0ERIODONTOLOGY
"RIAN -ULLALLY
#HRIS )RWIN (ASSAN :IADA
%DITH !LLEN AND 0ATRICK * "YRNE
0ERIODONTICS  .ON 3URGICAL
0ERIODONTAL 4HERAPY IN 'ENERAL
$ENTAL 0RACTICE
!BSTRACT .ON SURGICAL PERIODONTAL THERAPY IS AN INTEGRAL PART OF PERIODONTAL TREATMENT AND HAS BEEN DEFINED AS PLAQUE REMOVAL PLAQUE
CONTROL SUPRA AND SUBGINGIVAL SCALING ROOT SURFACE DEBRIDEMENT AND THE ADJUNCTIVE USE OF CHEMICAL AGENTS
#LINICAL 2ELEVANCE +NOWLEDGE OF THE ROLE OF NON SURGICAL PERIODONTAL THERAPY IS CENTRAL TO GOOD PATIENT CARE
$ENT 5PDATE    
!IMS OF NON SURGICAL
PERIODONTAL THERAPY
#URRENT APPROACHES FOR THE
MANAGEMENT OF PERIODONTITIS ARE AIMED
AT REDUCING THE INFECTIVE COMPONENT THUS
PROVIDING AN ENVIRONMENT COMPATIBLE
WITH HEALING OF THE PERIODONTAL TISSUES
"RIAN -ULLALLY #ONSULTANT3ENIOR ,ECTURER
$EPARTMENT OF 2ESTORATIVE $ENTISTRY
1UEENS 5NIVERSITY OF "ELFAST 3CHOOL OF
#LINICAL $ENTISTRY 2OYAL 6ICTORIA (OSPITAL
"ELFAST "4 "0 .ORTHERN )RELAND #HRIS
)RWIN 2EADER#ONSULTANT $EPARTMENT OF
2ESTORATIVE $ENTISTRY 1UEENS 5NIVERSITY OF
"ELFAST 3CHOOL OF #LINICAL $ENTISTRY 2OYAL
6ICTORIA (OSPITAL "ELFAST "4 "0 .ORTHERN
)RELAND (ASSAN :IADA 3ENIOR ,ECTURER
#ONSULTANT 5NIVERSITY $ENTAL 3CHOOL AND
(OSPITAL 7ILTON #ORK 2EPUBLIC OF )RELAND
%DITH !LLEN ,ECTURER $EPARTMENT OF
2ESTORATIVE $ENTISTRY 5NIVERSITY #OLLEGE
#ORK 5NIVERSITY $ENTAL 3CHOOL AND (OSPITAL
7ILTON #ORK 2EPUBLIC OF )RELAND AND 0ATRICK
* "YRNE ,ECTURER $UBLIN $ENTAL (OSPITAL
AND 0RACTICE ,IMITED TO 0ERIODONTICS IN
$UBLIN 2EPUBLIC OF )RELAND
 $ENTAL5PDATE
3UCCESSFUL TREATMENT PLANNING FOR
PATIENTS WITH PERIODONTAL DISEASE IS ONLY
POSSIBLE WHEN AN ADEQUATE ASSESSMENT
OF THE POTENTIAL CONTRIBUTORY FACTORS AND
A COMPREHENSIVE CLINICAL EXAMINATION HAS
BEEN CONDUCTED 0ART  $ENT 5PDATE 
    4HE LONG TERM SUCCESS OF
TREATMENT IS DEPENDENT UPON THE PROVISION
OF REGULAR EFFECTIVE MAINTENANCE THERAPY
0ART  )N PRESS  "OTH THE INITIAL AND
MAINTENANCE PHASES OF PERIODONTAL THERAPY &IGURE  #ALCIFICATION OF PLAQUE INTO CALCULUS
CONSIST PREDOMINANTLY OF NON SURGICAL PROMOTES THE RETENTION OF FURTHER PLAQUE
PROCEDURES INCLUDING ORAL HYGIENE SELF CARE
PERIODONTAL INSTRUMENTATION AND THE USE
OF CHEMOTHERAPEUTIC AGENTS 4HIS PAPER
WILL PRESENT A REVIEW OF THE APPROPRIATE TO PROTECT THE TISSUES FROM ANTIGENIC
PROVISION OF NON SURGICAL CARE IN THE INVASION 4HE POCKET ITSELF CONTAINS A
TREATMENT OF PERIODONTAL DISEASE COMPLEX MIXTURE BASED ON INFLAMMATORY
EXUDATE AND CONTAINING PRODUCTS OF BOTH
THE INFLAMMATORY RESPONSE AND TISSUE
4HE PERIODONTAL POCKET DESTRUCTION IN ADDITION TO MAINLY MOTILE
4HE PERIODONTAL POCKET IS A BACTERIA AND BACTERIAL PRODUCTS 4HE VAST
BLIND ENDED SACK BOUNDED BY BOTH HARD MAJORITY OF SUBGINGIVAL BACTERIA ARE FOUND
AND SOFT TISSUE WALLS 4HE SOFT TISSUE WALLS IN A BIOFILM COVERING THE HARD TISSUE WALL OF
ARE LINED BY AN ULCERATED EPITHELIUM THE POCKET ´ THE ROOT SURFACE 4HIS COMPLEX
OVERLYING AN INFLAMED CONNECTIVE TISSUE COMMUNITY OF BACTERIA AND EXTRA CELLULAR
CONTAINING MANY INFLAMMATORY AND POLYMERS SHOWS REMARKABLE ORGANIZATION
IMMUNE DERIVED CELLS 0OLYMORPHS MIGRATE PROVIDING PROTECTION NUTRITION AND
THROUGH THE POCKET WALL IN AN ATTEMPT COMMUNICATION FOR AND BETWEEN A VARIETY
*ULY!UGUST 
 0ERIODONTOLOGY
&IGURE  -ETAL FATIGUE FROM OVERSHARPENING OF A
CURETTE RESULTING IN FRACTURE OF ITS WORKING END
ACCESSIBLE POCKETS
4HE WORKING EDGE MUST BE
MAINTAINED BY SHARPENING WITH AN !RKANSAS
STONE OR SIMILAR LUBRICATED WITH SHARPENING
OIL &IGURE   )N THE INTEREST OF SAFE PRACTICE
SHARPENING SHOULD BE CARRIED OUT PRIOR TO
USE SO AS TO EXCLUDE THE POSSIBILITY OF A
SHARPS INJURY WITH A CONTAMINATED CURETTE
4HE OBJECTIVE OF SHARPENING IS TO RESTORE
A SHARP ACUTE ANGLE AT THE WORKING EDGE
OF THE INSTRUMENT BUT AT THE SAME TIME
TO MAINTAIN THE ORIGINAL SHAPE OF THE
BLADE 7HILE ELECTRICAL SHARPENING DEVICES
MAY REDUCE THE NEED FOR PHYSICAL EFFORT
IT IS IMPORTANT TO REALIZE THAT INSTRUMENT
MAINTENANCE IS MOST EFFECTIVE WHEN CARRIED
OUT ON A REGULAR BASIS AND IDEALLY SHOULD
BE PERFORMED EACH TIME BEFORE USING THE
INSTRUMENTS "LUNT CURETTES ARE INEFFECTIVE
FOR ROOT INSTRUMENTATION AS THEY RESULT IN
THE BURNISHING OF CALCULUS DEPOSITS AND
REQUIRE EXCESSIVE LATERAL PRESSURE ON THE
ROOT SURFACE !FTER CLINICAL USE INSTRUMENTS
SHOULD BE INSPECTED FOR SIGNS OF METAL
FATIGUE OR OTHER DAMAGE &IGURE  
4REATMENT SCHEDULE
)N  1UIRYNEN ET AL REPORTED
SIGNIFICANT MICROBIOLOGICAL AND CLINICAL
IMPROVEMENTS FOLLOWING A SINGLE VISIT FULL
MOUTH @DISINFECTION METHOD COMPARED TO
MULTIPLE VISIT QUADRANT BASED APPROACHES
TO PERIODONTAL THERAPY 4HE RATIONALE FOR
THIS THERAPY WAS THE PREVENTION OF RE
INFECTION OF TREATED SITES BY PATHOGENS
RESIDING IN NON TREATED SITES OR OTHER
INTRA ORAL NICHES DURING THE PERIOD OF
TREATMENT -ORE RECENTLY COMPARISON OF
BOTH TREATMENT SCHEDULES HAS FAILED TO
DEMONSTRATE A SIGNIFICANT DIFFERENCE WITH
THE ONE STAGE FULL MOUTH DISINFECTION
AND THE QUADRANT SCALING TECHNIQUES
 $ENTAL5PDATE
)NTERDENTAL #LEANING !ID
$ENTAL FLOSSTAPE
3UPERFLOSS
7OODSTICKS
)NTERDENTAL BRUSHES
3INGLE TUFTED BRUSHES
4ABLE  )NTERDENTAL CLEANING AIDS
BOTH RESULTING IN SIGNIFICANT CLINICAL
IMPROVEMENTS WITH THE CHOICE OF MODALITY
DEPENDING MORE ON PATIENT AND CLINICIAN
PREFERENCE
0LAQUE CONTROL
0LAQUE CONTROL IS A CRUCIAL
COMPONENT OF ANY NON SURGICAL PERIODONTAL
THERAPY 4HE IMPORTANCE OF THE PATIENTS
CONTRIBUTION MUST BE EMPHASIZED ´ IN
SIMPLE TERMS THE PATIENT IS RESPONSIBLE
FOR CLEANING SUPRAGINGIVAL AREAS WHILE
THE CLINICIAN HOLDS RESPONSIBILITY FOR THE
SUBGINGIVAL SITES 7HILE IT IS NOT REASONABLE
TO EXPECT PATIENTS TO ACHIEVE A PLAQUE
FREE DENTITION THEY MUST BE ABLE TO
MAINTAIN PLAQUE AT A LEVEL CONSISTENT WITH
PERIODONTAL HEALTH IN THAT INDIVIDUAL 4HE
MOST COMMONLY USED METHOD OF ORAL
HYGIENE CONTROL IN THE DEVELOPED WORLD IS
BY TOOTHBRUSHING WITH DENTIFRICE ,ANG ET AL
SUGGESTED THAT TOOTHBRUSH DESIGN SHOULD
TAKE ACCOUNT OF THE USERS AGE AND DEXTERITY
SO THAT THE HANDLE DESIGN AND HEAD SIZE ARE
APPROPRIATE FOR PROPER USE 4HIS GROUP ALSO
RECOMMENDED SOFT END ROUNDED BRISTLE
DESIGN IN POLYESTER OR NYLON 4HE MOST
COMMONLY USED TOOTHBRUSHING TECHNIQUE
IS THE "ASS TECHNIQUE WHERE THE BRISTLES OF
THE BRUSH ARE ORIENTATED AT ² TO THE TOOTH
SURFACE INTO THE GINGIVAL SULCUS AND SMALL
VIBRATORY STROKES USED
%LECTRIC POWERED TOOTHBRUSHES
ARE NOW COMMONPLACE AND IF USED
#LINICAL 5SAGE
!LL INTERDENTAL SPACES
#AN BE DIFFICULT TO USE EFFECTIVELY
-OST EFFECTIVE IN GINGIVAL SULCUS
"RIDGEWORK
!LL INTERDENTAL SPACES
3IMPLE TO USE
0OSTERIOR TEETH
&URCATION DEFECTS
0APILLARY RECESSION
#ROWDING
,OCALIZED RECESSION
CORRECTLY CAN BE EFFECTIVE PARTICULARLY
WHERE MANUAL DEXTERITY IS POOR 3TUDIES
HAVE SHOWN A SMALL IMPROVEMENT IN PLAQUE
CONTROL WHEN USING POWERED RATHER THAN
MANUAL TOOTHBRUSHES #LEREHUGH ET AL ALSO
DEMONSTRATED THEIR ADDITIONAL BENEFIT IN THE
CONTROL OF GINGIVITIS IN ORTHODONTIC PATIENTS
)NTERDENTAL CLEANING IS ALSO AN
ESSENTIAL COMPONENT OF EVERYDAY PLAQUE
CONTROL FOR THE PERIODONTAL PATIENT AND A
WIDE VARIETY OF TECHNIQUES AND DEVICES ARE
AVAILABLE 4ABLE   4HE CHOICE OF INTERDENTAL
CLEANING AID IS DEPENDENT ON BOTH THE
PATIENTS DEXTERITY AND THE CLINICAL SETTING
$ENTAL FLOSS AND TAPE ARE PARTICULARLY USEFUL
IN THE ANTERIOR SEGMENTS WHERE THEY ARE
EASIER TO USE AND CAN CLEAN INTO THE GINGIVAL
SULCUS )N POSTERIOR SEGMENTS PARTICULARLY
BETWEEN MULTI ROOTED TEETH OR IN AREAS OF
GINGIVAL RECESSION INTERDENTAL BRUSHES MAY
BE MORE BENEFICIAL &IGURE   3INGLE TUFTED
&IGURE )NTERDENTAL BRUSH BEING USED IN A THROUGH
AND THROUGH FURCATION DEFECT
*ULY!UGUST 

A B
&IGURE  A B (EALING FOLLOWING NON SURGICAL PERIODONTAL THERAPY
OF SPECIES #ALCIFICATION OF PLAQUE RESULTING
IN THE FORMATION OF CALCULUS PROMOTES
THE RETENTION OF PLAQUE AND MAY INCREASE
THE RATE OF PLAQUE FORMATION 4HE SURFACE
OF CALCULUS IS COVERED IN PLAQUE WHILE
ITS POROSITY ALSO PROVIDES A RESERVOIR OF
PATHOGENS &IGURE   4HE ROOT SURFACE ITSELF
COMPRISES POROUS AND NECROTIC CEMENTUM
2ATIONALE FOR NON SURGICAL
THERAPY
4HE HEALING PROCESS FOLLOWING
PERIODONTAL TREATMENT INVOLVES THE
REATTACHMENT OF A LONG JUNCTIONAL
EPITHELIUM TO A CLEANED ROOT SURFACE
&IGURE   0ERIODONTAL TREATMENT IS
THEREFORE PRIMARILY AIMED AT THE REMOVAL
OF SUBGINGIVAL PLAQUE AND CALCULUS 7HILE
THE REMOVAL OF CALCULUS FROM THE ENAMEL
SURFACES OF THE TEETH MAY BE ACHIEVED BY
SCALING ALONE DEPOSITS ON THE ROOT SURFACES
ARE FREQUENTLY LOCKED INTO IRREGULARITIES IN
THE CEMENTUM 4HE SUPERFICIAL PORTION OF
THE DEPOSITS CAN BE DETACHED BY SCALING
BUT RESIDUAL PIECES OF CALCULUS MAY REMAIN
EMBEDDED IN THE CEMENTUM 2ESIDUAL
CALCULUS DEPOSITS ON THE ROOT SURFACE MAY
ACT AS A NIDUS FOR CRYSTALLIZATION IN THE
MINERALIZATION OF NEW SUBGINGIVAL PLAQUE
4HESE RESIDUAL FRAGMENTS CAN BE ELIMINATED
BY REMOVING ALL OR SOME OF THE CEMENTUM
BY ROOT INSTRUMENTATION #EMENTUM ITSELF
IS PERMEABLE AND TOXINS FROM PATHOGENS
WITHIN SUBGINGIVAL PLAQUE MAY SEEP INTO
ITS STRUCTURE 4HIS CEMENTUM SHOULD BE
RENDERED SMOOTH AND CALCULUS FREE IN ORDER
TO FACILITATE PLAQUE REMOVAL AND REDUCE THE
INFLAMMATION WITHIN THE PERIODONTAL POCKET
7HILE THE COMPLETE REMOVAL OF SUBGINGIVAL
PLAQUE AND CALCULUS MAY BE DESIRABLE THIS IS
UNACHIEVABLE AND A MORE REALISTIC OBJECTIVE
*ULY!UGUST 
OF TREATMENT IS TO REDUCE THE SUBGINGIVAL
BACTERIAL LOAD TO A LEVEL COMMENSURATE WITH
PERIODONTAL HEALTH
)NSTRUMENT SELECTION
-ANY METHODS OF CALCULUS
REMOVAL HAVE BEEN ADVOCATED 4HESE
INCLUDE THE USE OF HAND SONIC AND
ULTRASONIC INSTRUMENTS 4HERE IS LITTLE
EVIDENCE TO SUGGEST THAT ANY SINGLE METHOD
IS SUPERIOR TO ANY OTHER AND IN REALITY A
COMBINATION OF TECHNIQUES ARE OFTEN USED
&ACTORS SUCH AS PATIENT COMFORT EXAMINER
FATIGUE ACCESS AND TIME CONSTRAINTS ARE
IMPORTANT IN THE DECISION MAKING PROCESS
WHEN SELECTING INSTRUMENTS FOR SCALING
&OR INSTANCE WHEN SCALING OR ROOT PLANING
PATIENTS WITH SENSITIVE TEETH WELL HONED
CURETTES MAY CAUSE LESS DISCOMFORT AND
SO ARE BETTER TOLERATED THAN ULTRASONIC
INSTRUMENTS 3ONIC AND PARTICULARLY
ULTRASONIC INSTRUMENTS ALLOW TASKS TO BE
COMPLETED MORE QUICKLY /THER FACTORS
SUCH AS THE DEPTH OF PERIODONTAL POCKETS OR
RESTRICTED ACCESS CAN AFFECT THE OPERATORS
ABILITY TO REMOVE ALL SIGNIFICANT DEPOSITS
3ONIC AND ULTRASONIC SCALING
4HE USE OF POWERED SCALERS
FOR SUBGINGIVAL INSTRUMENTATION PRODUCES
SIMILAR LEVELS OF DEPOSIT REMOVAL TO HAND
SCALING 4HIS EQUIVALENCE IN EFFECT ALONGSIDE
THE REDUCED TIME REQUIRED FOR TREATMENT
HAS RESULTED IN A SIGNIFICANTLY GREATER
USE OF POWERED SCALERS IN PERIODONTAL
THERAPY 0OWERED SCALERS CAN BE DIVIDED
INTO TWO TYPES ´ SONIC AND ULTRASONIC ´
DEPENDING ON THEIR OPERATING FREQUENCY
)N CURRENT PRACTICE ULTRASONIC SCALERS ARE
MOST COMMONLY USED 4HESE OPERATE AT
0ERIODONTOLOGY
FREQUENCIES OF  ´  CYCLES PER
SECOND (Z  4WO TYPES OF ULTRASONIC UNITS
ARE AVAILABLE
„ -AGNETOSTRICTIVE UNITS IN WHICH THE
ELECTRICAL CURRENT CAUSES AN INSERT TO EXPAND
AND CONTRACT ALONG ITS LENGTH 4HIS RESULTS
IN AN ELLIPTICAL PATTERN OF MOVEMENT OF THE
WORKING TIP ENSURING THAT ALL SURFACES OF THE
TIP ARE ACTIVE DURING SCALING AND
„ 0IEZZO ELECTRIC UNITS IN WHICH THE PATTERN
OF VIBRATION IS LINEAR WITH THE LATERAL SURFACES
OF THE TIP BEING MOST ACTIVE #ONSTANT
MOVEMENT OF THE TIP WITH OVERLAPPING
STROKES AND LIGHT PRESSURE PRODUCES OPTIMAL
RESULTS WHILE NOT DAMAGING THE ROOT SURFACE
3ONIC INSTRUMENTS VIBRATE AT
A MUCH LOWER FREQUENCY ´  ´ 
CYCLES PER SECOND (OWEVER COMPARATIVE
STUDIES HAVE SHOWN SIMILAR LEVELS OF EFFECT
BETWEEN SONIC AND ULTRASONIC SCALING IN THE
TREATMENT OF PERIODONTITIS
'RACEY CURETTES
2OOT INSTRUMENTATION CAN BE
PERFORMED USING HOES FILES OR CURETTES
#URETTES ARE SUPPLIED IN A VARIETY OF DESIGNS
4HE 'RACEY PATTERN OF INSTRUMENTS DIFFER
FROM THE 5NIVERSAL PATTERN IN THAT THEY
ARE DESIGNED FOR ROOT PLANING IN SPECIFIC
SITES AROUND THE MOUTH AND HAVE ONLY
ONE CUTTING EDGE ! FULL SET CONSISTS OF
NINE DOUBLE ENDED INSTRUMENTS ALTHOUGH
MANY CLINICIANS WOULD REGULARLY USE A SET
OF SEVEN 4HE INSTRUMENTS HAVE AN OFFSET
BLADE WITH ONE CUTTING OR WORKING EDGE
4HE BLADE IS CURVED IN MORE THAN ONE
DIRECTION TO ALLOW CLOSE ADAPTATION TO THE
ROOT SURFACE 6ARIATIONS ON THE ORIGINAL
DESIGN ARE AVAILABLE FROM A NUMBER OF
MANUFACTURERS AND MODIFICATIONS INCLUDE
MINIATURIZED BLADES AND LONGER LOWER
SHANKS TO ALLOW ROOT PLANING IN DEEPER LESS
&IGURE  !RKANSAS STONE
$ENTAL5PDATE 
 0ERIODONTOLOGY
&IGURE  -ETAL FATIGUE FROM OVERSHARPENING OF A
CURETTE RESULTING IN FRACTURE OF ITS WORKING END
ACCESSIBLE POCKETS
4HE WORKING EDGE MUST BE
MAINTAINED BY SHARPENING WITH AN !RKANSAS
STONE OR SIMILAR LUBRICATED WITH SHARPENING
OIL &IGURE   )N THE INTEREST OF SAFE PRACTICE
SHARPENING SHOULD BE CARRIED OUT PRIOR TO
USE SO AS TO EXCLUDE THE POSSIBILITY OF A
SHARPS INJURY WITH A CONTAMINATED CURETTE
4HE OBJECTIVE OF SHARPENING IS TO RESTORE
A SHARP ACUTE ANGLE AT THE WORKING EDGE
OF THE INSTRUMENT BUT AT THE SAME TIME
TO MAINTAIN THE ORIGINAL SHAPE OF THE
BLADE 7HILE ELECTRICAL SHARPENING DEVICES
MAY REDUCE THE NEED FOR PHYSICAL EFFORT
IT IS IMPORTANT TO REALIZE THAT INSTRUMENT
MAINTENANCE IS MOST EFFECTIVE WHEN CARRIED
OUT ON A REGULAR BASIS AND IDEALLY SHOULD
BE PERFORMED EACH TIME BEFORE USING THE
INSTRUMENTS "LUNT CURETTES ARE INEFFECTIVE
FOR ROOT INSTRUMENTATION AS THEY RESULT IN
THE BURNISHING OF CALCULUS DEPOSITS AND
REQUIRE EXCESSIVE LATERAL PRESSURE ON THE
ROOT SURFACE !FTER CLINICAL USE INSTRUMENTS
SHOULD BE INSPECTED FOR SIGNS OF METAL
FATIGUE OR OTHER DAMAGE &IGURE  
4REATMENT SCHEDULE
)N  1UIRYNEN ET AL REPORTED
SIGNIFICANT MICROBIOLOGICAL AND CLINICAL
IMPROVEMENTS FOLLOWING A SINGLE VISIT FULL
MOUTH @DISINFECTION METHOD COMPARED TO
MULTIPLE VISIT QUADRANT BASED APPROACHES
TO PERIODONTAL THERAPY 4HE RATIONALE FOR
THIS THERAPY WAS THE PREVENTION OF RE
INFECTION OF TREATED SITES BY PATHOGENS
RESIDING IN NON TREATED SITES OR OTHER
INTRA ORAL NICHES DURING THE PERIOD OF
TREATMENT -ORE RECENTLY COMPARISON OF
BOTH TREATMENT SCHEDULES HAS FAILED TO
DEMONSTRATE A SIGNIFICANT DIFFERENCE WITH
THE ONE STAGE FULL MOUTH DISINFECTION
AND THE QUADRANT SCALING TECHNIQUES
 $ENTAL5PDATE
)NTERDENTAL #LEANING !ID
$ENTAL FLOSSTAPE
3UPERFLOSS
7OODSTICKS
)NTERDENTAL BRUSHES
3INGLE TUFTED BRUSHES
4ABLE  )NTERDENTAL CLEANING AIDS
BOTH RESULTING IN SIGNIFICANT CLINICAL
IMPROVEMENTS WITH THE CHOICE OF MODALITY
DEPENDING MORE ON PATIENT AND CLINICIAN
PREFERENCE
0LAQUE CONTROL
0LAQUE CONTROL IS A CRUCIAL
COMPONENT OF ANY NON SURGICAL PERIODONTAL
THERAPY 4HE IMPORTANCE OF THE PATIENTS
CONTRIBUTION MUST BE EMPHASIZED ´ IN
SIMPLE TERMS THE PATIENT IS RESPONSIBLE
FOR CLEANING SUPRAGINGIVAL AREAS WHILE
THE CLINICIAN HOLDS RESPONSIBILITY FOR THE
SUBGINGIVAL SITES 7HILE IT IS NOT REASONABLE
TO EXPECT PATIENTS TO ACHIEVE A PLAQUE
FREE DENTITION THEY MUST BE ABLE TO
MAINTAIN PLAQUE AT A LEVEL CONSISTENT WITH
PERIODONTAL HEALTH IN THAT INDIVIDUAL 4HE
MOST COMMONLY USED METHOD OF ORAL
HYGIENE CONTROL IN THE DEVELOPED WORLD IS
BY TOOTHBRUSHING WITH DENTIFRICE ,ANG ET AL
SUGGESTED THAT TOOTHBRUSH DESIGN SHOULD
TAKE ACCOUNT OF THE USERS AGE AND DEXTERITY
SO THAT THE HANDLE DESIGN AND HEAD SIZE ARE
APPROPRIATE FOR PROPER USE 4HIS GROUP ALSO
RECOMMENDED SOFT END ROUNDED BRISTLE
DESIGN IN POLYESTER OR NYLON 4HE MOST
COMMONLY USED TOOTHBRUSHING TECHNIQUE
IS THE "ASS TECHNIQUE WHERE THE BRISTLES OF
THE BRUSH ARE ORIENTATED AT ² TO THE TOOTH
SURFACE INTO THE GINGIVAL SULCUS AND SMALL
VIBRATORY STROKES USED
%LECTRIC POWERED TOOTHBRUSHES
ARE NOW COMMONPLACE AND IF USED
#LINICAL 5SAGE
!LL INTERDENTAL SPACES
#AN BE DIFFICULT TO USE EFFECTIVELY
-OST EFFECTIVE IN GINGIVAL SULCUS
"RIDGEWORK
!LL INTERDENTAL SPACES
3IMPLE TO USE
0OSTERIOR TEETH
&URCATION DEFECTS
0APILLARY RECESSION
#ROWDING
,OCALIZED RECESSION
CORRECTLY CAN BE EFFECTIVE PARTICULARLY
WHERE MANUAL DEXTERITY IS POOR 3TUDIES
HAVE SHOWN A SMALL IMPROVEMENT IN PLAQUE
CONTROL WHEN USING POWERED RATHER THAN
MANUAL TOOTHBRUSHES #LEREHUGH ET AL ALSO
DEMONSTRATED THEIR ADDITIONAL BENEFIT IN THE
CONTROL OF GINGIVITIS IN ORTHODONTIC PATIENTS
)NTERDENTAL CLEANING IS ALSO AN
ESSENTIAL COMPONENT OF EVERYDAY PLAQUE
CONTROL FOR THE PERIODONTAL PATIENT AND A
WIDE VARIETY OF TECHNIQUES AND DEVICES ARE
AVAILABLE 4ABLE   4HE CHOICE OF INTERDENTAL
CLEANING AID IS DEPENDENT ON BOTH THE
PATIENTS DEXTERITY AND THE CLINICAL SETTING
$ENTAL FLOSS AND TAPE ARE PARTICULARLY USEFUL
IN THE ANTERIOR SEGMENTS WHERE THEY ARE
EASIER TO USE AND CAN CLEAN INTO THE GINGIVAL
SULCUS )N POSTERIOR SEGMENTS PARTICULARLY
BETWEEN MULTI ROOTED TEETH OR IN AREAS OF
GINGIVAL RECESSION INTERDENTAL BRUSHES MAY
BE MORE BENEFICIAL &IGURE   3INGLE TUFTED
&IGURE )NTERDENTAL BRUSH BEING USED IN A THROUGH
AND THROUGH FURCATION DEFECT
*ULY!UGUST 
 0ERIODONTOLOGY
BRUSHES ARE PARTICULARLY USEFUL IN AREAS OF
CROWDING AND LOCALIZED GINGIVAL RECESSION
#HEMICAL PLAQUE CONTROL
!NTIBACTERIAL AGENTS
INCORPORATED INTO MOUTHRINSES TOOTHPASTES
AND DENTAL FLOSS ARE USED TO SUPPORT
MECHANICAL CLEANING AND REDUCE PLAQUE
FORMATION IN THE MOUTH %XAMPLES OF
SOME OF THE MATERIALS THAT HAVE BEEN
SHOWN TO BE EFFECTIVE WHEN INCLUDED IN
ORAL HYGIENE PRODUCTS ARE CHLORHEXIDINE
DIGLUCONATE CETYLPYRIDINIUM CHLORIDE AND
OTHER QUATERNARY AMMONIUM COMPOUNDS
PHENOLS TRICLOSAN AND METHYL SALICYLATE
#HLORHEXIDINE AT A CONCENTRATION
OF  REMAINS THE MOST COMMONLY
USED MOUTHRINSE IN PERIODONTAL THERAPY
#HLORHEXIDINE IS BACTERICIDAL DISRUPTING
THE BACTERIAL CELL MEMBRANE !N IMPORTANT
PROPERTY IS ITS SUBSTANTIVITY INCREASING
RETENTION TIMES IN THE MOUTH AND THUS
INCREASING EFFECTIVENESS #HLORHEXIDINE
CAN HAVE SIDE EFFECTS INCLUDING TOOTH
STAINING PARTICULARLY ROOT SURFACES AND TASTE
DISTURBANCES )T SHOULD ONLY BE USED FOR
SHORT PERIODS OF ´ WEEKS FOR EXAMPLE
AFTER NON SURGICAL OR SURGICAL THERAPY TO
SUPPORT THE NORMAL MECHANICAL PLAQUE
REMOVAL 3URFACTANTS WITHIN TOOTHPASTES
INTERFERE WITH CHLORHEXIDINE ACTIVITY SO IT
IS NOT RECOMMENDED THAT CHLORHEXIDINE
MOUTHRINSES ARE USED IMMEDIATELY
FOLLOWING TOOTHBRUSHING
,ISTERINE4- CONTAINS THYMOL
EUCALYPTOL METHYL SALICYLATE AND METHANOL
#LINICAL STUDIES ON THE USE OF ,ISTERINE
HAVE REPORTED A REDUCTION IN PLAQUE AND
GINGIVITIS SCORES %SSENTIAL OIL MOUTHRINSE
SHOULD ALSO BE RECOMMENDED TO PATIENTS
WHOSE MECHANICAL ORAL HYGIENE PROCEDURES
MAY NOT BE ADEQUATE AND ITS INCLUSION HAS
BEEN SUGGESTED AS AN ADJUNCT TO DAILY ORAL
HYGIENE PROCEDURES
-OUTHRINSE FORMULATIONS ARE
NOT EFFECTIVE AT PENETRATING THE GINGIVAL
CREVICE AND ARE THEREFORE ONLY OF USE IN THE
CONTROL OF SUPRAGINGIVAL PLAQUE !TTEMPTS
TO INCREASE THE EFFICACY OF SOME OF THESE
MATERIALS IN THE SUBGINGIVAL ENVIRONMENT
HAVE INCLUDED THEIR USE AS SUBGINGIVAL
IRRIGANTS 4HERE ARE CONFLICTING REPORTS IN THE
LITERATURE REGARDING SUBGINGIVAL IRRIGATION
DEPENDING UPON THE MATERIALS USED THE
METHOD OF APPLICATION AND THE PERIOD OF
THERAPY )T WOULD SEEM HOWEVER THAT THE
 $ENTAL5PDATE
MECHANICAL FLUSHING ACTION MAY HAVE AN
ADDITIONAL EFFECT IN THE REDUCTION OF GINGIVAL
INFLAMMATION IN SUBJECTS WITH DEFICIENT ORAL
HYGIENE
4HERE HAS ALSO BEEN RENEWED
INTEREST IN TOPICAL ANTISEPTICS IN THE
MANAGEMENT OF PERIODONTITIS 0OVIDONE
AND IODINE IN A  SOLUTION HAS BEEN
USED IN CONJUNCTION WITH ULTRASONIC SCALING
AND AS A SUBGINGIVAL IRRIGANT 3ODIUM
HYPOCHLORITE HAS ALSO BEEN SUGGESTED AS
 SOLUTION FOR SUBGINGIVAL IRRIGATION 4HE
MAIN SHORTCOMING OF SUBGINGIVAL IRRIGATION
AS A THERAPY FOR PERIODONTAL TREATMENT IS
THE QUICK ELIMINATION OF THE IRRIGANTS FROM
THE PERIODONTAL POCKET 4HIS HAS LED TO THE
DEVELOPMENT OF A NUMBER OF GEL BASED
MATERIALS FOR SUBGINGIVAL APPLICATION IN
COMBINATION WITH THE MORE TRADITIONAL
METHODS OF NON SURGICAL PERIODONTAL
THERAPY SEE BELOW 
2ESPONSE TO NON SURGICAL
TREATMENT
)T IS WELL ESTABLISHED THAT IN THE
MOTIVATED PATIENT NON SURGICAL THERAPY WILL
RESULT IN AN IMPROVEMENT IN PERIODONTAL
HEALTH 4HE DATA SHOW THAT THE DEGREE OF
IMPROVEMENT IN TERMS OF POCKET DEPTH
REDUCTION IS DEPENDENT ON THE INITIAL
POCKET DEPTH )N SHALLOW POCKETS OF 
MM OR LESS THERE IS LITTLE IMPROVEMENT IN
POCKET DEPTH AND INDEED THERE CAN BE
FURTHER ATTACHMENT LOSS FOLLOWING ROOT
INSTRUMENTATION )N POCKETS OF ´ MM THE
AVERAGE POCKET DEPTH REDUCTION IS AROUND
 MM WHEREAS IN THOSE SITES WITH AN INITIAL
DEPTH OF AT LEAST  MM A REDUCTION OF  MM
OR MORE COULD BE EXPECTED 0ERIODONTAL
HEALING MOSTLY OCCURS WITHIN THE FIRST
MONTH POST TREATMENT BUT MAY CONTINUE
FOR ´ MONTHS AFTER INSTRUMENTATION AND
PREMATURE RE EVALUATION MAY UNDERESTIMATE
THE RESPONSE
"LEEDING ON PROBING ALSO
SIGNIFICANTLY REDUCES FOLLOWING NON
SURGICAL THERAPY !LTHOUGH BLEEDING ON
PROBING IS WIDELY USED AS AN INDICATOR OF
DISEASE IN CLINICAL PRACTICE IT SHOWS ONLY
A WEAK CORRELATION TO THE PROGRESSION
OF PERIODONTAL DESTRUCTION 4HE ABSENCE
OF BLEEDING IS BETTER CORRELATED WITH
PERIODONTAL HEALTH AND SHOULD BE USED TO
INDICATE PERIODONTAL STABILITY 4HUS DEEP
PERIODONTAL POCKETS WHICH HAVE SHOWN A
REDUCTION IN POCKET DEPTH AND NO BLEEDING
FOLLOWING THERAPY SHOULD BE MAINTAINED
THROUGH A PROGRAMME OF SUPPORTIVE
PERIODONTAL CARE 2ESIDUAL DEEP SITES WHICH
BLEED ON PROBING SHOULD BE CHECKED FOR
RESIDUAL CALCULUS AND INFECTED CEMENTUM
AND RE INSTRUMENTED AS REQUIRED
0ERIODONTAL SURGERY MAY WELL BE REQUIRED AT
SUCH SITES WHERE STABILITY IS NOT ACHIEVED
-ICROBIAL RESPONSE
)N AN EVALUATION OF  SPECIES
USING $.! CHECKERBOARD HYBRIDIZATION
 MONTHS AFTER COLONIZATION (AFFAJEE ET
AL FOUND THAT SCALING AND ROOT PLANING
ACHIEVED A SIGNIFICANT REDUCTION IN
PROPORTIONS AND COUNTS OF 0 GINGIVALIS "
FORSYTHUS AND 4 DENTICOLA ALTHOUGH OTHER
SPECIES WERE UNCHANGED 4HE REDUCTION
IN WHAT 3LOTS REFERRED TO AS THE RED SPECIES
WAS ACCOMPANIED BY AN IMPROVEMENT IN
PERIODONTAL INDICES !LTHOUGH NON SURGICAL
INSTRUMENTATION CAN RESULT IN REMOVAL OF
MORE THAN  OF THE MICRO ORGANISMS
WITHIN  MONTHS THESE MAY REBOUND TO
BASELINE LEVELS 2ECOLONIZATION RATES CAN
VARY MARKEDLY BETWEEN SPECIES 3UGGESTED
REASONS FOR THIS VARIATION INCLUDE THE
FASTIDIOUS NATURE OF THE AFFECTED MICRO
ORGANISMS LOSS OF NUTRIENT SUPPLY AND
EPITHELIAL REPAIR WITHIN THE POCKET WALL AND
RESOLUTION OF INFLAMMATION
!NTIMICROBIAL THERAPY
!DJUNCTIVE TREATMENTS CAN BE
USED IN PERIODONTAL THERAPY IN ADDITION TO
CONVENTIONAL MECHANICAL THERAPY 4HEY CAN
BE DIVIDED INTO SYSTEMIC OR LOCAL DELIVERY
AND IN THE LATTER THE ADJUNCTIVE MATERIAL
IS DELIVERED DIRECTLY INTO THE PERIODONTAL
POCKET !S PERIODONTAL DISEASE IS ESSENTIALLY
AN INFECTION THE USE OF ANTIMICROBIALS
MAY INITIALLY APPEAR A REASONABLE OPTION
(OWEVER FOR A NUMBER OF REASONS RELATING
TO EFFECTIVENESS THE NATURE OF THE DISEASE
AND COST BENEFIT THE USE OF ANTIMICROBIALS IS
ONLY SUPPORTED IN SPECIFIC AREAS
4HE MAJOR PROBLEM RELATED TO
THE USE OF ADJUNCTIVE THERAPEUTICS IS GAINING
ACCESS TO TARGET BACTERIA 3UBGINGIVAL
BACTERIAL PLAQUE IS AN EXTREMELY COMPLEX
BIOFILM PROTECTING THE COMPONENT BACTERIA
FROM ANTIMICROBIAL ATTACK 4HE LACK OF
PENETRATION OF THE BIOFILM BY ANTIBIOTICS
NEGATES CLINICAL EFFECTIVENESS !NTIMICROBIAL
AGENTS CAN ONLY BE EFFECTIVE IF THE PLAQUE
*ULY!UGUST 
 0ERIODONTOLOGY

THESE RECENT STUDIES ARE RELATIVELY SHORT

#ONDITION !NTIBIOTIC USED AS AN ADJUNCT
TERM AND ARE BUILDING THE EVIDENCE BASE
FOR ANTIBIOTIC USAGE )T IS STILL TOO EARLY TO
'ENERALIZED AGGRESSIVE PERIODONTITIS #OMBINATION OF AMOXICILLIN  MG
STATE THAT ALL CASES OF THE ABOVE CONDITIONS
METRONIDAZOLE  MG
REQUIRE SYSTEMIC ANTIBIOTICS RATHER THEY
SHOULD BE CONSIDERED ON AN INDIVIDUAL BASIS
'ENERALIZED ADVANCED PERIODONTITIS -ETRONIDAZOLE  MG THREE TIMES
&OR EXAMPLE 7INKEL ET AL FOUND THAT THE
WITH SUPPURATION DAILY FOR n DAYS
USE OF SYSTEMIC ANTIBIOTICS IN THE TREATMENT
OF ADVANCED PERIODONTITIS ONLY HAD A
.ECROTIZING ULCERATIVE GINGIVITIS -ETRONIDAZOLE  MG THREE TIMES
SIGNIFICANT EFFECT ON TREATMENT OUTCOME
DAILY FOR n DAYS
IN THOSE PATIENTS HARBOURING 0 GINGIVALIS
4HERE WAS NO ADJUNCTIVE BENEFIT IN PATIENTS
!CUTE PERIODONTAL ABSCESS WITH -ETRONIDAZOLE  MG THREE TIMES
WITHOUT THIS PATHOGEN !S THERE ARE NO
SYSTEMIC MALAISE DAILY FOR  DAYS
RELIABLE SYSTEMS READILY AVAILABLE TO DENTISTS
4ABLE  3UGGESTED DOSAGES FOR SYSTEMIC ANTIBIOTICS IN PERIODONTAL THERAPY TO DETECT SPECIFIC PERIODONTAL PATHOGENS IT
IS NOT POSSIBLE TO DETERMINE THEIR PRESENCE
,OCAL DELIVERY -ATERIAL !NTIBACTERIAL !PPLICATION 0REPARATION IN A PATIENT
AGENT COMMERCIAL AGENT AND STORAGE !T PRESENT THE ONLY CONDITIONS
NAME WHERE THE USE OF SYSTEMIC ANTIBIOTICS SHOULD
BE CONSIDERED ARE
-ETRONIDAZOLE GEL 'EL  2EAPPLY AFTER 3TORE AT ROOM „ !CUTE ULCERATIVE GINGIVITIS
%LYZOL -ETRONIDAZOLE  WEEK TEMPERATURE „ 'ENERALIZED AGGRESSIVE PERIODONTITIS
„ 'ENERALIZED ADVANCED PERIODONTITIS WITH
-INOCYCLINE GEL 'EL  2EAPPLY AT 3TORE IN EVIDENCE OF SUPPURATION
$ENTOMYCIN -INOCYCLINE n DAYS REFRIGERATOR „ !CUTE PERIODONTAL ABSCESS WITH EVIDENCE
OF SYSTEMIC MALAISE
$OXYCYCLINE GEL 'EL  MG 3INGLE $UAL SYRINGE 4HE MAIN GROUPS OF
!TRIDOX $OXYCYCLINE APPLICATION MIXING SYSTEM ANTIMICROBIALS FOR SYSTEMIC USE ARE
HYCLATE METRONIDAZOLE THE TETRACYCLINES
AND THE COMBINATION OF AMOXYCILLIN
#HLORHEXIDINE CHIP #HIP  MG 3INGLE 3TORE IN AND METRONIDAZOLE 4HE PERIODONTAL
0ERIOCHIP #HLORHEXIDINE APPLICATION REFRIGERATOR PATHOGENS ! ACTINOMYCETEMCOMITANS AND
0 GINGIVALIS HAVE BEEN ASSOCIATED WITH
4ETRACYCLINE FIBRES &IBRE  2EMOVE AFTER #UT FIBRE AND GENERALIZED AGGRESSIVE PERIODONTITIS "OTH
!CTISITE 4ETRACYCLINE  DAYS SECURE WITH BACTERIA HAVE THE ABILITY TO INVADE THE
ADHESIVE GINGIVAL TISSUES PROVIDING A DEGREE OF
4ABLE  ,OCAL DELIVERY ANTIMICROBIAL AGENTS  NOT CURRENTLY AVAILABLE IN 5+  PROTECTION FROM MECHANICAL CLEANING !S !
ACTINOMYCETEMCOMITANS WAS KNOWN TO BE
SENSITIVE TO TETRACYCLINES THESE ANTIBIOTICS
WERE OFTEN USED AS ADJUNCTIVE THERAPY IN
BIOFILM IS INITIALLY DISRUPTED BY MECHANICAL 3YSTEMIC ANTIBIOTICS AGGRESSIVE DISEASE 7ITH THE DEVELOPMENT
CLEANING THUS EXPOSING THE PERIODONTAL )T IS CLEAR FROM CLINICAL STUDIES OF TETRACYCLINE RESISTANT STRAINS OF !
PATHOGENS THAT THE USE OF SYSTEMIC ANTIBIOTICS IN CASES ACTINOMYCETEMCOMITANS RECENT RESEARCH
OF MILD OR MODERATE CHRONIC PERIODONTITIS HAS FOCUSED ON THE USE OF COMBINED
HAS NO ADDITIONAL BENEFIT FOR THE PATIENT METRONIDAZOLE  MG 4)$ AND AMOXICILLIN
'IVEN THE POTENTIAL FOR THE DEVELOPMENT  MG 4)$ FOR  DAYS IN THE TREATMENT OF
OF RESISTANT STRAINS FOLLOWING CONTINUED THESE CASES 4ABLE  
ANTIBIOTIC THERAPY IT IS ESSENTIAL THAT
ANTIBIOTICS ARE NOT USED IN THESE CASES
)N RECENT YEARS A NUMBER OF ,OCAL DELIVERY ANTIMICROBIALS
CLINICAL TRIALS HAVE REPORTED AN ADDITIONAL ! NUMBER OF PRODUCTS FOR THE
BENEFIT IN THE USE OF SYSTEMIC ANTIBIOTICS LOCAL DELIVERY OF ANTIMICROBIAL AGENTS INTO
IN CASES OF GENERALIZED ADVANCED OR THE PERIODONTAL POCKET HAVE RECENTLY
AGGRESSIVE PERIODONTITIS PARTICULARLY IN THE BECOME COMMERCIALLY AVAILABLE 4ABLE  
PRESENCE OF SUPPURATION !GAIN THE MAJOR 4HE POTENTIAL ADVANTAGES OF LOCAL DELIVERY
&IGURE  -ETRONIDAZOLE GEL %LYZOL¸  BENEFIT WAS ONLY SEEN IN DEEP SITES OF  INCLUDE
MM OR DEEPER  )T MUST BE STRESSED THAT „ 4O ALLOW DIRECT ACCESS TO THE DISEASED SITE

*ULY!UGUST  $ENTAL5PDATE 

 0ERIODONTOLOGY
&IGURE  -INOCYCLINE GEL $ENTOMYCIN ¸
A OLEATE 4HE DELIVERY MECHANISM IS BY WAY
B PERIODONTAL POCKET AND CAN BE RETAINED
&IGURE  A B 4OPICAL DOXYCYCLINE !TRIDOX¸ 
„ 4O ENSURE SUFFICIENT CONCENTRATION OF
ANTIBIOTIC AT THE SITE OF ACTION
„ 4O REDUCE THE RISK OF SYSTEMIC SIDE EFFECTS
„ 4O NEGATE THE NEED FOR PATIENT
COMPLIANCE
"EFORE DISCUSSING INDIVIDUAL
PRODUCTS IT MUST BE EMPHASIZED THAT THE
A B
&IGURE  A B #HLORHEXIDINE CHIP 0ERIOCHIP¸
 $ENTAL5PDATE
SUCCESSFUL MANAGEMENT OF PERIODONTITIS IS
DEPENDENT UPON ADEQUATE CALCULUS REMOVAL
AND DISRUPTION OF THE PLAQUE BIOFILM
WHICH CANNOT BE ACHIEVED BY LOCAL DELIVERY
SYSTEMS ALONE 4HESE PRODUCTS SHOULD BE
USED ONLY AS ADJUNCTS TO ROUTINE MECHANICAL
THERAPY
-ETRONIDAZOLE GEL
4HIS MATERIAL IS PRODUCED AS A
 METRONIDAZOLE BENZOATE IN A MATRIX
CONTAINING SESAME OIL AND GLYCERYL MONO
OF A BLUNT METAL CANNULA ATTACHED TO A
PLASTIC SYRINGE SYSTEM &IGURE   )NITIAL
STUDIES COMPARING METRONIDAZOLE GEL WITH
MECHANICAL INSTRUMENTATION OF PERIODONTITIS
SITES SUGGESTED EQUIVALENCE IN EFFECT
BETWEEN BOTH THERAPIES -ORE RECENT
STUDIES INDICATE A SMALL BENEFICIAL EFFECT OF
METRONIDAZOLE GEL WHEN USED AS AN ADJUNCT
TO SCALING AND ROOT INSTRUMENTATION
-INOCYCLINE GEL
4HIS PRODUCT $ENTOMYCIN¸
HAS BEEN COMMERCIALLY AVAILABLE FOR
PROFESSIONAL USE IN THE 5NITED +INGDOM
FOR ALMOST A DECADE &IGURE   )T HAS THE
GREAT ADVANTAGE OF BEING SIMPLE TO USE
BUT HAS LOW VISCOSITY AND CAN BE EASILY
WASHED FROM THE POCKET ! NUMBER OF
CLINICAL INVESTIGATIONS DEMONSTRATE SOME
SUPERIORITY IN CLINICAL AND MICROBIOLOGICAL
RESPONSE WHEN MINOCYCLINE GEL WAS APPLIED
IN CONJUNCTION WITH MECHANICAL TREATMENT
ALTHOUGH THESE DIFFERENCES WERE RELATIVELY
SMALL
$OXYCYCLINE GEL
¸
4OPICAL DOXYCYCLINE !TRIDOX IS
SUPPLIED AS A  GEL SYSTEM WHICH NEEDS TO
BE THOROUGHLY MIXED PRIOR TO PLACEMENT
&IGURE   /N CONTACT WITH MOISTURE THE
GEL SETS TO A SEMI SOLID AND CAN BE PACKED
INTO THE POCKET USING A DENTAL INSTRUMENT
&IGURE   $OXYCYCLINE IS RELEASED FROM
THE POLYMER CARRIER OVER A PERIOD OF ´
DAYS 4OPICAL DOXYCYCLINE HAS BEEN SHOWN
TO HAVE A BENEFICIAL EFFECT WHEN USED AS AN
ADJUNCT TO SCALING AND ROOT INSTRUMENTATION
PARTICULARLY IN DEEP SITES )N A COMPARATIVE
STUDY INVESTIGATING THE EFFECTS OF !TRIDOX¸
%LYZOL¸ AND 0ERIOCHIP¸ IN RESIDUAL PERIODONTAL
POCKETS * MM ALL THREE MATERIALS SHOWED
A SIGNIFICANT REDUCTION IN POCKET DEPTH
COMPARED TO MECHANICAL TREATMENT ALONE
WHILE !TRIDOX¸ ALSO SHOWED A SIGNIFICANT GAIN
IN MEAN ATTACHMENT LEVELS
4ETRACYCLINE FIBRES
!CTISITE¸ COMPRISES WOVEN
ETHYLENE VINYL ACETATE POLYMER FIBRES
IMPREGNATED WITH  TETRACYCLINE 4HE
FIBRE HAS TO BE CAREFULLY PLACED INTO THE
USING A TISSUE GLUE OR PERIODONTAL PACK
#LINICAL STUDIES ON THE TETRACYCLINE
FIBRE SHOWED PROMISING RESULTS WITH
IMPROVEMENTS IN POCKET DEPTH REDUCTION
BLEEDING ON PROBING AND GAIN IN
ATTACHMENT LEVEL )N ONE COMPARATIVE STUDY
!CTISITE¸ PERFORMED BETTER THAN BOTH %LYZOL¸
AND $ENTOMYCIN¸ AS AN ADJUNCTIVE TREATMENT
IN RESIDUAL DEEP SITES (OWEVER THE
PERCEIVED DIFFICULTIES IN PLACEMENT OF THE
FIBRE HAS GREATLY REDUCED ITS USE IN CLINICAL
PRACTICE IT IS NO LONGER AVAILABLE IN THE
5NITED +INGDOM
#HLORHEXIDINE CHIP
#HLORHEXIDINE HAS BEEN IN
COMMON USAGE IN CLINICAL PERIODONTICS
FOR ALMOST THREE DECADES AND A RECENT
DEVELOPMENT HAS BEEN TO INCORPORATE IT INTO
A GELATIN CHIP FOR PLACEMENT IN PERIODONTAL
POCKETS AS A LOCAL DELIVERY DEVICE &IGURE
A  4HESE CHIPS ARE RESORBABLE AND ARE
SUPPLIED AS AN ADJUNCTIVE MATERIAL TO
BE USED IN RESIDUAL POCKETS IN EXCESS OF
 MM WHICH CONTINUE TO BLEED IN SPITE
OF RIGOROUS MECHANICAL THERAPY &IGURE
B  -ORE RECENTLY THE ADVOCATES OF THIS
THERAPY SUGGEST THAT IT HAS A PLACE IN THE
MAINTENANCE PHASE OF TREATMENT )N A
MULTICENTRE RANDOMIZED CONTROLLED TRIAL
COMPARING THE USE OF COMBINED CHIP
AND MECHANICAL THERAPY WITH MECHANICAL
THERAPY ALONE IN PERIODONTAL SITES *
*ULY!UGUST 

MM IN DEPTH *EFFCOAT ET AL REPORTED THAT
COMBINATION THERAPY RESULTED IN A HIGHER
PREVALENCE OF POCKET DEPTH REDUCTION OF
 MM OR MORE COMPARED WITH SCALING AND
ROOT INSTRUMENTATION ALONE 7HILE THE EFFECT
OF THE ADJUNCTIVE CHIP ON PROBING DEPTH
REDUCTIONS IN THIS STUDY WAS FOUND TO BE
STATISTICALLY SIGNIFICANT THE MEAN DIFFERENCE
BETWEEN COMBINATION THERAPY INCLUDING
0ERIOCHIP AND ROUTINE MECHANICAL THERAPY
WAS  MM
,OCAL DELIVERY ANTIMICROBIALS ´
SUGGESTIONS FOR USE
7HEN THEY FIRST ARRIVED ON
THE MARKET MANY STUDIES INVESTIGATED
LOCAL DELIVERY ANTIMICROBIALS AS POTENTIAL
REPLACEMENTS FOR MECHANICAL THERAPY
4ODAY THESE MATERIALS ARE CONSIDERED AS
ADJUNCTS TO ROUTINE SCALING AND ROOT SURFACE
DEBRIDEMENT )T MUST BE REMEMBERED
THAT DISRUPTION OF THE SUBGINGIVAL PLAQUE
BIOFILM IS NECESSARY FOR SUCCESSFUL CHEMICAL
ANTIMICROBIAL THERAPY )N ADDITION SIMPLE
MECHANICAL THERAPY ON ITS OWN WILL
INDUCE A SIGNIFICANT IMPROVEMENT IN THE
PERIODONTAL CONDITION AND IN MANY CASES
IS SUFFICIENT TO INDUCE PERIODONTAL STABILITY
.EVERTHELESS THERE ARE CLINICAL SITUATIONS
WHEN ADJUNCTIVE TOPICAL ANTIMICROBIAL
THERAPY COULD BE CONSIDERED 4HESE INCLUDE
„ ,OCALIZED AGGRESSIVE PERIODONTITIS
„ 2ESIDUAL PERIODONTAL POCKETING *
MM WITH BLEEDING ON PROBING FOLLOWING
MECHANICAL THERAPY
„ ,OCALIZED CHRONIC PERIODONTAL ABSCESS
$RUGS WHICH AFFECT THE HOST RESPONSE
"ESIDES THE ANTI INFECTIVE
PROPERTIES OF ANTIBIOTICS SUCH AS
TETRACYCLINES THEIR ABILITY TO MODULATE
HOST RESPONSE BY THE REDUCTION OF
COLLAGENASE ACTIVITY HAS ALSO BEEN
UTILIZED IN PERIODONTAL THERAPY #URRENTLY
A LOW DOSAGE FORM OF DOXYCYCLINE
HYCLATE 0ERIOSTAT¸ IS AVAILABLE AS A HOST
MODULATION AGENT IN THE MAINTENANCE OF
PERIODONTAL HEALTH FOR PATIENTS WITH CHRONIC
PERIODONTITIS 4HIS IS PRESCRIBED AS A  MG
CAPSULE FOR PATIENTS TO TAKE TWICE DAILY FOR
UP TO  MONTHS 4HE LOW DOSE DOXYCYCLINE
HAS NO ANTIBACTERIAL EFFECTS BUT RATHER
INHIBITS COLLAGENASE ACTIVITY IN THE TISSUES
#ATON HAS REPORTED SOME IMPROVEMENT
IN PROBING DEPTH AND ATTACHMENT LEVELS
*ULY!UGUST 
ASSOCIATED WITH 0ERIOSTAT¸ USE OVER A
 MONTH PERIOD )N ADDITION THIS STUDY
SHOWED A REDUCTION IN THE PREVALENCE OF
SITES LOSING  MM OR MORE IN THE 0ERIOSTAT¸
GROUP DURING THE STUDY PERIOD )N A
MULTICENTRE TRIAL 0RESHAW ET AL REPORTED
THAT A SUBANTIMICROBIAL DOSE DOXYCYCLINE
PRESCRIBED AS AN ADJUNCT TO SCALING AND
ROOT INSTRUMENTATION RESULTS IN STATISTICAL
AND CLINICAL IMPROVEMENTS IN PERIODONTAL
HEALTH OVER AND ABOVE THOSE ACHIEVED
BY MECHANICAL THERAPY ALONE (OWEVER
SCALING AND ROOT PLANING MUST BE THOROUGH
TO MAXIMIZE THE BENEFITS OF ADJUNCTIVE
THERAPY 4HE SUB MINIMUM INHIBITORY
CONCENTRATIONS OF DOXYCYCLINE ENSURE NO
DEVELOPMENT OF RESISTANT BACTERIAL STRAINS
(OWEVER PATIENT COMPLIANCE OVER A 
MONTH PERIOD CAN BE PROBLEMATICAL
#ONCLUSIONS
4HE EFFICACY OF NON SURGICAL
PERIODONTAL THERAPY IN THE CONTROL OF MOST
FORMS OF PERIODONTITIS IS WELL SUPPORTED
BY A DIVERSITY OF STUDIES IN THE PERIODONTAL
LITERATURE 4HE IMPORTANCE OF A THOROUGH
AND CAREFUL PRE TREATMENT ASSESSMENT
AND THE DEVELOPMENT OF A GOOD WORKING
RELATIONSHIP BETWEEN CLINICIAN AND PATIENT
CANNOT BE OVERSTATED 4HE PATIENT MUST
BE MADE AWARE OF THE NEED FOR GOOD
COMPLIANCE TO ORAL HYGIENE REGIMES FROM
THE OUTSET OF TREATMENT AND THE CLINICIAN
SHOULD ALSO DEVOTE SUFFICIENT TIME AND
ENERGY INTO EDUCATING HISHER PATIENTS
ABOUT THE NATURE OF PERIODONTAL DISEASE
7HILE SOME FACTORS SUCH AS GENETIC
PREDISPOSITION TO PERIODONTITIS MAY BE OUT
OF THE SPHERE OF CONTROL OF THE CLINICIAN AND
THE PATIENT OTHER FACTORS SUCH AS CIGARETTE
SMOKING CAN AND SHOULD BE ADDRESSED IF A
SUCCESSFUL OUTCOME IS TO BE ACHIEVED 4HE
NEED FOR LIFELONG MAINTENANCE PROGRAMMES
CUSTOMIZED TO SUIT THE INDIVIDUAL ARE
CRUCIAL TO STABILIZE PERIODONTAL HEALTH
AND THE INVOLVEMENT OF DENTAL HYGIENISTS
UNDER THE DIRECTION OF GENERAL DENTAL
PRACTITIONERS IN THE PROVISION OF THIS CARE
CAN FACILITATE THIS "ASED UPON CURRENT
EVIDENCE THE RECOMMENDATIONS FOR
ANTIMICROBIAL THERAPIES ARE THAT THEY ARE
NOT AN ALTERNATIVE BUT RATHER THAT THEY
HAVE THE POTENTIAL TO ENHANCE NON SURGICAL
MECHANICAL THERAPY
0ERIODONTOLOGY
2EFERENCES
 (ERMANN *3 2IEDER # 2ATEITSCHAK +(
(EFTI !& 3ONIC AND ULTRASONIC SCALERS
IN A CLINICAL COMPARISON ! STUDY IN
NON INSTRUCTED PATIENTS WITH GINGIVITIS
OR SLIGHT ADULT PERIODONTITIS 3CHWEIZ
-ONATSSCHR :AHNMED  
´
 1UIRYNEN - "OLLEN #-, 6AN
DER (ERCKHOVE ".! $EKEYSER #
0APAIOANNOU 7 %YSSEN ( &ULL VS
PARTIAL MOUTH DISINFECTION IN THE
TREATMENT OF PERIODONTAL INFECTIONS
SHORT TERM CLINICAL AND MICROBIOLOGICAL
OBSERVATIONS * $ENT 2ES  
´
 "OLLEN #-, -ONGARDINI #
0APAIOANNOU 7 6AN 3TEENBERGHE $
1UIRYNEN - 4HE EFFECT OF ONE
STAGE FULL MOUTH DISINFECTION ON
DIFFERENT INTRAORAL NICHES #LINICAL AND
MICROBIOLOGICAL OBSERVATIONS * #LIN
0ERIODONTOL   ´
 +OSHY ' +AWASHIMA 9 +IJI - .ITTA (
5MEDA - .AGASAWA 4 )SHIKAWA )
%FFECTS OF SINGLE VISIT FULL MOUTH
ULTRASONIC DEBRIDEMENT VERSUS
QUADRANT WISE ULTRASONIC DEBRIDEMENT
* #LIN 0ERIODONTOL   ´
 ,ANG .0 !TTSTROM 2 ,OE ( 0ROCEEDINGS
OF THE %UROPEAN 7ORKSHOP ON
-ECHANICAL 0LAQUE #ONTROL "ERLIN
1UINTESSENCE 
 #LEREHUGH 6 7ILLIAMS 0 3HAW 7#
7ORTHINGTON (6 7ARREN 0 ! PRACTICE
BASED RANDOMIZED CONTROLLED TRIAL
OF THE EFFICACY OF AN ELECTRIC AND A
MANUAL TOOTHBRUSH ON GINGIVAL HEALTH
IN PATIENTS WITH FIXED ORTHODONTIC
APPLIANCES * $ENTISTRY  
´
 #HARLES #( 0AN 0# 3TURDIVANT ,
6INCENT *7 )N VIVO ANTIMICROBIAL
ACTIVITY OF AN ESSENTIAL OIL CONTAINING
MOUTHRINSE ON INTERPROXIMAL PLAQUE
BACTERIA * #LIN $ENT   ´
 3LOTS * 3ELECTION OF ANTIMICROBIAL
AGENTS IN PERIODONTAL THERAPY
* 0ERIODONTAL 2ES   ´
 #OBB #- .ON SURGICAL POCKET THERAPY
MECHANICAL !NN 0ERIODONTOL  
´
 ,ANG .0 *OSS ! /RSANIC 4 'USBERTI &!
3IEGRIST % "LEEDING ON PROBING A
PREDICTOR FOR THE PROGRESSION OF
PERIODONTAL DISEASE * #LIN 0ERIODONTOL
$ENTAL5PDATE 
 0ERIODONTOLOGY
  ´
 (AFFAJEE !$ #UGINI -! $IBART 3
3MITH # +ENT 2, *R 3OCRANSKY 33
4HE EFFECT OF 320 ON THE CLINICAL
AND MICROBIOLOGICAL PARAMETERS
OF PERIODONTAL DISEASES * #LIN
0ERIODONTOL   ´
 3LOTS * 4HE PREDOMINANT CULTIVABLE
MICROFLORA OF ADVANCED PERIODONTITIS
3CAND * $ENT 2ES   n
 2OONEY * 7ADE 7' 3PRAGUE 36
.EWCOMBE 2' !DDY - !DJUNCTIVE
EFFECTS TO NON SURGICAL PERIODONTAL
THERAPY OF SYSTEMIC METRONIDAZOLE
AND AMOXYCILLIN ALONE AND COMBINED
! PLACEBO CONTROLLED STUDY * #LIN
0ERIODONTOL   ´
 'UERRERO ! 'RIFFITHS '3 .IBALI , 3UVAN
* -OLES $2 ,AURELL , 4ONETTI -3
!DJUNCTIVE BENEFITS OF SYSTEMIC
AMOXICILLIN AND METRONIDAZOLE
IN NON SURGICAL TREATMENT OF
GENERALIZED AGGRESSIVE PERIODONTITIS
A RANDOMIZED PLACEBO CONTROLLED
CLINICAL TRIAL * #LIN 0ERIODONTOL  
"OOK2EVIEW
4HE 0OWER OF 5LTRASONICS "Y &RIDUS VAN DER
7EIJDEN .EW -ALDEN 1UINTESSENCE "OOKS
 PP PB a  )3".     
4HIS BOOK WAS A JOY TO READ )T IS NICELY
ILLUSTRATED AND COVERS THE SCIENCE AND CLINICAL
ASPECTS OF ULTRASONICS IN A STRAIGHTFORWARD
AND UNDERSTANDABLE MANNER 4HE AUTHOR
SHOULD BE CONGRATULATED ON THE HIGH QUALITY
OF THE PRESENTATION 4HE BOOK COVERS THE
BIOPHYSICAL ASPECTS AND LINKS THESE TO THE
CLINICAL SITUATION 4HIS ALLOWS THE CLINICIAN
TO UNDERSTAND A SIMPLE INSTRUMENT WHICH
HAS A COMPLEX ACTION "Y UNDERSTANDING THE
BACKGROUND IT WILL ALLOW MORE EFFECTIVE USAGE
OF SUCH INSTRUMENTATION IN THE CLINIC
4HE STRIKING ASPECT OF THE
BOOK IS THE EXCELLENT PHOTOGRAPHY AND
THE IMAGINATIVE PAGE LAYOUT WHICH ALLOWS
TEXT DESCRIPTORS TO BE BROUGHT ALIVE BY
THE FIGURES AND DIAGRAMS 4HE AUTHOR HAS
BACKED UP THIS WITH AN EVIDENCE BASE FROM
THE CONTEMPORARY LITERATURE ON THIS SUBJECT
4HE LAYOUT COVERS MECHANICAL SCALERS AND
THEN SONIC SCALERS 4HE BIOPHYSICAL EFFECTS
OF THE ULTRASONIC SCALER AND THE PRESENCE OF
CAVITATION IS COVERED 4HE BULK OF THE TEXT
COVERS THE EFFECTS OF PROFESSIONAL SUPRA AND
 $ENTAL5PDATE
´
 7INKEL %' 6AN 7INKELHOFF !*
4IMMERMAN -& 6AN DER 6ELDEN 5
6AN DER 7EIJDEN '! !MOXICILLIN PLUS
METRONIDAZOLE IN THE TREATMENT OF
ADULT PERIODONTITIS PATIENTS ! DOUBLE
BLIND PLACEBO CONTROLLED STUDY * #LIN
0ERIODONTOL   ´
 'RIFFITHS '3 3MART '* "ULMAN *3
7EISS ' 3HROWDER * .EWMAN (.
#OMPARISON OF CLINICAL OUTCOMES
FOLLOWING TREATMENT OF CHRONIC
ADULT PERIODONTITIS WITH SUBGINGIVAL
SCALING OR SUBGINGIVAL SCALING PLUS
METRONIDAZOLE GEL * #LIN 0ERIODONTOL
  ´
 VAN 3TEENBERGHE $ 2OSLING " 3ODER
0/ ,ANDRY 2' VAN DER 6ELDEN 5
4IMMERMAN -& ET AL !  MONTH
EVALUATION OF THE EFFECTS OF REPEATED
SUBGINGIVAL MINOCYCLINE IN CHRONIC
ADULT PERIODONTITIS * 0ERIODONTOL 
 ´
 3ALVI '% -OMBELLI ! -AYFIELD ,
2UTAR ! 3UVAN * 'ARRETT 3 ,ANG .0
SUBGINGIVAL DEBRIDEMENT 4HIS INCLUDED
REVIEWING THE REMOVAL OF PLAQUE BIOFILMS THE
EFFECT ON THE COMPOSITION OF THE MICROFLORA
AND CALCULUS REMOVAL 4HERE IS DISCUSSION
ON THE REMOVAL OF ENDOTOXINS AND ROOT
CEMENTUM AND PATIENT ACCEPTANCE )T ALSO
COVERS THAT FINAL QUESTION @(OW EFFECTIVE IS
ULTRASONIC SCALING 4HE READER IS ENCOURAGED
TO READ THE BOOK TO FIND THE ANSWER TO THIS
QUESTION
#LINICAL CONCERNS ABOUT THE
POTENTIAL DAMAGING EFFECTS OF THE INSTRUMENT
ON THE TOOTH AND SURROUNDING TISSUES IS
COVERED 4HE CLINICAL APPLICATIONS ARE COVERED
IN DETAIL INCLUDING ADJUSTING THE POWER
SETTINGS AND THE TECHNIQUE TO BE USED 4HIS
SECTION WILL BE OF GREAT USE TO ALL HEALTHCARE
PROFESSIONALS WHO USE ULTRASONIC AND SONIC
SCALERS ON A REGULAR BASIS
4HE FINAL CHAPTERS COVER NEW
APPLICATIONS SUCH AS FIBRE OPTIC LIGHTING
USE OF PLASTIC TIPS OR CARBON FIBRE TIPS TO
CLEAN IMPLANTS 4HE USE OF ULTRASOUND IN
ENDODONTICS BOTH FOR ROOT END RESECTION AND
FOR INSTRUMENTATION INCLUDING IMPROVING THE
SETTING OF GLASS IONOMERS CEMENT IS DISCUSSED
4HERE IS ALSO COVERAGE OF USING ULTRASONICS FOR
CROWN REMOVAL 4HERE IS A VERY BRIEF MENTION
,OCAL ANTIMICROBIAL THERAPY AFTER
INITIAL PERIODONTAL TREATMENT * #LIN
0ERIODONTOL   ´
 +INANE $& 2ADVAR - ! SIX MONTH
COMPARISON OF THREE PERIODONTAL LOCAL
ANTIMICROBIAL THERAPIES IN PERSISTENT
PERIODONTAL POCKETS * 0ERIODONTOL
  ´
 *EFFCOAT -+ "RAY +3 #IANCIO 3' ET
AL !DJUNCTIVE USE OF A SUBGINGIVAL
CONTROLLED RELEASE CHLORHEXIDINE CHIP
REDUCES PROBING DEPTH AND IMPROVES
ATTACHMENT LEVEL COMPARED WITH
SCALING AND ROOT PLANING ALONE
* 0ERIODONTOL   ´
 #ATON *' %VALUATION OF 0ERIOSTAT FOR
PATIENT MANAGEMENT #OMP #ONT %DUC
$ENT   ´
 0RESHAW 0- (EFTI !& .OVAK -*
-ICHALOWICZ "3 0IHLSTROM ", 3CHOOR
2 ET AL 3UBANTIMICROBIAL DOSE
DOXYCYCLINE ENHANCES THE EFFICACY OF
SCALING AND ROOT PLANING IN CHRONIC
PERIODONTITIS A MULTICENTER TRIAL
* 0ERIODONTOL   ´
OF THE RECENT WORK ON IMPLANTS AND IT IS
HOPED THAT A FUTURE BOOK COULD BE EXPANDED
TO COVER MORE OF SUCH MATERIAL
)N SUMMARY THIS IS A HIGHLY
PROFESSIONALLY PRODUCED BOOK THAT WILL
INTEREST MANY READERS )T IS A MUST FOR ALL
CLINICIANS WHO USE SUCH INSTRUMENTS ON A
REGULAR BASIS AND ) RECOMMEND IT FOR PURCHASE
0ROFESSOR !$ 7ALMSLEY
5NIVERSITY OF "IRMINGHAM 3CHOOL OF
$ENTISTRY
*ULY!UGUST