Author: Dr Peter Galgut (Periodontist)
For many years it has been known that to control periodontal diseases it is necessary to decontaminate the teeth and roots from plaque bacterial debris and other toxic microbial biofilm products.
For sometime it is generally accepted that periodontal pockets of infection are treated by scaling foreign material out of the periodontal pockets of infection. Instruments were large and cumbersome and it was virtually impossible to introduce them deeper than 3 or 4mm below the gum margins. So the answer was surgery! Simply open and expose the roots by flap surgery, clear off all of the contaminated material by what was called root-planing, and then with everything decontaminated and clean suture back the gingivae and healing would take place. Well, it became known that very often it didn’t work!
In recent years we have come to realise the surgical procedures and root planing were excessively invasive forms of treatment and gentler non-surgical procedures have been developed using new, thinner and better designed instruments and more elegant decontamination techniques. Debridement of root surfaces can now easily be decontaminated non-surgically, even in the deepest of pockets.
It is now widely accepted that we can’t clean root surfaces completely by mechanical means alone. Additionally it is now known that it is not only dental plaque biofilm that causes periodontal disease, but the host response to that dental plaque. In other words some people’s immune systems tolerate dental plaque better than others. Increasingly mechanical debridement is enhanced with pharmacological products and these are broadly divided into 2 groups:
- Anti-septics (such as chlorhexidine-based products)
- Antibiotics (such as Doxicycline or minocycline-based products)
- Host modulating products (such as hyaluronan based Gengigel).
Gengigel is the first completely natural topically applied wound healing and inflammation reducing product for use in the mouth. By calming the inflammatory process and promoting tissue healing, enhanced tissue repair can often be achieved. This exciting new product provides opportunities to better manage all sorts of intra-oral inflammatory conditions such as xerostomia, mouth ulcers, burning mouth syndrome, and many other uncomfortable oral conditions, as well as periodontal disease that is resistant to resolution.
The difficult question for practitioners is when to use debridement alone or enhanced with these pharmacological products. The decision is difficult to make particularly as there are many, often contradictory, publications on the subject. There are no agreed protocols as to which product or which combination of products might be best for any given clinical situation. In the absence of any agreed protocols for the use, I can only make a suggestion based on my clinical own experience of using these products in my practice.
So my treatment is always based on achieving thorough and meticulous root surface debridement in patients with high levels of oral hygiene maintenance. The decision as to whether to use adjunctive agents should be based on clinical judgement.
As a general rule I use the following 3 criteria in my decision-making process at the 4 weeks post treatment assessment appointment:
- If healing is progressing well I use no adjunctive products.
- If healing is poor and during probing I find significant amounts of plaque like debris or a discharge I would use a topical anti-microbial.
- If healing is poor and during probing I find extensive bleeding with very little discharge and/or sub gingival debris accumulation or extensive bleeding with very little periodontal pocketing I would tend to use Gengigel.
However I cannot over emphasise the fact that these guidelines are huge oversimplification of a highly complex and multifactorial disease process, and other factors need to be considered and dealt with as part of a comprehensive treatment plan to get the very best treatment outcomes.
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