Nonsurgical therapy for teeth and implants – when and why?
Determining the proper protocol for periodontally involved patients can feel overwhelming at times. Until the mid-1980s surgical periodontal therapy was included for all periodontally involved patients. So much so that it was considered malpractice to only treat periodontally involved patients with nonsurgical therapy. What criteria should we be evaluating to determine the need for surgical periodontal therapy, when is nonsurgical therapy alone the best treatment for patients? A review published in March 2019 in Periodontology 2000 offers some guidance.1
In the early to mid-1980s several randomized controlled trials were conducted to evaluate the significance, or lack of significance, in pocket reduction with nonsurgical therapy alone or nonsurgical therapy followed by flap surgery in patients with moderate to advanced periodontitis. These trials showed only periodontal sites with probing depths of > 7 mm showed a significant reduction with flap surgery after nonsurgical therapy. However, attachment levels were maintained with or without flap surgery. This initiated a paradigm shift in the way we treat periodontal patients.
Further studies were conducted and surprisingly (at the time), most of the improvement in probing depths and the gain in clinical attachment was attributed to nonsurgical periodontal therapy. This determined that the clinical significance of periodontal involvement could only be properly determined at 1-month post nonsurgical therapy. Consequently, to these studies, it was determined that nonsurgical periodontal therapy should be a prerequisite to the recommendation of flap surgery.
Knowing when to recommend surgical therapy is the key to maintaining health in patients with periodontitis. The concept of “critical probing depth” is discussed. Critical probing depth is described as “a concept where the clinical attachment level change is plotted against the initial (pretherapeutic) probing depth”. After plotting the probing depths regression lines were calculated, the point at which the regression line crosses the initial probing depth is defined as the critical probing depth. This concept suggests that additional surgical interventions should only be considered for sites above a critical probing depth of 6 mm observed after nonsurgical therapy has been completed.
The concept of critical probing depth is a good guideline to follow when deciding if surgical therapy is necessary. However, as a clinician, we must consider the long-term maintenance of the patient’s periodontium. Longitudinal cohort studies have shown that most periodontal sites remain stable, there is a small percentage that becomes re-infected despite supportive care. Nonsurgical therapy should aim to maintain pockets depths <6 mm, pocket depths with > 6 mm were more likely to result in tooth loss. This indicates a need for further evaluation and possible surgical therapy for sites that become re-infected and progress to probing depths > 6 mm.
The increased use of implants to replace missing teeth adds a new dimension to periodontal care. A cause-effect relationship between biofilm and implant-mucositis has been observed in humans. This leads to the understanding that mechanical control of biofilm is necessary and very important in maintaining a healthy periodontium for optimal implant support and success. Maintenance care is the driving factor in implant success. In a longitudinal study, 43% of patients with peri-implant mucositis that did not follow supportive maintenance care recommendations advanced to peri-implantitis within a 5-year span, as compared to 18% of patients that adhered to an appropriate supportive maintenance care program.
Treating peri-implant mucositis and peri-implantitis is more challenging than treating natural tooth structure. Unlike nonsurgical therapy in normal tooth surfaces, nonsurgical therapy alone for peri-implantitis showed only modest improvements. Based on findings of a case series “mechanical debridement in conjunction with peri-implant pocket irrigation with 0.5% chlorhexidine and adjunctive systemic delivery of ornidazole for 10 days yielded positive clinical and microbiological results”. However, in the case of moderate to advanced peri-implantitis a surgical approach may be indicated.
Photodynamic therapy is yet another option that has been explored to treat periodontitis and peri-implantitis. Clinical studies show using photodynamic therapy after nonsurgical therapy may result in “statistically significant higher short-term clinical improvements”. Evidence supports the use of photodynamic therapy as adjunctive therapy to nonsurgical periodontal therapy. However, current studies do not support the use of photodynamic therapy as a replacement for systemic antibiotics in severe cases of chronic periodontitis or aggressive periodontitis.
After reading this study will you revamp your nonsurgical and surgical therapy recommendations? Will you change your treatment protocol for peri-implantitis? Do you currently utilize photodynamic therapy? Have you seen good results with photodynamic therapy when used in conjunction with nonsurgical therapy?
- Lang NP, Salvi GE, Sculean A. Nonsurgical therapy for teeth and implants-When and why?. Periodontol 2000. 2019;79(1):15–21. doi:10.1111/prd.12240
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