By Mark Kacerik, RDH, MS
The goal of phase I or initial periodontal therapy is to eliminate the microbial and contributing factors of periodontal disease with the intention of arresting of preventing the progression of the disease. The expected outcome is to maintain comfort, function esthetics and the integrity of the periodontium (gingiva, periodontal ligament, cementum, and alveolar bone). The American Academy of Periodontology established the following parameters for phase I therapy: (Parameter on Chronic Periodontitis with Advanced Loss of Periodontal support J of Periodontology 2000; 71:856-858.)
• Assessment and control of risk factors, which include systemic diseases, nutrition, medications, smoking, pregnancy, and substance abuse. Consultation with the patient's physician may be indicated.
• Assessment of oral self-care practices and instruction for the control of dental biofilm.
• Periodontal debridement to remove supra and subgingival calculus and biofilm.
• Assessment of microbial samples and application of antimicrobial agents.
• Control or elimination of contributing local factors such as overhangs, ill-fitting prostheses, carious lesions, and occlusal trauma.
Traditional approaches to the initial phase of periodontal therapy include multiple visits for the removal of dental biofilm, calculus, and endotoxins (periodontal debridement) from the crown, root surface and periodontal pocket.
Currently, the most widely used and accepted approach to nonsurgical periodontal therapy has been to plan a series of multiple appointments for periodontal debridement. This sequence of appointments referred to as quadrant scaling typically involves scheduling a series of appointments at approximately one to two week intervals to allow for oral hygiene instruction, debridement, healing, and re-evaluation of treatment at each appointment. Upon completion of quadrant scaling, the healing response is assessed and supplemental antimicrobial agents are applied.
Quadrant scaling at multiple appointments has been preferred to the earlier method of gross scaling or gross calculus removal in which large deposits of supragingival and subgingival calculus were removed from the entire mouth during the initial visit with the remaining deposits removed at subsequent visits. This approach to treatment has been discouraged because it allows for the continued proliferation of microorganisms, increases the potential for abscess formation, makes access to subgingival deposits more difficult due to partial healing at the gingival margin and leads to decreased patient compliance once supragingival deposits have been removed.(1, 2)
A more recent approach to periodontal debridement currently being researched is full-mouth debridement. This approach is defined as debridement that is completed in a single appointment or in two appointments within a 24-hour period. Full-mouth periodontal debridement supplemented with the application of chlorhexidine at the time of debridement and followed by daily oral rinsing with chlorhexidine for two months is termed full-mouth disinfection.(2, 3) The premise for this approach to treating periodontal disease is that bacteria from untreated areas could interfere with healing of treated sites.
Current research studies present varying results. Comparison studies of full-mouth and partial-mouth disinfection (quadrant scaling) found significant improvements in the reductions of microorganisms including spirochetes and motile rods and greater reduction in probing depths when full mouth disinfection was employed versus quadrant scaling.(4, 5, 6) Other studies indicate that there is no significant difference in clinical outcome when comparing quadrant scaling to full mouth disinfection. In addition further research is needed to determine the extent to which antimicrobials contribute to the results obtained from full-mouth disinfection.(7)
At present, the dental hygienist should consider both full and partial-mouth disinfection as viable options in the initial phase of periodontal therapy. Consideration should be given to the number and length of the appointments that best meet the patient's needs and is most likely to achieve patient compliance.
References
1. Wilkins E. Clinical Practice of the Dental Hygienist Eighth ed. 1999:547.
2. Nield-Gehrig S J. Fundamental of Periodontal Instrumentation & Advanced Root Instrumentation Fifth ed. 2004:278,378.
3. Darby M, Walsh M. Dental Hygiene Theory and Practice Second ed. 2003: 461.
4. Quirynen M, Mongardini C, Pauwels M, Bollen ML C, Van Eldere J, van Steenberghe D,. One Stage Full- Versus Partial-Mouth Disinfection in the Treatment of Chronic Adult or Generalized Early-Onset Periodontits. II. Long-Term Impact on Microbial Load. J Periodontology 1999;70:646-656.
5. Mongardini C, van Steenberghe D, Dekeyser C, Quirynen M. One Stage Full- Versus Partial-Mouth Disinfection in the Treatment of Chronic Adult or Generalized Early-Onset Periodontits. I. Long-Term Impact on Microbial Load. J Periodontology 1999;70:632-645.
6. De Soete M, Mongardini C, Pauwels M, Haffajee A, Socransky S, van Steenberghe D, Quirynen M. One Stage Full-Mouth Disinfection. Long-Term Microbiological Results Analyzed by Checkerboard DNA-DNA Hybridization. J Periodontology 2001;72.
7. Greenstein G. Full-Mouth Therapy Versus Individual Quadrant Root Planing: A Critical Commentary. J Periodontology 2002;73.
