunctive chemotherapeutic agents for controlling plaque and
gingivitis could be as simple as placing the patient on an antimicrobial mouthrinse and/or
toothpaste with agents such as
fluorides,
chlorhexidine or
triclosan, to name a few. Since supragingival plaque reappears within hours or days after its removal, it is important that patients have access to effective alternative chemotherapeutic products that could help them achieve adequate supragingival plaque control. Recent studies, for example, have documented the positive effect of
triclosan toothpaste on the long-term maintenance of both
gingivitis and
periodontitis patients. Daily irrigation with a powered irrigation device, with or without an
antimicrobial agent, is also useful for decreasing the
inflammation associated with
gingivitis and
periodontitis. Clinically significant changes in probing depths and attachment levels are not usually expected with irrigation alone. Recent reports, however, would indicate that, when daily irrigation with water was added to a regular
oral hygiene home regimen, a significant reduction in probing depth,
bleeding on probing and Gingival Index was observed. A significant reduction in
cytokine levels (
interleukin-1beta and
prostaglandin E2, which are associated with destructive changes in inflamed tissues and
bone resorption also occurs. If patient-applied antimicrobial
therapy is insufficient in preventing, arresting, or reversing the
disease progression, then professionally applied
antimicrobial agents should be considered including sustained local
drug delivery products. Other, more broadly based pharmacotherapeutic agents may be indicated for multiple failing sites. Such agents would include systemic
antibiotics or host modulating drugs used in conjunction with
periodontal debridement. More aggressive types of
juvenile periodontitis or severe rapidly advancing
adult periodontitis usually require a combination of surgical intervention in conjunction with systemic
antibiotics and generally are not controlled with nonsurgical anti-infective
therapy alone. It should be noted, however, that, to date, no home care products or devices currently available can completely control or eliminate the pathogenic plaques associated with
periodontal diseases for extended periods of time. Daily home care and frequent recall are still paramount for long-term success. Nonsurgical
therapy remains the cornerstone of periodontal treatment. Attention to detail, patient compliance and proper selection of adjunctive
antimicrobial agents for sustained plaque control are important elements in achieving successful long-term results. Frequent re-evaluation and careful monitoring allows the practitioner the opportunity to intervene early in the disease state, to reverse or arrest the progression of
periodontal disease with meticulous nonsurgical anti-infective
therapy.