Acceleration in periodontal instrumentation

by Kristy Menage Bernie, RDH, BS

A look at some of the controversies surrounding full-mouth disinfection.

Quandrant scaling and root planing represent the gold standard in initial periodontal therapy. Once a client has been slated for these procedures, clinicians are faced with a number of challenges, including insufficient appointment time and multiple office visits. The challenges result in missed appointments and an extended period of time before a case is completed.

A small body of research has attempted to tackle the issue of a drawn-out instrumentation process and its impact on healing and clinical outcome. The reinfection potential from untreated quadrants to those that are meticulously debrided poses an interesting hypothesis and may account for the hit-and-miss successes seen with initial scaling and root planing therapy. This fact, combined with immune response within the debrided quadrant being potentially compromised, gives rationale for careful consideration and review of traditional instrumentation philosophies.

Appointment sequencing or recommended time for treatment completion is not referenced in dental hygiene textbooks. There seems to be a range of opinion among educators about scheduling quadrant-by-quadrant therapy two weeks apart vs. completing instrumentation as quickly as possible. Among dental hygiene students, there seems to be no agreed-upon timeframe in which to complete scaling and root planing.

As with any infection, periodontal disease represents a number of "wounds" that can be treated in a variety of ways. It makes sense to treat the wounds as quickly as possible to initiate the healing process and boost the immune response. One would not think of treating an open wound in segments - yet this appears to be the prevailing philosophy for periodontal infection.

The client further complicates the reality behind quadrant scaling and root planing. Clinicians often are at the mercy of hectic schedules and missed appointments, which further delay the opportunity for optimal therapy and clinical results. It is no wonder that registered dental hygienists experience burnout with this approach to care and clients are also doubtful, when no discernible or tangible results are experienced or realized.

Accelerating the periodontal instrumentation process makes sense from both health and time management standpoints.

Full-mouth vs. partial mouth

Research compared full-mouth disinfection (FMD) with partial mouth disinfection. The latter is defined as quadrant-by-quadrant instrumentation completed in a series of four appointments over six weeks. The FMD protocol included two appointments approximately one hour in length of full-mouth scaling and root planing. One-half of the mouth was treated at each appointment, which were performed within 24 hours of each other and immediately followed by oral disinfection procedures. These procedures included application of chlorhexidine to supragingival and subgingival environments along with tongue brushing and mouth rinsing with chlorhexidine.

Pockets were irrigated with a 1 percent chlorhexidine gel prior to instrumentation, followed by additional disinfection procedures. First, the tongue was brushed for 60 seconds with a 1 percent chlorhexidine gel, followed by rinsing twice with a 0.2 percent chlorhexidine solution for one minute. Then the pharynx was sprayed with 0.2 percent chlorhexidine and finally, subgingival irrigation was conducted on all pockets three times within 10 minutes with a 1 percent chlorhexidine gel. Subgingival application of 1-percent chlorhexidine gel was repeated on the eighth day. In addition to daily interdental plaque control, toothbrushing and brushing of the dorsum of the tongue by both groups, the test populations also rinsed with and sprayed tonsils twice a day with 0.2-percent chlorhexidine for two months.

The results realized via this protocol vs. standard therapy included:

A significant reduction in probing depths and gain in clinical attachment with probing depth reductions of 3.7 mm and 2.9 mm for single- and multi-rooted teeth in the test group
vs. 1.9 mm and 1.6 mm in the control group with additional reductions of 1.8 mm and 1.3 mm, respectively.

With respect to primary clinical outcomes, the test group experienced a significant gain in clinical attachment over the control population. These results were maintained for eight months without additional instrumentation appointments. In the test population, the reduction of probing depths, bleeding on probing, and gain in the clinical attachment continued to improve from the baseline data. In addition, the FMD population experienced a greater reduction in spirochetes and motile bacteria, eradication of p. gingivalis and decrease of oral malodor.

The results seemed to be directly linked to the acceleration of instrumentation. This was demonstrated in a later study that eliminated chlorhexidine gluconate from the protocol. The results between patients receiving the antimicrobial agent and those who did not were the same, with the exception of one parameter. The group receiving chlorhexidine gluconate experienced oral malodor reduction over the group who did not receive the treatment.

Chlorhexidine gluconate is a broad spectrum antimicrobial affecting both gram-positive and gram-negative organisms in addition to neutralizing volatile sulfur compounds (VSC), which are the odor-producing by-products of gram-negative organisms. This would account for the reduced oral malodor in the test population. Using chlorhexidine is warranted because VSC not only causes bad breath but also has proven potentially detrimental to the healing process. VSC have been associated with an increase permeability of mucosa, which results in increased bacteria invasion. Most importantly, VSC have been shown to interfere with collagen and protein synthesis. In light of this, chlorhexidine or other VSC-neutralizing agents will be beneficial to use during scaling and root planing.

Controversies surrounding FMD

Questions surrounding the benefits of full-mouth disinfection have surfaced recently. While there are a limited number of studies, the premise of accelerated instrumentation is practiced in a variety of research protocols. For example, those studies researching the efficacy of locally delivered antimicrobials begin at a baseline of instrumentation that includes full-mouth scaling and root planing. The completion time for full-mouth instrumentation ranges between studies, but most cases are completed within a matter of days or weeks vs. a six-week time span.

This fact is important for clinicians utilizing these agents because the placement of medicaments only occurs after full-mouth scaling and root planing, not quadrant-by-quadrant, which seems to be the practice reality in many instances. This leads clinicians to consider appropriate usage protocols for these adjunctive therapies. The results are based upon all factors, not just the presence of the medicament. Thus rationale for full-mouth accelerated scaling and root planing is evidence-based and more closely represents the study design that produced the clinical results.

Recent research abstracts have been presented that also claim no benefit to accelerating instrumentation times; however, these reports are based upon a few pocket sites being evaluated vs. all periodontal pockets. Logic and reason prevail when considering the advantages to accelerating instrumentation protocols where both clinicians and clients would be well served with strategic and rapidly progressive intervention. The opportunity to maximize results; fast-track treatment plans, including esthetic procedures; and refer cases for surgical intervention sooner outweigh any potential objection that might be raised with this process of care.

Modifying FMD protocols

The protocol stipulated in the FMD studies represents a challenge for both the clinician and client. Therefore, modifying the protocol using advanced technology and more effective means for debridement will allow it to be easily incorporated into clinical practice. The chart on page 68 details the process of care that may prove more advantageous and time efficient. Rinsing with a VSC neutralizing agent that will also control aerosolize flora certainly makes sense, particularly for those clinicians utilizing automated scaling instruments.

The use of automated scalers is becoming standard of care for quick, efficient, and more comfortable scaling options. Irrigating through these devices also will provide adequate pocket coverage of the agent and assist in neutralizing odor-causing and tissue-harming VSC subgingivally. This may be an effective option over irrigation with 1 percent chlorhexidine three times within 10 minutes as the original research indicated. Instead of brushing the tongue for 60 seconds with chlorhexidine, deplaquing the tongue with a tongue scraper and antimicrobial agent will be more comfortable and even more effective.

Finally, antimicrobials now can be placed - using local delivery - according to the research protocols that studied these agents. Some clinicians are opting to place these agents at the two-month evaluation phase in those sites that did not respond, instead of placement at the original scaling and root planing appointment. These minor modifications are easily implemented and will establish evidence-based protocols for those clinicians utilizing adjunctive therapy and may provide superior clinical results.

Accelerating the scaling and root planing process must be considered and standardized within professional protocols. Bringing practice realities in line with research protocols is essential for achieving optimal oral health and maintaining evidence-based practice.

Kristy Menage Bernie, RDH, BS, is the director of Educational Designs, a consulting service based in California. She is the current president of the California Dental Hygienists' Association. Ms. Bernie can be contacted at kme [email protected].

Proposed alternative FMD clinical protocol

•Two appointments of appropriate length scheduled within 24 hours, 1/2 mouth per appointment

•Pre-procedural antimicrobial rinse for 30 seconds

•Anesthesia administration

•Instrumentation

Powered instrumentation with self-contained water/medicament reservoir and antimicrobial irrigant
Hand instrumentation

•Tongue deplaquing/scraping with antimicrobial agent

•Post-procedural rinse for 30 seconds with antimicrobial agent

•Two-month evaluation. Baseline data should be collected prior to the initiation of instrumentation phase for comparative analysis.

Utilization of diagnostic devices to assess clinical outcome:
PerioProbe 2000 - Sulfide-detecting probe, identifies VSC active sites
BANA Test - Enzyme detection strips, tests for the presence of p. gingivalis, t. denticola and b. forsytheus
Dental View Perioscopy - subgingival fiberoptic camera, the only way to have visual access subgingivally