In yet another study extolling the value of excellent oral hygiene, good protocols as part of minimally invasive non-surgical therapy (MINST) are highly effective in preserving teeth that might once have been considered a lost cause. Moreover, there is emerging evidence that bone infill can take place after extended periods of enhanced hygiene both in the surgery and at home. However, for MINST to be effective, patient education is key.
The principle of the MINST approach to periodontal treatment hinges on effective decontamination of root surfaces, and infection control within periodontal pockets. Studies have demonstrated the effectiveness of this approach in reducing the clinical and radiographic depth of intra-bony defects.
A shift in prevalence, and a shift in treatment protocols
Between 2011 and 2020, periodontitis in dentate adults was estimated to be around 62 per cent and severe periodontitis 23.6 per cent. This represents a significant increase from figures compiled in the previous decade, which show a 50 per cent and 11 per cent prevalence respectively. Effective treatment for periodontal disease is essential to prevent periodontitis and the ensuing complications that result in tooth loss as well as damaging effects to patients’ systemic health and oral health related quality of life.
Periodontitis, being a microbial infection affecting gingival tissue, is generally treated with a focus on root surface decontamination and infection control. Up until recently, scaling and root planing combined with gingival curettage was common practice. Root planing involved the removal of contaminated cementum and dentine to restore the biocompatibility of diseased root surfaces. This approach was based on the concept that endotoxins and lipopolysaccharides from gram-negative bacteria penetrate the cementum. However, aggressive and repeated root planing is now generally considered to be an over-treatment. Endotoxins only loosely adhere to the root surface and don’t penetrate the cementum. In addition, there is generally evidence of subgingival recolonisation within four to eight weeks of planing or scaling.
Traditionally provided alongside scaling and root planing, gingival curettage is a surgical procedure designed to remove the soft tissue lining of the periodontal pocket with a curette, leaving only a gingival connective tissue lining. Short and long-term clinical trials have confirmed that gingival curettage provides no additional benefit in achieving probing depth reduction, attachment gain, or inflammation reduction.
New protocols
Supragingival and subgingival debridement, disrupting plaque and biofilm build-up is an essential treatment, and is considered the gold standard in periodontal treatment after a baseline examination to gauge patient motivation, and instruct them on proper oral hygiene.
Pocket and root instrumentation should be staged according to the severity of the condition, and ultrasonic devices with delicate tips, small curettes with longer terminal shanks and thinner blades used with magnification are recommended to carry out treatment according to MINST protocols. Healing should be monitored and clinically assessed before proceeding to a more invasive form of treatment.
Using these protocols, studies have shown a significant reduction in mobility and bleeding on probing (BOP), that is greater than reductions recorded using more invasive methods. In addition to this, randomised, controlled trials have shown that patients treated according to MINST protocols demonstrated slightly lower pocket depths than control groups, and significantly less gingival recession in deep molar pockets.
Prevention and management of periodontal disease
As well as an emphasis on oral hygiene and minimally invasive debridement and curettage methods over more invasive cementum removal procedures, MINST prioritises preventative treatment and advice. Optimal plaque control is essential for the success of non-surgical as well as surgical periodontal therapy. Toothbrushing alone is not sufficient for managing oral hygiene to effectively manage subgingival plaque. Interdental cleaning with interdental brushes has been shown in numerous studies to be the most effective way of managing enhanced oral hygiene.
Flexi Interdental brushes from Tandex are a great solution to recommend to patients at risk of developing or experiencing periodontal disease to help them implement enhanced oral hygiene at home. Adding a small amount of Prevent Gel from Tandex adds the healing effect of 900 ppm fluoride and the antibacterial power of 0.12 per cent chlorhexidine.
In the person-focused, prevention-based dental practice model, approaches that prioritise evidence-based, healthy outcomes are to be embraced. In addition to the right approach to professional cleaning, with the correct advice on maintaining excellent oral hygiene, patients can gain control of their oral health.
References available on request.
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