Therapeutic Concepts and Techniques

All of the new knowledge gleaned in recent years, particularly in the areas of etiology and pathogenesis, have led to a true paradigm shift in treatment philosophy. This can be seen in many areas of practice. Following early diagnosis and early treatment, methods of and successes in prevention have become manifest. Only a few years ago, pocket elimination and freedom from plaque stood clearly in the foreground; however, today many other possibilities for combating periodontitis have entered the therapeutic larder.

Elimination/Reduction of Pathogenic Bacteria

It is impossible to achieve total freedom from plaque, either supragingivally or subgingivally. Therefore the goal of therapy is not the elimination of periodontopathic microorganisms, but rather “only” a significant reduction of the total number of microorganisms in the oral cavity. The goal is the creation of a homeostatic balance between resident bacteria and the host organism. Non-pathogenic microorganisms may be viewed as beneficial, because they often to maintain periodontopathic microorganisms in check (Fig. 444).

Elimination of the Biofilm—Causal Therapy

The first step toward such homeostasis is achieved mainly by mechanical disruption of the closed community of microorganisms represented by the biofilm within the periodontal pocket, and the subsequent removal of these microbes. Disrupting the biofilm permits attack by the host defense systems and topical medicaments. This type of pocket treatment, particularly the treatment of the root surface, is performed mechanically either “closed” or “open,” using ultrasonic instruments and/or conventional hand instruments.

The traditional closed mechanical treatment is particularly effective today when used in the “full mouth therapy” method (FMT; Quirynen et al. 1995, De Soete et al. 2001, Saxer 2002a, b). In the FMT technique, the pockets are continuously rinsed with a disinfectant solution (e.g., CHX, betadine etc.) during root planing. This combined technique improves the therapeutic results significantly, especially when all four quadrants are treated within a 24-hour period of time (p. 281).

Open (surgical) treatment also has as its primary goal the elimination of periodontopathic microorganisms within the biofilm. In addition, any morphologic defects of the bony pocket can be improved or corrected.

Corrective Therapy—Treating the Bony Defects

New knowledge makes it possible to predict regeneration of damaged periodontal structures:

• Filling of hard tissue defects with bone and bone replacement materials

• Using membrane-guided tissue regeneration (or combining both methods)

• Use of signal molecules such as matrix proteins, growth factors etc.

Influencing the Host

Unavoidable (non-alterable) risk factors such as genetic defects cannot be therapeutically influenced today; systemic diseases must, however, be diagnosed and treated by the physician. Thus, for example, a well controlled diabetic can be offered periodontal therapy with a good chance of success.

The patient’s alterable risk factors (p. 54) must also be eliminated or severely reduced.

Protecting the “Beneficial” Microorganisms

As mentioned, following periodontal therapy there should exist in the oral cavity an ecological homeostatic balance. In this regard, it is important that if the mechanical therapy is augmented by systemic medications, an antibiotic be selected that does not also eliminate the “useful or beneficial” microorganisms.