December 7, 2015
by Jo-Anne Jones, RDH
With the prevalence of periodontal disease in our population, today’s dental clinician is continually challenged to employ critical thinking and evidencebased decision making on the selection of adjunctive treatment options to complement nonsurgical therapeutic modalities. How prevalent is periodontal disease in today’s population? The CDC (Centers for Disease Control) initiated a population-based surveillance to study and improve the validity of prevalence estimates of periodontal disease.
The following data was reported as a result of this initiative:1
• 47.2 percent of adults aged 30 years and older have some form of periodontal disease
• Periodontal disease increases with age. 70.1 percent of adults 65 years and older have periodontal disease
• More common in men than women (56.4% vs 38.4%), those living below the federal poverty level (65.4%), those with less than a high school education (66.9%), and current smokers (64.2%)
The purpose of the article is to provide a succinct summary of the JADA (Journal of the American Dental Association) guidelines with respect to nonsurgical treatment of chronic periodontitis published in July 2015. Methods and clinical recommendation statements will be discussed, as well as how they impact the therapeutic measures we select as adjuncts to scaling and root planning.
Clinical Guidelines for non Surgical Treatment of Chronic Periodontitis
The recently published evidence-based clinical practice guideline on the nonsurgical treatment of chronic periodontitis by means of scaling and root planing with or without adjuncts was founded on a comprehensive systematic review of 72 research articles providing clinical attachment level data on trials of at least six months’ duration. The strength of each recommendation is based on an assessment of the level of certainty of evidence for the treatment’s benefit in combination with an assessment of the balance between the magnitude of benefit and the potential for adverse effects.2
Definitions for the strength and direction of recommendations were split into the following categories:2
‘In favor’ – evidence favors providing this intervention; a high level of certainty exists with benefits balancing potential harm or moderate level of certainty with benefits outweighing the potential for harm
‘Weak’ – evidence suggests implementing after other alternatives have been considered; moderate level of certainty of benefits balanced with potential harms or uncertainty of level of benefit
‘Expert opinion for’* – expert opinion suggests this intervention can be implemented however there is a low level of certainty of benefits or benefit-to-harm balance
*Note that ‘expert opinion for’ does not imply endorsement but rather signifies that evidence is lacking and certainty is low.
‘Expert opinion against’ – expert opinion suggests this intervention not be implemented because there is a low level of certainty; there is no benefit or the potential harms outweigh benefits.
Limitations and First Considerations
Studies did not discuss any additional benefits of laser bacterial reduction beyond the therapeutic outcome related to clinical attachment or probing depths. “Common protocols are needed to allow for repeatable results…the wide ranges for CAL gain/loss demonstrate need for additional studies to evaluate properly the potential benefits of laser use as an adjunct to SRP.”3
Clinical Recommendation Statements (Table 1):2
In Favor of – for patients with chronic periodontitis, clinicians should consider SRP as the initial treatment.
In Favor of – for patients with moderate to severe chronic periodontitis, clinicians may consider a systemic subantimicrobial-dose doxycycline (20 milligrams twice a day) for three to nine months as an adjunct to SRP.
Weak – for patients with moderate to severe chronic periodontitis, clinicians may consider systemic antimicrobials as an adjunct to SRP.
Weak – for patients with moderate to severe chronic periodontitis, clinicians may consider locally delivered chlorhexidine chips, and ‘Expert Opinion for’* doxycycline hyclate gel or minocycline microspheres as an adjunct to SRP.
Weak – for patients with moderate to severe chronic periodontitis, clinicians may consider photodynamic therapy (PDT) using diode lasers as an adjunct to SRP.
Expert Opinion against – for patients with moderate to severe chronic periodontitis, clinicians should be aware that current evidence shows no net benefit from non surgical use of diode, Nd:YAG or erbium lasers when they are used as adjuncts to SRP.
Comprehensive treatment planning for chronic periodontitis involves risk assessment, risk management, reduction of the bacterial burden and addressing the host-mediated response. Bacteria will initiate the infection, however it is the variations in host response that are the major determinants in periodontal disease susceptibility.3
One of the strongest host-mediated responses to the bacterial infection is the elevated collagenase activity in the gingival crevicular fluid of patients with adult periodontitis. The preceding JADA clinical recommendation statements published ‘in favor’ of the use of a SDD (systemic subantimicrobial dose doxycycline) 20 mg prescribed twice daily for three to nine months as an adjunct to SRP to reduce the impact of host collagen-degrading enzymes.4
Systemic antimicrobials and systemic SDD were considered separately because the latter appears to inhibit collagenase activity (matrix metalloproteinase 8) and not function as an antibiotic.7,8 Systemic antimicrobials have a higher potential for adverse effects.4,5,6
The subantimicrobial-dose doxycycline is prescribed under the name of Periostat®. Periostat® is a systemically delivered collagenase inhibitor and the first FDA approved systemic drug for host modulation as an adjunct to SRP in the treatment of periodontitis.
The American Academy for Periodontology states, “In a three-month follow up study, where patients received no additional therapy, pocket depth reductions and clinical attachment level gains observed following nine months adjunctive Periostat were maintained.”7,8,9 Periostat® therapy was shown to provide a 71 percent benefit in clinical attachment levels over SRP alone.2
The above systematic review with evidence-based guidelines aids today’s dental professional in clinical decision-making and the delivery of quality patient care.
Jo-Anne Jones is a recognized international speaker, consultant, author and President of RDH Connection Inc. She can be reached at email@example.com.
Oral Health welcomes this original article.
1. Eke PI, Thornton-Evans G, Dye B, Genco R. Advances in Surveillance of Periodontitis: The Centers for Disease Control and Prevention Periodontal Disease Surveillance Project. J Periodontol November 2012, Vol. 83, No. 11, Pages 1337-1342.
2. Smiley CJ, Tracy SL, Abt E, et al. Evidence-based clinical practice guideline on the nonsurgical treatment of chronic periodontitis by means of scaling and root planing with or without adjuncts. JADA 2015 146(7):525-535
3. Hasturk H, Kantarci A. Paradigm shift in the pharmacological management of periodontal diseases. Front Oral Biol. 2012;15:160-76.
4. Gu Y, Walker C, Ryan ME, Payne JB, Golub LM. Non-antimicrobial tetracycline formulations: clinical applications in dentistry and medicine. J Oral Microbiol. 2012;4:19227.
5. Golub LM, Wolff M, Lee HM, et al. Further evidence that tetracyclines inhibit collagenase activity in human crevicular fluid and from other mammalian sources. J Periodontol Res. 1985;20(1):12-23.
6. Golub LM, Ciancio S, Ramamurthy NS, Leung M, McNamara TF. Low-dose doxycycline therapy: effect on gingival and crevicular fluid collagenase activity in humans. J Periodontol Res. 1990;25(6):321-330.
7. http://www.perio.org/resources-products/periostat.htm (Accessed October 2015)
8. Caton J, Blieden T, Adams D, et al. Subantimicrobial doxycycline therapy for periodontitis. J Dent Res 1997;76:177.
9. Caton J, Ciancio S, Crout R, Hefti A, Polson A. Adjunctive use of subantimicrobial doxycycline therapy for periodontitis. J Dent Res 1998;77:1001.
The author received no compensation for the writing of this article. The purpose of the preceding article is to provide an overview only. The reader is encouraged to review the full manuscript of the Clinical Recommendation Statements from the American Dental Association Council on Scientific Affairs’ Nonsurgical Treatment of Chronic Periodontitis Expert Panel.