periodontal health maintenance · the dental courses are accepted/approved in the following states:...

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Dynamic Dental Educators – Periodontal Health Maintenance

Periodontal Health Maintenance Home Study Course #5031 Dynamic Dental Educators designates this activity for 3 continuing education credits

This activity has been planned and implemented in accordance with the standards of the Academy of General Dentistry Program Approval for Continuing Education (PACE) through the joint program provider approval of Dynamic Dental Educators and Relias. Dynamic Dental Educators is approved for awarding FAGD/MAGD credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 11/1/2017 to 10/31/2021. Provider ID #300115.

The Dental courses are accepted/approved in the following states: AL, AK, AZ, AR, CA, CT, DE, FL, GA, HI, ID, IL, IN, IA KS, KY, LA, ME, MD, MA, MI, MN, MS, MO, MT, NE, NV, NH, NJ, NM, NY, NC, ND, OH, OK, OR, PA, PR, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV. For Florida and California, DDE is an approved provider (Florida Board of Dentistry Approved Provider #50- 557; Dental Board of California Registered Provider #3964.)

Dynamic Dental Educators is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Dynamic Dental Educators designates the listed activities continuing education credits after each course title.

This continuing education activity has been planned and implemented in accordance with the standards of the ADA Continuing Education Recognition Program (ADA CERP) through joint efforts between Dynamic Dental Educators and Relias.

For assistance, please contact: Relias @ 800-950-4248

Copyright 2003 Dynamic Dental Educators. All Rights Reserved. No portion of this text may be copied, reproduced or

used in any way without the written permission of Dynamic Dental Educators.

Our course content is unbiased and free from commercial influenc e. Everyone involved with the development of this course have no conflict of interest and have no financial relationships with the content of this course. Our home study continuing education courses are only meant for re-licensing purposes. Limited information is provided as an

overview of the subject matter and potential risks exist when attempting to incorporate techniques or procedures using limited knowledge and without supervised clinical experience. This course is not intended to be a comprehensive or authoritative source.

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Table of Contents

Objectives.................................................................................................3

Introduction ..............................................................................................4 Oral Health Maintenance Goals ...............................................................4 Oral Health Maintenance in 2 to 17 Year Olds........................................4

Oral Health Maintenance in Adults .........................................................5 Initiation of Oral Health Maintenance .....................................................5

Appointment Frequency...........................................................................6 Treatment Considerations ........................................................................6 Compliance ..............................................................................................6

Restorative Needs of the Adult Dental Patient ........................................7 Special Considerations .............................................................................8

Oral Health Maintenance after Non-Surgical Therapy ............................9 Antimicrobial Therapy .............................................................................9 Supragingival Irrigation .........................................................................10

Subgingival Irrigation ............................................................................10 Local Antibiotic Therapy .......................................................................10

Systemic Antibiotic Therapy .................................................................11 Home Oral Healthcare ...........................................................................12

Dentrifices ..........................................................................................12

Mouth Rinses .....................................................................................13 Home Care Devices ...........................................................................14

Conclusion .............................................................................................16 References ..............................................................................................17

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Objectives

The purpose of any oral health maintenance program for both children and adults.

The determination of specific guidelines and tracking assessment for each patient in an oral health maintenance program.

The ability of local changes in the mouth and systemic changes in the body to influence the level of oral health maintenance care.

The value and selection of various local and systemic antibiotic therapies for professional use during an

oral health maintenance program.

The value and selection of supportive home care treatments.

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Introduction Advances in dental techniques over the years have improved the longevity of teeth just as advances in medicine have improved the longevity of our lives. The improved function, esthetics, and performance of our teeth increases the need for ongoing hygiene care to maintain the integrity of our teeth for as long as possible. Active dental therapy for the mouth includes the treatment provided to eradicate diseases of the hard and soft tissue and all services related to the restoration of the function and esthetics of the teeth. Periodontal disease is the major cause of tooth loss in adults, affecting three out of four people at some point in their life. Adults over the age of 35 lose more teeth to periodontal disease than from cavities. Orthodontic movement, periodontal grafts, dental implants, bonding procedures, all-porcelain restorations, fixed and removable bridgework, fixed and removable dentures, and other dental appliances need to be managed carefully to enable the most appropriate treatment for an oral health maintenance program. Systemic health changes, prescription or herbal medicine additions or deletions, altered diets and dexterity will require further adjustments in oral health care.

Oral Health Maintenance Goals The purpose of any oral health care maintenance program is to:

Prevent disease,

Prevent recurrence of previous disease,

Monitor home hygiene education and behavior,

Monitor clinical signs of oral diseases,

Provide specialized instruction for dental restorations, Gain patient compliance through motivation.

Prevention of periodontal disease or carious lesions is dependent upon the dental professional’s ability to assist the patient with an active oral health maintenance program. New and recurrence of previous dental diseases can be avoided by instructing a patient on proper home care using behavior modification, visual demonstrations, and educational tools. Recurrence of a patient’s previous infections can be effectively managed, by the dental professional and the patient, through careful monitoring of the patient during their regular office visits. During these visits, early signs of any new oral activity should be observed and confirmation of the patient’s home oral health care habits need to be reviewed to ensure they are properly following instructions to prevent recurrence. When new dental restorations or appliances have been placed, or when oral or periodontal surgery has been performed, these sites may require new or different approaches for maintenance care as well as new instructions for improving home care for the patient.

Oral Health Maintenance in 2 to 17 Year Olds During the initial office visit, the dental professional will need to evaluate and record the current periodontal condition of the patient, to establish a baseline for future comparison. The periodontal status of most patients under the age of 18 is healthy except for those manifesting white blood cell disorders or immune deficiency disorders. Uncharacteristically, aggressive periodontitis can affect young children without warning and without systemic cause. Adolescents have been shown to develop periodontal attachment loss. These disorders and episodes of aggressive periodontitis can complicate routine maintenance programs. Except for these few conditions, normal hygiene maintenance for the majority of healthy patients under age 18 requires six-month recalls as a minimum to detect signs of new disease and to monitor home care. Parents may need to supervise a child’s home care from the time they receive their first tooth until the age of 9 or 10.

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Children and adolescents may need orthodontic care to realign their teeth. Attention should be given to patients utilizing removable appliances to ensure their oral hygiene is adhered to more closely. Those who must rely on fixed appliances to realign teeth must be monitored more closely in proper home care, under parent supervision, and may require more frequent oral hygiene maintenance visits to reduce damage from plaque build-up and avoid enamel decalcifications. The addition of Oral Irrigators, Water Piks and electric toothbrushes, topical fluorides and fluoride mouth rinses as well as discussing good eating habits during this active phase of therapy is strongly recommended. Patients under the age of 18 are most susceptible to caries due to:

New teeth development,

Diets high in sweetened products,

Poor nutrition, Poor oral hygiene,

Lack of oral hygiene instruction. Frequent caries development leading to new dental restoration placement is strong evidence that poor dental hygiene exists within the home. The dental professional should continue to record any changes between visits to compare and look for evidence of future problems. If a patient is not effectively brushing using a manual toothbrush, then suggesting a power toothbrush can be a healthy alternative to help improve poor dental hygiene.

Oral Health Maintenance in Adults Adult teeth are subject to many more changes throughout a lifetime. Factors that contribute to gingival changes in the mouth are primarily plaque induced, but, may also involve non-plaque induced lesions of bacterial, viral, fungal, or genetic origin. Mucocutaneous disorders, allergic reactions, traumatic lesions, and foreign body reactions can also contribute to gingival changes. Chronic periodontitis results when gingival changes become more progressive and affect the surrounding periodontal attachment, periodontal ligament, and the crestal bone. However, the onset of periodontitis can begin at any age, thus reclassifying this condition as aggressive periodontitis. Periodontitis can also manifest itself from a hematological disease or genetic disorder. Special diagnostic and treatment challenges in periodontitis occur when necrotizing periodontal disease, periodontal abscesses, perio-endo lesions, and developmental or acquired deformities and conditions around the teeth exist. Any abnormal periodontal conditions must be treated accordingly.

Initiation of Oral Health Maintenance It is important to understand that oral health maintenance for periodontitis begins only after active therapy has been completed to treat periodontitis and that proper results have been obtained after the treatment. Documentation and diligent monitoring of the patient’s improvements is necessary to determine if any further treatments may be necessary. Active therapy may need to be repeated when:

The patient is not performing good dental hygiene,

Periodontal maintenance under the existing continuing care program is no longer effective in maintaining reduced pocket depths and controlling bleeding on probing,

Marked changes in dental or systemic health have created an altered state of oral health.

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Appointment Frequency Risk factors that increase the need for more periodontal maintenance appointments include:

Periodontal disease activity,

Dental caries,

Frequent tobacco and alcohol abuse,

Predisposing diseases or conditions that can harm the periodontium,

Patients not following a proper home oral maintenance program,

History of previous periodontal treatment,

Rate of calculus formations,

New restorative complications. Once a dental patient has been diagnosed with gingivitis and treated successfully, normal prophylaxis procedures can be continued. When a dental patient has been diagnosed with a form of periodontitis and treated successfully, a high probability exists normal prophylaxis procedures may never be resumed. The frequency of a continuing care program depends upon the risk factors stated above. On average, it has been shown that recolonization of pathogens within the periodontal pocket generally return to pretreatment levels within 9 – 11 weeks after the removal of dead, contaminated or adherent tissue or foreign material. But, some patients may not need retreatment, especially if their home care dental hygiene habits improve. Researchers have studied intervals for periodontal maintenance treatment varying from every two weeks up to eighteen months. Generally, periodontal maintenance is performed four times a year in clinical situations. Customization of any maintenance program is managed between the dental professional, the patient, and the risk factors associated with that patient.

Treatment Considerations The following items should be included in a periodontal maintenance visit subject to previous exams, history, and clinical judgment:

Review and update of medical history,

Clinical examination of extraoral, intraoral, dental and periodontal tissues, implants, and recording of results,

Radiographic examination,

Clinical and radiographic disease evaluation,

Oral hygiene assessment,

Treatment needed,

Communication and consultation,

Planning future appointments. The time requirement for each maintenance visit can usually vary from 45 to 60 minutes, but should be customized based on the number of teeth involved, oral hygiene efficacy, systemic health, previous appointment frequency, instrumentation access, history of disease or complications, and sulci distribution and depth.

Compliance It has been shown that patients who were treated for periodontitis and followed their suggested periodontal maintenance intervals had experienced less attachment and tooth loss than patients who did not maintain their periodontal maintenance intervals. In one study, patients following up with their maintenance check up was

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shown to be less than 50% in a ten year study. In another study, another 28% of patients did not follow up with their first periodontal maintenance visit after their initial treatment. Studies have also shown that people who do not maintain regular oral hygiene have 20 times the amount of bone loss as those who do. It is essential to reinforce periodontal maintenance guidelines with the entire dental team to encourage patient follow up and reduce scheduling changes. Follow up reminders and periodic notes can be sent to patients to remind them of the continuing care process and the need for compliance with the maintenance schedule which has been setup for them.

Restorative Needs of the Adult Dental Patient When disease, functional problems, or esthetics create opportunities for changes in the dentition, proper oral health maintenance may need to be modified or completely changed. The following topics reinforce the need for continual good oral health maintenance:

Loss of teeth – once a tooth or teeth are lost, functional changes in chewing occur, and moderate shifting and inclination of teeth can develop with subsequent alterations of the gingival attachment or the creation of periodontal pockets. Plaque may also develop on surfaces inaccessible by the manual toothbrush. Interdental devices may be required.

Removable bridgework – maintenance of missing teeth becomes more challenging when removable

bridgework fills the spaces. The additional clasps can create aggressive forces that may weaken susceptible teeth or inflame the gingiva. In addition, plaque can build up on the bridgework and needs to be removed daily by the patient at home.

Fixed bridgework – ceramometal or ceramic bridges modify tooth structure to create a chewing surface that replaces missing teeth. Although cemented in permanently, interproximal cleansing beneath the bridgework space and along adjacent teeth is necessary to minimize plaque build-up. Sulcular surfaces in contact with the bridgework should be maintained well and identified for any alterations which may impact oral health.

Crowns, onlays, and veneers – traditional crowns strengthen fractured teeth and rebuild structure for previously diseased teeth. Recent aesthetic advances can use crowns or veneers to create a straighter and whiter smile. All of these restorations need to be maintained well and that starts by evaluating the gingival health prior to preparation of the restorations. Mucogingival defects, periodontal pocketing, crowded and overlapped teeth, gingival margin discrepancies, gingival recession and tooth mobility should be noted prior to beginning major restorative work. These permanent changes may alter the methods used for the periodontal maintenance program.

Implants – implants are supported by bone and a long connective tissue attachment regardless if they support a crown, a fixed bridge, or a removable denture. All of the implant fixtures are made of titanium. Plastic instruments or air-powder abrasives are used to remove dead, contaminated or adherent tissue or foreign material on these surfaces to avoid scratching the titanium and creating areas for plaque to adhere.

The patient who has lost all of their teeth due to periodontal pathogens is at no greater risk for peri-implantitis due to these same pathogens. However, patients with partial tooth loss and active periodontal disease are at a greater risk for peri-implantitis. It may be more challenging to maintain dental implant sites alongside natural dentition. Adjustments to the patient’s maintenance program may be need in the future.

Flossing and toothbrushing with soft bristles is preferred around implants. If lingual access is compromised, an oral irrigation device set on low setting is adequate. Chlorhexidine rinses can be used while using the irrigation device. Fixed implant prostheses may require the use of interdental aids and

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power toothbrushes. The removable prosthesis should be cleaned with a stiff nylon denture brush daily. All probing should be performed with a plastic periodontal probe. Ultrasonic scalers should be covered with plastic tips when in use around the implants. Radiographs of the implant should be taken at 3 month intervals the first year and then annually.

Orthodontics – children, teenagers, and adults wear orthodontic appliances. Fixed appliances are the hardest to maintain. Gingival inflammation can occur even in previously non-active sites due to poor accessibility. Dental hygiene and periodontal maintenance schedules should be modified to reflect these changes. A more regimented home care program is important and should be emphasized to the patient. The use of power toothbrushes and fluoride rinses will aid the improvement of home care.

Dental fillings – more and more dental practices are converting to composites for filling cavities. Whether or not a composite is used to fill the tooth, a thorough follow-up is necessary to observe for any unusual tissue reaction or cleansing problems. Tooth surfaces need to remain polished to reduce plaque adherence.

Teeth whitening – the whitening of teeth using peroxide-based solutions has become quite common. To obtain and maintain a whiter smile, one or more appointments may be necessary to remove stains from teeth. Especially those which have been stained by tea, coffee, wine and tobacco. Once the stains are removed, greater emphasis should be placed on reducing or eliminating what initially caused the stains. Also, the use of a power toothbrush has been shown to help maintain the whiter smile after the completion of a teeth whitening procedure.

Special Considerations Undiagnosed or poorly controlled Type 2 diabetes mellitus patients may be particularly vulnerable to periodontal diseases. Conversely, most well controlled diabetic patients can maintain good periodontal health. If diabetes is poorly controlled, antibiotic prophylaxis should be considered. Some studies suggest that periodontal treatment in people with Type 2 diabetes helps improve their blood sugar levels. Patients with long-standing, poorly controlled diabetes are at risk of developing oral candidiasis, and the evidence indicates that periodontitis is a risk factor for poor glycemic control and the development of other clinical complications

of diabetes. Evidence suggests that periodontal changes are the first clinical manifestation of diabetes. Hormonal fluctuations in females can contribute to changes in periodontal health. Menstrual cycles, menopause, and the use of oral contraceptives can precipitate these changes. Pronounced changes occur during pregnancy and periodontal treatment should be postponed in the first trimester. Maintenance, during pregnancy, can be performed as needed. Gingival enlargement can be caused by drugs such as anticonvulsants, calcium channel blockers, and cyclosporine. Modification of drug therapy and even gingival excision may be necessary when consultation with the patient’s physician is necessary. Acute leukemia can demonstrate hemorrhagic gingival enlargement in early stages. Chronic leukemia patients manifest similar, but, less severe periodontal changes. A specialist should be considered prior to performing any periodontal intervention, especially prior to planned bone marrow transplantation. Immune system disorders can cause more severe periodontal disease. This includes AIDS patients, organ transplant recipients, patients undergoing cancer treatment, and others who need to take immunosuppressive medications. All of these patients should be evaluated and given proper care to avoid opportunistic infections and adverse drug reactions. Periodontal pathogens may contribute to atherogenic changes and thromboembolic events in the coronary arteries and may increase the risk of a stroke. Because bacteremias intensifies in periodontitis , a stringent periodontal maintenance program for cardiovascular patients will help to reduce the risk of heart disease and

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stroke associated with periodontal pathogens.

Oral Health Maintenance after Non-Surgical Therapy An oral maintenance program should be created and followed after active periodontal therapy has been completed. Periodontal pockets between 4 and 6 millimeters can be maintained well without surgical intervention because an average pocket reduction of 1.29 mm can be achieved by a combination of increased clinical attachment and gingival recession. A clinical effectiveness of 1 mm reduction should be expected. Continual vertical bone loss, subgingival bleeding and subgingival plaque retention may require surgical intervention when their measurements have increased from baseline readings. Surgical intervention may also be required when periodontal pockets reach 7 mm or more. Extraction of teeth becomes necessary when repeated treatment to manage the periodontium continues to result in acute periodontal lesions, extreme mobility, or pain.

Antimicrobial Therapy Surgical needs for extraction may be reduced and recommended periodontal surgery may be spared when a combination of removing dead, contaminated or adherent tissue or foreign material, and short-term use of antimicrobial agents are used. For chronic periodontitis patients actively treated only with scaling and root planning, clinical evaluations and microbial assessments should be repeated at 3 month intervals during the oral health maintenance phase. The results of this treatment should show decreased periodontal pathogen populations. It takes plaque about three months to develop into an aggressive infection. In the first three months there is minimal bone loss, but after ninety days the breakdown dramatically increases. If the plaque is removed every three months, the plaque aggressiveness will stay low. Several antimicrobial agents have been used to effectively suppress periodontal pathogen growth. Although mechanical therapy is effective for the majority of patients exhibiting mild to moderate chronic periodontitis, this therapy alone is not sufficient to suppress the bacterial species Actinobacillus actinomycetemcomitans.

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Supragingival Irrigation The use of topical antimicrobial agents for subgingival irrigation is less effective than scaling and root planning because the biofilm on root surfaces is not removed by irrigation. However, antimicrobial mouth rinses can aid in reducing the general microbial population. A 0.12% chlorhexidine solution during active therapy is an effective antimicrobial mouth rinse, but, its ability to readily stain teeth precludes its use during an oral maintenance program and it cannot deliver effective antimicrobial therapy subgingivally. The chlorhexidine can be diluted with 5 parts water and used in a home irrigation system with reduced staining. A stannous fluoride solution may also be used for irrigation. When a 0.02% stannous fluoride solution is used as an oral irrigator, it has been shown to decrease plaque levels and gingival inflammation, but, some staining occurs as with chlorhexidine.

Subgingival Irrigation All subgingival irrigation must be performed in the dental office by qualified personnel to be effective. The best results during in-office oral irrigation occur only after scaling and root planning have preceded the maintenance program. An irrigation tip placed 1mm apical to the gingival margin has shown to attain 90% pocket penetration when probing depths of 6 mm or less. Subgingival irrigation can be done at home with proper instruction and with the correct devices and irrigation cannulas. Chorhexidine. A 0.2% chlorhexidine solution, when used in subgingival irrigation, has clearly demonstrated to be effective during routine periodontal maintenance. However, only a 0.12% chorhexidine solution is approved for use in the United States.

Local Antibiotic Therapy Several localized antibiotic therapy treatments have been introduced to reduce the periodontal pathogen population and increase clinical attachment. The use of local antibiotic therapy is recommended for patients that fail to respond to mechanical instrumentation. This may be observed especially during routine oral health maintenance. None of the local delivery therapies are effective against tissue-invasive organisms, such as A. actinomycetemcomitans. None of these systems should be used in children and in pregnant or nursing women. Chlorhexidine gluconate (Perio Chip). Placement of 2.5 mg of Perio Chip in gelatin will decrease pocket depths of 5 mm or greater. It may take 2 or 3 treatments over several months to achieve these results. Significant improvements occur when Perio Chip is used as an adjunct to scaling and root planing. Mild to moderate sensitivity may occur during the first week of pocket treatment. Toothbrushing can continue, but, flossing the site should be avoided for 10 days following treatment. Minocycline hydrochloride 1 mg. (Arestin). This antibiotic is also from the tetracycline class delivered in a form known as microspheres. It has been used in controlled studies to treat pockets up to 7 mm deep including furcation areas. Arestin is effective for clinical attachment gain and probing depth reductions. This form of antibiotic is considered to be the most effective treatment for eradicating certain periodontal pathogens. The delivery method of Arestin is by injection into the periodontal pocket base to expel the powder. No anesthesia is required, and no separate dressing or adhesive is required since it is readily bioadhesive. No hard, crunchy or sticky foods can be eaten for one week following treatment. Brushing can be postponed for 12 hours, but, any interproximal cleansing should be avoided for 10 days. Some sensitivity is normal. Treatment of periodontal pockets with Arestin has been shown to be the most effective local antibiotic when used as a stand alone therapy for chronic periodontitis. It is most effective when it used as an adjunctive therapy to scaling and root planing. This form of antibiotic therapy is also effective for smokers and for clients

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with cardiovascular disease. As with all classes of tetracycline antibiotics, patients should be alerted to the possibility of sensitivity to sunlight when local administration of these antibiotics have been made, along with the possibility of tooth staining.

Systemic Antibiotic Therapy Systemic therapy works best in conjunction with local antibiotic therapy. In addition, a periodontal maintenance program must follow and surgical therapy or extraction of teeth is to be delayed or not desired and routine treatment of chronic periodontitis is not indicated. Systemic antibiotics should be added to a therapeutic maintenance program when:

Meticulous mechanical instrumentation does not cease disease progression,

Aggressive periodontitis related to persistent periodontal pathogen growth occurs,

Impaired host resistance develops,

Acute infections are discovered. Along with localized forms of antibiotic therapy, systemic antibiotics promote clinical attachment gain and reduced pocket depth in patients with chronic periodontitis. None of these therapies are recommended for children or pregnant or nursing women. The long term use of oral antibiotics is generally not advised due to the risks of bacterial resistance. Doxycycline 20 mg. (Periostat). One capsule taken in the morning and one in the evening one hour before meals with adequate fluids is recommended to decrease the host’s enzyme response to the presence of periodontal pathogens. The enzymes released by the host which cause tissue destruction, in the presence of periodontitis, are known as collagenases. A 3, 6, or 9 month therapy depending on the host’s periodontal health status, and the unwillingness to undergo cessation of smoking, is prescribed to reduce gingival collagenase activity. No antimicrobial activity occurs with the prescribed use of Periostat because of its low concentration, therefore, it does not alter the microbial flora, nor contribute to antibiotic resistance forms. Metronidazole. Administration of either 250 mg three times a day for up to 2 weeks or 500 mg two times a day for two weeks has shown tremendous benefits in reducing the periodontal pathogen population in conjunction with the removal of dead, contaminated or adherent tissue or foreign material. Flagyl in combination with tetracycline or amoxicillin may be used for severe and chronic periodontal disease. One study using metronidazole therapy followed patients initially diagnosed with requiring either periodontal surgery or extractions for five years. After five years, patients remaining in the study averaged less than one tooth per patient requiring surgery or extraction. These studies indicated that anywhere from 62% to 87% of teeth initially recommended for invasive treatment were sustained for five more years. A routine periodontal maintenance phase of 3 month intervals was followed after an initial removal of dead, contaminated or adherent tissue or foreign material, metronidazole treatment, and a 4 to 6 week follow-up for each patient in the study. Systemic and local antibiotic therapy were repeated if it was still determined that reduced probing depth, new clinical attachment, and absence of bleeding had not taken place during the 3 month intervals during the first year. Metronidazole targets anaerobic organisms because of its broad spectrum activity. Since an estimated 90% of periodontal patients have anaerobic bacterial infections, this is the drug of choice for their treatment. Typically, a 7 day course of metronidazole treatment would be given following oral prophylaxis or anytime when the fewest numbers of bacteria can repopulate surfaces after the removal of dead, contaminated or adherent tissue

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or foreign material is complete. Caution must be given to patients who intend to drink alcohol while on metronidazole because a small percentage of patients have an Antabuse type of reaction. This reaction includes an intolerance to alcohol and can cause serious side effects: headache, nausea, vomiting, dizziness, sweating, pounding heart, blurred vision or weakness; which can last from 30 minutes to several hours. Other Treatments. Doxycycline 100 mg twice a day for one week is the second drug of choice after metronidazole, but, antibiotic resistant strains have been shown to develop more frequently. No such resistant strain has been found with metronidazole for 50 years. Another drug of choice is clindamycin 150 mg four times a day for one week, but, some patients can develop ulcerative colitis with this drug. Augmentin (amoxicillin with clavulonic acid) has also been used. Azithromycin (AZM) has also been shown to be effective when treating smokers. Polyphenols (Antioxidants). Newer studies are focusing on antioxidants known as polyphenols found in red wine, grape seed extracts, blueberries, and cranberries. They help to reduce tissue inflammation in the body including around periodontal sites. It has also been observed that components in cranberry extract help to reduce the biofilm build-up on tooth surfaces. A natural substance in cranberries inhibits the bioadhesion of bacteria to tooth surfaces. Cranberries have also been shown to inhibit the enzymes associate with the formation of plaque, prevent the formation of acids, and reduce the tolerance of cariogenic organisms.

Home Oral Healthcare Dentrifices

Fluoride Dentifrices. The active ingredient in most toothpaste is fluoride. Fluoride is formulated for release to bind with calcium on teeth in the form of sodium fluoride, sodium monofluorophosphate, stannous fluoride, and stannous fluoride/amine fluoride. All fluorides have been proven to control tooth decay, but stannous fluoride, available in such products as Colgate’s Gel Kam and Crest’s Pro Health, have demonstrated effectiveness for controlling gingivitis, plaque retention, and dentinal sensitivity. Antimicrobials. Stannous fluoride is also a broad spectrum antimicrobial agent. One study using 0.45% stannous fluoride/sodium hexametasphosphate for participants who had no response to minimizing their gingivitis, after six months of a sodium fluoride/triclosan/copolymer dentifrice, had greater than 50% less gingivitis when they used this dentifrice. This study was repeated and gave similar results. Triclosan, a disinfectant, is an antimicrobial agent added to some toothpaste to control the oral bacterial population. In order for it to be effective, triclosan must be carried in the toothpaste formulation by a polymer to enable it to retain presence long after tooth brushing is complete. When used in conjunction with fluoride, it has been shown to help prevent tooth decay, plaque and gingivitis. Zinc citrate has been used in toothpastes to inhibit plaque and gingival inflammation. A twelve week clinical study concluded that 2% zinc citrate with 0.76 % sodium monofluorophosphate reduced calculus by 31.9% over a non-tartar control toothpaste. Tartar control toothpastes. Pyrophosphates in toothpaste help to control tartar. Pyrophosphates are formulated as tetrasodium pyrophosphate, tetrapotassium pyrophosphate and disodium pyrophosphate to be absorbed into the enamel as a calcium complex that inhibits growth of crystals. This helps to reduce the formation of tartar. Pyrophosphates contribute to the abrasiveness of these toothpastes. Silica is the main abrasive component in toothpaste necessary to enable the scrubbing of teeth to remove stains. Other toothpaste formulations with less abrasiveness may be necessary when abrasion or the surfaces of dental restorations are to be observed. Tartar control toothpastes can cause tissue irritation which may be due to the increased alkalinity, increased detergent, or the increased flavoring needed to incorporate the pyrophosphate formulation.

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Desensitizing toothpaste. Strontium chloride, potassium nitrate, and sodium citrate interact with calcium phosphate in teeth. They block the dentinal tubules, and in the case of potassium nitrate, inactivate intradental nerves by raising extracellular potassium ions, causing teeth to be less sensitive. Baking soda toothpaste. Baking soda formulations in toothpaste remove extrinsic stain and inhibit the ability of plaque to attach to teeth. They are able to neutralize acids in the mouth and can clean with low abrasion. Yet, one study done with whitening dentifrices containing silica or calcium carbonate (a chalk abrasive) showed less abrasion with resin-based esthetic restorative materials than with sodium bicarbonate (baking soda). The whitening toothpaste Rembrandt, has the lowest abrasive formulation that does not use sodium bicarbonate. Detergents. Detergents such as sodium lauryl sulfate, sodium laurylsarcoside, and sodium monoglyceride sulfate act to loosen, emulsify, and remove debris from the teeth with their foaming action. The use of detergent formulations with sodium lauryl sulfate have been known to cause infrequent sensitivity to some people.

Mouth Rinses Daily mouthrinses are used to control and prevent periodontal disease. This is an effective method of delivering antimicrobial agents to sites in the mouth that harbor periodontal pathogens. Additions to mouthrinses such as zinc citrate are used to reduce calculus deposits. The safety of mouthrinses has not been established in children, especially for those containing alcohol. For effectiveness, the most important time of the day to use a mouthrinse is just before bedtime. If a mouthrinse is used at any other time other than bedtime, it is recommended to not rinse for 30 minutes after using the mouthrinse. Since, mouthrinses are not capable of reaching bacteria subgingivally, additional devices are needed to direct the mouthrinse into these areas. Essential Oils. Patients can benefit from an essential oil (EO) mouthrinse because they reduce gingivitis when tooth brushing and flossing are performed at the same time. EO’s work by altering the bacterial cell wall, without remaining on tooth surfaces for a long period of time. Over a six month period, a comparison of Listerine (an EO) and 0.12% chlorhexidine was performed. At the end of this study, no measurable differences of antiplaque and antigingivitis activity were observed between the two solutions. Usually, EO mouthrinses contain a considerable amount of ethyl alcohol in their formulations, which would not be recommended for recovering alcoholics. There has been no meaningful differences shown between alcoholic and non-alcoholic mouthrinses in effectiveness, and no associated risk with oral cancer exists. Alcoholic mouthrinses should not be used in patients who have used antidepressant drugs or cardiovascular medications, demonstrated dehydration, received radiation therapy for oral and pharyngeal cancer, and have developed xerostomia (dry mouth) or systemic diseases such as diabetes. EO’s in mouthrinses include thymol, menthol, eucalyptol, and methylsalicylate. Cetylperidinium chloride. A 0.07% solution of cetylperidinium chloride (CPC) used twice a day provides an antiplaque and antigingivitis efficacy similar to that of essential oils (the study was conducted by the manufacturer). CPC mouthrinse was also discovered to be successful in gingivitis and plaque control when used with tooth brushing. CPC mouthrinses are normally non-alcoholic and are formulated to increase bacterial cell wall permeability, along with having minimal retention on tooth surfaces. Triclosan. As with dentifrices, this disinfectant is used in mouthrinses as an antimicrobial agent capable of reducing plaque growth on teeth. To work effectively, it must be delivered along with a copolymer, so it may adhere to the tooth surface after rinsing is complete. Hydrogen peroxide. A high concentration of hydrogen peroxide or a long duration of use can damage teeth by reducing their microhardness, especially when used at a 30% concentration. Hydrogen peroxide, with as little as a 1.5% concentration, has been shown to reduce the bond strengths of glass ionomer cements, as well as, irritate the oral mucosa. But, these same adverse effects have not occurred at a 1.0% concentration.

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No adverse effects of hydrogen peroxide, on soft tissue, have occurred when a 1.5% to 3.0% concentration has been used in dentifrices. Most over the counter concentrations of hydrogen peroxide are in a 3.0% concentration. Even at a dilution of at least 2 and preferably 3 times with water, this solution is still beneficial. Its benefits include reduction of plaque, reduction of gingivitis, and most significantly, acceleration of wound healing. Chlorine dioxide. Chlorine dioxide is used for breath control. It has no effect on plaque or gingivitis. It is capable of reducing mouth odors by reducing the volatile sulfur compounds (VSC’s), produced by bacteria in the mouth, for up to 8 hours. Yet, when studies were done for longer periods of time, it was found that CPC based mouthrinses remained effective against bad breath for 2 to 4 weeks after initial use, when proper mouthrinsing instructions were followed. All mouthrinses containing chlorhexidine, triclosan, essential oils, or CPC begin to reduce oral malodors within 4 hours after use.

Home Care Devices Power toothbrushes. Manual and power toothbrushes use the scrubbing action of the brush head’s bristles to clean teeth. The hand generates around 300 strokes per minute when brushing teeth manually. Electric toothbrushes produce speeds capable of delivering 2500 to 7500 strokes per minute. Sonic toothbrushes, namely the Sonicare by Philips, use technology capable of creating vibrating speeds of up to 40,000 brush strokes per minute. Due to the intense speed of vibration of electric toothbrushes, energy is transferred to salivary and gingival fluids around the teeth causing molecules in these fluids to vibrate as well. This fluid vibration assists in the dislodging of dental plaque beyond where the toothbrush bristles touch. About 65% of dental plaque is removed from tooth surfaces at a 2 mm distance from teeth in just 5 seconds with the Sonicare. Sonic toothbrushes have had numerous studies performed with them. Sonicare by Philips holds patents that demonstrate greater amplitude in brushing proving their effectiveness in reducing tooth hypersensitivity, reducing dentin and root surface wear, and reducing plaque around orthodontic fixtures when compared to manual toothbrushes. All power toothbrushes have wide handles that benefit arthritic or handicapped patients when brushing. Both manual and power toothbrushing are capable of reaching subgingivally up to 2 mm. Flossing is effective up to 3 mm. Oral irrigators. The simple use of water as an irrigant has been show to improve clinical signs of periodontitis. The purpose of an oral irrigant is to reduce gingivitis, prevent periodontitis, remove periodontal pathogens, and massage and stimulate the gingiva. Supragingival irrigation can reach 2 to 4 mm, or about 40% of pocket depth. This is the level of treatment that can easily be performed at home with standard oral irrigation. Special irrigation tips specific for use in periodontal pockets can be used by patients at home to deliver subgingival irrigation up to 4 to 5 mm or about 70% of the pocket depth effectively. These tips can deliver oral irrigant to 90% of the total pocket area at a 6mm depth or 64% of the total pocket area at a 7 mm depth. Professional oral irrigation in the office can deliver oral irrigation to the full periodontal pocket at 100%. Certain oral irrigation devices use magnetized water to deliver treatment to the gingiva. It has been show that pulsation of water with these devices can achieve a 64% reduction in the accumulation of calculus. All oral irrigation devices can use antimicrobial and antiplaque solutions other than water to increase the benefit in the reduction of gingivitis and the prevention of periodontitis. Manufacturers caution the use of certain ingredients, which may cause clogging of the ports and channels inside the oral irrigators. Proper rinsing and care instructions should be followed to be able to deliver the best home irrigation care to the

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mouth.

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Conclusion A number of treatments have been identified to assist the dental professional in controlling the onset of initial or recurrent periodontal disease during the oral health maintenance phase. Each case must be monitored closely and managed carefully to deliver the best results for the patient. It is always imperative for the patient to remain diligent with their home and professional care to maintain the desired results. The long term prevention of periodontal disease is dependent on adequate mechanical plaque control. Every patient, whether they are a current or a new patient, may have varying circumstances which affect their oral health throughout their lifetime. This fluctuation means the dental professional will encounter different causes for the same oral problems and should not always approach the problem thinking the causes will be the same for each patient. Aging, dietary habits, health conditions, oral home care, and other mentally and physically stressful conditions can gradually cause or rapidly force changes in the delivery of oral health maintenance in the professional office. It is imperative to record oral health changes, seek reasons for these changes, and deliver the most appropriate treatment available to improve these oral conditions. This is the best way to deliver quality care to your patient who may be constantly experiencing a changing oral environment and who wishes to improve their oral health.

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