CLINICAL REPORT

-

I SIrhis approach to periodontal

:herapy shows promise for

'estoring patients to optimal

)ral health while bringing

)ractical benefits to

:Iinicians.

ty Kristy Menage Bernie, R.D.H., B.S.

Peri~~hip@

~

Atridox'i Atridox is indicated for for usein the treatment of chronic adult

10%Block Drug Corp.

doxycycline

hyclate800-0K-BLOCK

(800-652-5625)periodontitis for a gain in clinicalattachment, reduction in probing depth,and reduction in bleeding on probing.

------------

ArestinN OraPharma Inc'. I mg resorbable Adjunctive treatment for adultminocycline periodontal disease used in conjunction

866-ARESTIN microspheres with scaling and root planing.

PeriostatN ColiaGenex 20 mg Periostat is indicated for use as anPharmaceuticals doxycycline adjunct to scaling and root planing to

hyclate promote attachment level gains and to888-339-5678 reduce pocket depth in patients with

adult periodontitis,

s.."ce: Manulaclu,...' packaging 'n...'s; olso, ... rolerenco. 23-25, 2~

Kristy Menage Bernie,

RDH, BS, is co-founder and

director of Educational

Designs, a national

marketing and consulting

company. She lectures

nationally on infection

control, innovations in

periodontal therapy and

aesthetic dental hygiene,

and is an active member of

the American Dental

Hygienists' Association.

She also serves as a section

editor for the Journal of

Practical Hygiene. She can

be reached via e-mail at

kmenageb@aol.com or

telephone at 925-735-3238.

.

.application

cedures be completed in two appoint-ments within 24 hours of each other. Thisapproach provides an interesting treat-ment option and proves more effectivethan traditional quadrant scaling and rootplaning, or partial-mouth disinfection.What follows is an overview of the re-search, clinical application, and necessaryarmamentarium.

Quirynen, eta!., first reported the con-cept of FMD in the Journal of Dental Re-search in 1995.' Since then, FMD has been

he American Dental Hygienists'Association defines optimal oralhealth as a standard of health ofthe oral and related tissues that en-

able an individual to eat, speak or social-ize without active disease, discomfort orembarrassment, and one that contributes togeneral well-being and overall health.' Inlight of recent research establishing the oralinfection/systemic health connection,' pro-gressive clinicians and patients alike havebecome increasingly interested in methodsto enhance the effectiveness of periodon-tal therapy and achieve optimal oral health.As a result, there has been a renewed in-terest in the concept of full-mouth disin-fection (FMD).'"

Overview of FMDFMD protocol requires that full-mouth in-strumentation and oral disinfection pro-

T

a successful treatment modality in bothchronic, advanced and early-onset peri-odontitis populations. The purpose ofQuirynen's studies was to investigate FMDas a means of reducing the re-infection thattheoretically can occur with traditionalquadrant scaling and root planning.'.'"

The research compared FMD to par-tial-mouth disinfection, which is defined

d

Controlled/sustained release gel forsubgingival application. Hardens to awax-like consistency upon subgingival-application; 14-day release.

Results were equal toSRP with secondaryAND primaryoutcome variablesachieved.

SR~The only ADA sealed product foruse in the arrest of

periodontids.

",Restrict interdental care intreated area.

Powder substance placedsubgingivally; 14-day release

Clinical data online

at are,tin.com

Oral capsule. 20 mg twice a day (BID).

No restriction on oral hygiene care.

Results showedimprovement overSRP group. including

secondary and

prlmaryouttomevariables achieved.

Oral enzyme suppresse" Researchbased upon baseline SRP and Periostattaken twice a day with clinical

perimeters measured at three. six,and nine months. No additionalinstrume~tation was performed atthose intervals.

I

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and decrease of ora] ma]odor."'"The initial pilot study and studies that

followed suggest that the clinical out-comes are directly related to the acceler-ated instrumentation and disinfectionprocess. The re-infection potentia] sig-nificantly decreases as a result of thisprocess and the authors also suggest thatthe results are comparable to those seenwith local delivery, controlled-release an-timicrobial agents. Although this researchwas conducted with small populationsand represents only a few completed stud-ies, the results warrant consideration forclinical application in initiating peri-odontal therapy for both aggressive andchronic periodontitis populations."""

It is important to note in reviewing themethodology of these studies that the con-centrations of ch]orhexidine utilized arenot currently available in the United States.Regard]ess, this limitation may actuallyrepresent an opportunity to explore and uti-lize currently available agents and proce-dures that may, in fact, enhance theoutcome of FMD. With regard to chlorhex-idine application subgingivally and to in-traoral surfaces, a recently published studycompared the FMD protocol with andwithout chlorhexidine." The results indi-cated no difference between the two pop-ulations and concluded the mechanical in-strumentation within 24 hours was thereason for improved results over tradition-al scaling and root planing. With this inmind, the unavailability of the concentrat-ed chlorhexidine used in this research be-comes less critical when one considerswhether to implement this procedure. Clin-icians should consider additional optionsthat could enhance FMD results.

as "quadrant or sextant scaling and rootplaning that is completed, quadrant byquadrant, at two-week intervals, or sixweeks from instrumentation of the firstquadrant to completion of the fourthquadrant" Control populations receivedthe standard instrumentation protocol, orpartial-mouth disinfection, while the'oth-er group underwent FMD.

FMD consists of two appointmentswithin 24 hours, each approlljmately onehour in length, at which full-mouth scal-ing and root planing are pe.rformed andimmediately followed by oral disinfectionprocedures. The disinfection proceduresincluded application of chlorhexidine tosupra- and subgingival environmentsalong with tongue brushing and mouthrinsing with chlorhexidine. Prior to in-strumentation, pockets were irrigated witha 1% chlorhexidine gel. After instrumen-tation, the following additional disinfec-tion procedures were performed:

1. Brushing the tongue was for 60 sec-onds with a I % chlorhexidine gel

2. Rinsing twice with a 0.2% chlorhexi-dine solution for one minute

3. Spraying the pharynx with 0.2%chlorhexidine

4. Subgingival irrigation of all pocketsthree times within 10 minutes with a1% chlorhexidine gel

Subgingival application of 1 % chlorhex-idine gel was repeated at day eight. In ad-dition to daily interdental plaque control,toothbrushing, and brushing of the dorsumofthe tongue by both groups, the test pop-ulations also rinsed with and sprayed ton-sils twice a day with 0.2% chlorhexidinefor two months.

Implementation of FMDinto periodontal therapyCertainly, completing full-mouth instru-mentation within 24 hours is a patient-centered approach. However, actually in-corporating the basic premise of FMDinto a practice's current periodontal ther-apy services requires clinicians to con-sider innovative methods and agents com-mercially available in the United States torealize and potentially improve upon theFMD results seen in the literature.

Even more motivation to modify thedisinfection protocol is provided by thelatest follow-up study, which illustratesthat the disinfection procedures with low-concentratiowetJlorhexidine did not re-sult in any improved outcomes." Theo-ries behind these results include the factthat the chlorhexidine was not of suffi-cient concentration and did not reach thesite of the disease, combined with the factthat the chlorhexidine was not retained inthe disease sites for any significant peri-od of time.

Research resultsThe patients who underwent FMD in anumber of studies exhibited both primaryand secondary gain in clinical attachmentoutcomes.""" Primary clinical outcomevariables included an increase in clinicalattachment of alveolar bone, while sec-ondary clinical outcome variables includ-ed reduction in probing depths, bleedingon probing, and inflammation as well as adecrease in microbial counts. II The FMD

population showed a significant reductionin probing depths and gain in clinical at-tachment over those receiving standardthempy. The pooled results of the FMDdata demonstrated significant reduction inprobing depths for test groups over the

control groups.With respect to primary clinical out-

comes, the test groups experienced a moresignificant gain in clinical attachment thanthe control population in all studies. Theseresults were maintained for eight months,and in the test population the reduction ofprobing depths, bleeding on probing, andgain in the clinical attachment continuedto improve from the baseline data. In ad-dition, the FMD populations experienceda greater reduction in spirochetes andmotile bacteria, eradication of p. gingiva/is,

Modified FMD protocolGiven this information, what follows is a

proposed modification to the FMD pro-tocol that utilizes currently available 10-

U.._:_-- D . U "'M

)roposed alternative:MD clinical protocol

Two appointments ofappropriate lengthscheduled within 24 hours

cal delivery agents and includes realistic.

easily implemented processes.

Pre-procedural rinsingTo begin the disinfection process and re-duce aerosolized bacteria during the pro-cedure, the FMD appointment should beinitiated with antimicrobial pre-proce-dural rinsing with chlorhexidine or es-sential oils.

Pre-procedural antimicrobialrinse for 30 seconds with,antimicrobial agent '

Scaling and root planingAnesthesia administration

Initially, the use of powered instrumentation

will provide an effective method for de-

briding and irrigating subgingival environ-

ments. Powered instruments that incorpo-

rate self-contained water/medicamentreservoirs will be advantageous for use with

antimicrobial agents, such as 0.12%chlorhexidine. Combined with hand instru-mentation, powered instruments may offeradditional benefits of tissue detoxification,quick, effective removal of subgingival de-posits, and reduction in operator fatigue.

While irrigation with chlorhexidine islimited in long-term antimicrobial bene-tits, this agent neutralizes volatile sulfurcompounds (VSCs),-\U which are the odor-associated by-products produced by gram-negative, anaerobic bacteria. VSCs havebeen associated with increasing perme-ability of mucosa, which results in in-creased bacteria invasion; and, most im-portantly, VSCs have been shown tointerfere with collagen and protein syn-thesis. ". ,.. ".Ih For this reason, use of an an-

timicrobial agent is warranted to eliminateVSCs and improve oral malodor." Addi-tional VSC-neutralizing agents include tri-closan, essential oils, chlorine dioxide, andzinc. Numerous commercially availabledaily-use products that contain these ac-tive ingredients can be used long-term toreduce VSCs and bad breath."

Scaling and root planing: t

. Powered instrumentation withself-contained water/medicamentreservoir and antimicrobial iITigant. Hand instrumentation

Tongue deplaquing/scrapingwith antimicrobial agent

Post-procedural rinsefor 30 seconds withantimicrobial agent

2-month evaluation

Placement of local delivery!

controlled release agent or

prescription for subclinical

dosage doxycycline:

. 2.5 mg. chlorhexidine chip

. 10% doxycycline gel

. I mg. minocycline microsphere

power. 20 mg. systemic! subclinical dosage

doxycycline bid

Schedule appropriate recare.

Re-evaluation at appropri-ate time, with referral fornon responsive cases.

Oral disinfection proceduresAt the completion of mouth instrumenta-tion/irrigation, tongue and buccal mucosadisinfection procedures should be per-formed. In the FMD studies, the tonguewas brushed with a I % chlorhexidine gelfor 60 seconds. Most of the bacteria ac-cumulation is on the posterior one-thirdof the tongue, and brushing may not reachthis area or be comfortable for the patient.

Procedurally, this presents a problemsince 1% chlorhexidine gel is not avail-able in the U.S., combined with the factthat most bacteria accumulationis~n theposterior third of the tongue, and brush-ing may not reach this area or be com-fortable for the patient.

While brushing the tongue with an an-timicrobial will eliminate some of the bac-teria, deplaquing with a tongue scraper willbe safer and more effective. ". ". '" Addi-

tionally, the patient will find the de-plaquing procedure with a scraper morecomfortable. Recommended protocolwould include having the patient extendthe tongue, applying an antimicrobial

continued on page 12

Note: Daily oral hygiene should include

toothbrushing. interdental cleansing. and

tongue deplaquing along with appropriate

adiuncave chemotherapy.

. Reduction in probing depths

over traditional quadrantscaling and root planing

. Gain in clinical attachment

. Reduction in oral malodor

. Greater reduction in spiro-

chetes and motile organ-isms in subgingival flora

Utilized in both chronic and

early-onset populations

CLiNICA

rongue disinfection continued from page 11agent to the tongue surface, and endingwith the scraping/deplaquing procedure.This is an important step in the FMDpro-tocol and for daily application by the pa-tient as the tongue's coating on the poste-rior one-third has been implicated as amajor contributor to oral malodor and VSCcontent of the oral cavity. Additionally,scraping has been shown to reduce VSCsby up to 75% compared to tongue brush-ing, which resulted in a 25% reduction ofVSCs. n." The final phase of the disinfec-

tion procedure will include Iinsing with anantimicrobial mouthwash, instructing thepatient to gently gargle prior to expecto-rating to disinfect the tonsilar region.

Deplaquing with a tongue scraperis safer and more effective thanbrushing the tongue with anantimicrobial alone.

Oral hygiene considerations

The FMD studies included daily oral hy-giene protocol for both test and controlpopulations that featured brushing, inter-dental and tongue. The test population alsoused 0.2% chlorhexidine to disinfect oralniches. With this in mind, it is essential toconsider daily oral hygiene practices as anintegral part of any successful periodon-tal therapy and to implement the FMDprotocol. In addition to daily plaque con-trol by traditional means-the modifiedBass technique and flossing-cliniciansshould consider automated technology.

Patients spend an average of 24 to 60seconds on oral hygiene routines and only2% to 10% ofthe population flosses regu-larly and effectively." Given these dismalcompliance realities, the availability anduse of automated technology is warranted.Automatic toothbrushes have proven safeand effective and can minimize undesir-able side effects, such as chlorhexidinestaining; they also can provide patientswith tangible visual and tactile cues of suc-cessful plaque control. The FMD protocolincludes twice-a-day use of chlorhexidinerinse for two months. This agent is ap-proved as an anti-gingivitis/plaque agent

Local delivery

The PerioChip is one of threebioabsorbable delivery vehicleoptions available for use in theFMD protocol.

References

n

tion process should include assessment of

periodontal tissues, including probingdepths, clinical attachment, and pres-ence/absence of inflammation and bleed-ing. Those sites that have not respondedand exhibit evidence of continuing peri-odontal infection represent ideal candi-dates for adjunctive local therapy. Locallydelivered controlled-release agents areconsidered effective in reducing peri-opathogens if they provide minimum in-hibitory concentrations for more than oneday. In addition, these agents are placed atthe site of infection and deliver a lower to-tal dosage of the drug in a more controlledconcentration. With a lower systemicdosage and improved patient compliance,these agents are a welcome addition andoption in periodontal therapy. In light ofthe recent study" that showed no differencein those receiving disinfection withchlorhexidine from those who did not, lo-cal delivery/controlled-release agents mayprovide the additional benefit for full-mouth disinfection and improved peri-odontalhealth.

Three bioabsorbable delivery vehicle op-tions are currently available (see chart onpage 10): 2.5-mg chlorhexidine chip (Peri-oChip@ by Dexcel); 10% doxycycline(AtridoxTM by Block Drug) and I-mg

minocycline (ArestinTM by OraPharma).All of these products have been shown toreduce pocket probing depths, inflamma-tion, and bleeding (and in the case of Atri-dox, a gain in clinical attachment) whencompared to scaling and root planing alone.

At this time, there are no published head-to-head comparisons of these options. Clin-icians should carefully review the literatureto determine which medicament will bestsuit the patient's therapeutic needs. Basicparameters for use include pocketing of 5mm or greater. In addition, research on allthree agents allowed for additional place-ment at certain intervals of time. 2J."."

It is also important to check with state

and also has been shown to reduce oralmalodor and VSCs. For clinicians choos-ing to use this agent, patients should be in-structed to lightly gargle to disinfect thetonsilar region as well. The FMD protocoldoes not appear to rely upon the use oflow-concentration chlorhexidine andshould be used on a case-by-case basis.

A fairly new option to the automatedmarket has been interdental aids. Two ex-amples-the Oral-B InterClean and theWater Pik Flosser powered flossingaids-both are supported by published re-search that indicate they are equally as ef-fective as manual flossing.

In addition to interdental care, patientsshould perform daily tongue deplaquing.The most effective method for tongue de-plaquing is with a tongue scraper. Tonguescrapers produce a cleaner tongue, providea safe means for tongue coating removaland remove more bacteria than tradition-al toothbrushes. "-'O-,,

Evaluation of FMDOnce patients have completed the FMDprocess, they should be scheduled for atwo-month evaluation appointment. At thetwo-month appointment, oral disinfectionprocedures with chlorhexidine were pro-vided as in the initial FMD appointments.In these studies it was determined that theFMD protocol had little effect on A. actin-omycetemcomitans, a tissue-invasive bac-teria. As a result, additional clinical inter-ventions might include use of localdelivered/control1ed-release, antimicrobial

agents or systemic sub-antimicrobialdoxycycline. These medicaments havebeen used successful1y as adjuncts to tra-ditional scaling and root planing and mayprovide additional benefits outside ofthose demonstrated in the FMD studies.

Adjunctive, non-surgicalinnovationsEvaluation of the accelerated instrumenta-

Mav 20(J/ . Hval R.aart

boards regarding the use hf these agentsby registered dental hygienists. Place-ment by the registered dental hygienist isrestricted in California, pending in NewYork, and only the PerioChip can beplaced by the registered dental hygienistin Florida. As of press time, all otherstates permit placement, with 33 stites

having specific language regarding usageof the agents within the dental hygienepractice act. ".,

An additional treatment strategy is theuse of a systemic subclinical dosage ofdoxycycline for generalized pocketing.For the most part, the local delivered/con-trolled-release agents are considered ap-propriate for localized pocketing. Local-ized pocketing is defined as S30% of sitesare involved, while generalized refers to;<: 30% of the sites are involved.'" In thesecases, use of systemic sub-antimicrobial

doxycycline (PerioStatTM by CollaGenex)may be warranted. Use of this producttwice a day, one hour prior to meals, in-terferes with the production of tissue-de-stroying enzymes, such as collagenase.The dosage of doxycycline is not concen-trated enough to eradicate periopathogens;however, research demonstrates the inter-ference with tissue-destructive enzymeswill reduce probing depths and result in again in clinical attachment levels when ac-companied by scaling and root planing."

The need for these agents at the two-month point is determined by initialhealing response from the FMD proce-dure. Given the concern regarding use oftopical or systemic antibiotics, this ap-proach not only will minimize indis-criminate use of these agents but alsowill provide a more economical optionfor patients." This evidence-based strat-egy will provide maximum benefit andpotential for both the FMD protocol andthe conservative use of newly available

therapeutic agents.Although the research on FMD utilized

small patient populations, the results war-rant consideration for application in peri-odontal therapy. This patient-centered ap-proach allows the maximum host immuneresponse and minimum re-infection po-tential, compared to partial-mouth disin-fection or traditional quadrant scaling androot planing.

Practice concerns, benefitsScheduling two appointments within 24hours for complete scaling and root plan-ing and disinfection procedures may pres-ent a challenge for practices in which pe-riodontal/preventive appointments arebooked in advance. In these cases, delay-ing treatment until the needed appointmenttime becomes available would in all like-lihood be no different than traditional scal-ing and root planing, which can take any-where from six to 12 weeks or more tocomplete. Additionally, the FMD approachwill afford clinicians the opportunity to ac-

celerate therapy, which could lead toquicker referrals for surgical intervention

for those cases that do not respond.For clinicians who have the goal to

help patients achieve optimal oral health,FMD represents an additional method andapproach to periodontal therapy. Thismethod also provides key patient bene-fits, such as reduction in oral malodor."Bad breath is a key reason individuals

..

~

"'"ni"m' R"nnrl " Mm' 1m'

seek dental care, and it should be ad- isha O'Hehir, RDH, BS, 'These new find-ings have the potential to not only changethe way we provide conservative peri-odontal therapy, but also the result~ we canexpect" Continued research on this prem-ise would be advantageous ana perhapschange the traditional periodontal therapy.After all, it is a matter of total health. i!!jJ

dressed because patients expect assess-ment and treatment of the condition bythe dental professional.

Clinicians reap benefits as well, by ex-pediting therapy and having a new meansto improve periodontal health. To quote in-ternationally renowned dental hygienist, Tr-

IDiagnosis.'

Chronic AdultPeriodontitis

Treatment:

Atridox@(doxycycline hyclate) 10%

.i)

The only antimicrobial gelthat flows deeply intoperiodontal pockets... !Significant clinicalperformance!. increased clinical attachment.. reduced pocket depth.. decreased bleeding on probing.

Easy to use. bioabsorbable. minutes to prepare and apply. no anesthesia required

For clinical informationor to order Atridox@, see yourlocal Block Dental Consultant,call1-800-0K-BLOCK(1-800-652-5625) or visitwww.blockdrug.com

OX(doxycycline hyclate) 10%

Antimicrobial actionright where you want if'M

In clinical trials. AtrldoX" was generally well-tolerated.Side effects were similar to those of placebo. Themost common side effects were: headache.common cold. gum discomfort. pain or soreness.toothache. and tooth sensitivity. AtrldoX"should notbe used by patients who are hypersensitive todoxycycline or any other drugs in the tetracyclineclass. The use of drugs In the tetracycline classduring tooth development may cause permanentdiscoloration of the teeth. Tetracycline drugs,therefore, should not be used In pregnant women,unless other drugs are not likely to be effective orare contraindicated.

ATRID

.Atridox"and scaling and root planing were superior toplacebo and oral hygiene. Long-term efficacy vs. scalingand root planing has not been established.'

Please see adjacent page for brief summary of Prescribing Information.

[ti]BLOCK DRUG CORPORATION

Use 504 on cord or at www.dentalproducts.net ..