Full mouth disinfection

FMD

1. Full Mouth Disinfection

2. Contents Introduction Disinfection Rationale Chlorhexidine Aim of FMD concept Advantages Disadvantages Evolution of FMD concept Full-mouth treatment with CHX Full-mouth treatment without CHX, The extension of hygiene and duration of post treatment CHX use The replacement of antiseptics Supplementation with antibiotics, Probiotics Full-mouth antimicrobial photodynamic therapy One-stage FMD combined with a periodontal dressing Conclusion

3. Introduction : The most common periodontal diseases are plaque-induced inflammatory condition that arise as a result of interactions between bacterial plaque and the host immune and inflammatory responses.

4. The concept of bacterial specificity in periodontal infections has become largely accepted. Three factors are currently considered for the establishment of an active periodontal infection : a susceptible host, the presence of periodontopathogens , and the absence of beneficial Species. Slots & Rams 1991

5. These interactions result in : Loss of connective tissue attachment to the root surface; Necrosis of root surface cementum ; Apical migration of the junctional epithelium; Pocket formation; and Further plaque biofilm developing in the subgingival environment. L oss of supporting alveolar bone occurs, which may lead to increased mobility and tooth loss

6. The conventional approach to periodontal treatment is largely based around the mechanical removal of bacterial deposits from the teeth and root surfaces. This involves thorough subgingival debridement to remove plaque and calculus, decontamination of root surfaces and disruption of the subgingival biofilm .

7. What is Disinfection?

8. Disinfection  describes a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects -CDC

9. Rationale of Full Mouth Disinfection

10. In the presence of adequate supragingival plaque control, this initial cause-related therapy allows resolution of inflammation and a reduction in probing pocket depths.

11. Pathogenic microrganisms also colonize other intra-oral niches such as the tonsils, the tongue, and other mucous membranes. Since most periodontopathogens colonize several niches in the oral cavity (Van Winkelhoff et al., 1986) and can be transmitted from one site to another ( Quirynen et al., 1995).

12. In periodontitis patients, keypathogens such as Actinobacillus actinomycetemcomitans , Porphyromonas gingivalis and Prevotella intermedia detected in all of the above mentioned niches existence of an intra-oral translocation (from one niche to another) of periodontopathogens . Saliva can be considered a major vehicle of transmission . ( Quirynen et al . 1996).

13. The degree of elimination of the exogenous periodontopathogens , was found to have a major impact on the treatment outcome ( Slots and Rams, 1990 ). Therefore , the target organisms during periodontal therapy are the exogenous species . Also several pathogenic micro-organisms have been found to spread subgingivally , including at sites without clinical loss of periodontal attachment ( Van Winkelhoff et al., 1994 ).

14. Historically , the standard approach for delivering periodontal treatment has been to undertake scaling and root planing in one quadrant at a time over a series of appointments . A full-mouth disinfection in one session seems logical when compared with the standard strategy (of quadrant-wise disinfection at several time intervals).

15. In QSRP, translocation occurs rapidly, recently scaled and root planed pockets can be re- colonised by pathogenic bacteria from remaining untreated pockets, or from other intraoral niches, before a new and less pathogenic ecosystem has been established

16. In order to reduce the chance for such a bacterial translocation, and thereby prevent a re-infection by periodontal pathogens of previously rootplaned pockets, a ‘‘one stage fullmouth ’’ disinfection, obtained by performing all scaling and root planing within 24 h together with a repeated application of chlorhexidine to all intraoral niches, has been introduced

17. Why CHLORHEXIDINE??

18. Chlorhexidine Second generation chemical plaque control agent Highly bacteriostatic in nature Also used as antiseptic in various specialities Available in different forms for use

19. HISTORY Developed in 1940s by Imperial Chemical Industries, England Marketed in 1954 as antiseptic for skin wounds Later, widely used in medicine and surgery including obstetrics, gynaecology , urology and pre-surgical skin preparation In dentistry, initially as pre-surgical disinfectant of mouth and in Endodontics

20. 1969 - Schroeder investigated Plaque inhibition by CHX 1970 - Loe and Schiott did a definitive study on it Rinsing for 60 sec BD with 10ml of a 0.2% CHX solution without normal tooth cleaning inhibits plaque regrowth and development of gingivitis

21. Forms of chlorhexidine WATER SOLUBLE Digluconate Acetate SPARINGLY SOLUBLE Hydrochloride

22. ON THE TOOTH SURFACE: 1) CHX gets attached to the salivary proteins and desquamated epithelial cells Blocks acidic groups on salivary glycoproteins Reduces glycoprotein adsorption on tooth surface Prevents pellicle formation

23. 2) Prolonged antiseptic release Bacteriostatic action that lasts for more than 12 hours Prevents the adsorption of bacterial cell wall on to the tooth surface Prevents plaque formation

24. 3) Competes with calcium ions Blocks agglutination of plaque Prevents binding of mature plaque

25. ON THE BACTERIAL CELL MEMBRANE : AT LOW CONCENTRATIONS: CHX adheres to bacterial cell membrane Binds to phospholipids in the inner cell membrane Leakage of lesser molecular weight components Sub lethal stage – reversible bacteriostatic action

26. Intracellular coagulation Slows down leakage of intracellular components Cytoplasmic coagulation Irreversible cell damage [bactericidal]

27. Pin-cushion effect The dicationic CHX molecule, attaches to the tooth surface by one cation , to the bacteria attempting to colonize the tooth surface with the other. This Is called the Pin-Cushion effect. This prolongs the CHX action Its long bacteriostatic action lasting for about 12 hours in the oral cavity after a single rinse . Hence CHX is well known for its substantivity .

28. ADVERSE EFFECTS a) Extrinsic staining b) Alteration in taste perception c) Oral mucosal erosion d) Enhanced supragingival calculus formation e) Parotid gland swelling

29. Formulations Mouthrinses Sprays Gel Tooth paste Varnishes Local drug delivery.

30. Full Mouth Disinfection

31. Aim of FMD approach

32. To avoid the potential rapid translocation of periodontal pathogens; To prevent the reinfection of previously treated sites by untreated pockets or by other intraoral niches Aim of FMD approach

33. The reduced probability of an intra-oral transmission of periodontopathogens from one of their niches to the subgingival environment of treated teeth. A more efficient way of delivering treatment Fewer treatment sessions Lower cost Less surgery needs Advantages

34. Disadvantages Carrying out all treatment over one or two sessions for a full-mouth disinfection procedure does not provide as frequent opportunities for patient motivation and oral hygiene monitoring as conventional treatment. Some patients also find it difficult to tolerate the long appointments necessary for full-mouth procedures. Multiple separate review appointments may not always be possible.

35. Evolution of FMD CONCEPT

36. Since the FMD technique was first described , a total of 8 modified protocols: Full-mouth treatment with CHX Full-mouth treatment without CHX, The extension of hygiene methods and an increase in the duration of posttreatment CHX use The replacement of CHX with other antiseptics Supplementation with antibiotics, Probiotics Full-mouth antimicrobial photodynamic therapy and One-stage FMD combined with a periodontal dressing

37. Full-mouth treatment with CHX

38. For maximal disinfection, the new protocol combined : ( 1) The scaling and root planing of all teeth within 24 hours to disrupt and reduce the number of subgingival pathogenic organisms ( Mousques et al., 1980; Walsh et al ., 1986 ; Loos et at., 1988);

39. (2) Brushing the dorsum of the tongue with a 1% chlorhexidine gel for 1 minute;

40. (3) Rinsing the mouth twice for one min and gargling for final 10 secs with a 0.2% chlorhexidine solution to reduce the number of bacteria in the saliva and on the tonsils ( Rindom et al., 1976 );

41. (4) Irrigating all pockets with a 1% chlorhexidine gel (3x in 10 min to increase the contact time) immediately after each of the 2 sessions and 8 days later to reduce (up to 99%) the number of remaining bacteria ( oosterwaal et al., 1991 );

42. (5) Twice-daily rinsing with 10 ml of 0.2 % chlorhexidine for two weeks and use brushing aids to retard the subgingival re-establishment of pathogenic species ( Magnusson et al., 1984 ).

43. FULL MOUTH TREATMENT WITHOUT CHX

44. FULL MOUTH TREATMENT WITHOUT CHX The question remained , however, whether the benefits of a one stage full mouth disinfection were Due to the use of the chlorhexidine (preventing a re-infection from other intra- oral niches) or Because of the one stage scaling and root planing (preventing re-infection from remaining untreated pockets and/or the immunological consequences of such an approach).

45. The one stage full-dentition scaling and root planing is the key factor to the additional clinical and microbiological improvements over a classical stepwise periodontal therapy.

46. This might be due to the elimination of the gross of the periodontopathogens from the pocket with Mechanical debridement (indicating that the pockets are important reservoirs for the colonization of the oral cavity by periodontopathogens ) and/or Due to an acute immunological reaction at the second day of the treatment (a schwartzman or vaccine reaction). The adjunctive disinfection with chlorhexidine can be advisable because it will result in a faster initial healing and offers additional effects in less complying patients.

47. Quirynen et al . (2000) FMD > FMS alone > QRSP : M ore reduction of PPD and CAL gain in FMD. Spirochetes were significantly decreased only in FMD. Apatzidou et al . 2004 compared the FMS group to the QSRP group and observed that patients treated with FMS had more postoperative pain compared to those who received conventional therapy with CHX

48. Extension of Hygiene Methods

49. Extension of Hygiene Methods and Increased Duration of Post treatment CHX Use Bollen et al . assessed the use of CHX (mouthwashes and tonsil sprays) for a period of 2 months after treatment instead of 2 weeks However , at the end of this study, the authors could not demonstrate a direct relationship between the observed results and the increased CHX use. According to the authors, these results could be due to the effectiveness of the full-mouth method compared with that of the quadrant method

50. The extended time of CHX use was associated with adverse events such as tooth staining, taste changing, and difficulties in patients’ adherence and side effects over the course of 60 days.

51. Replacement of CHX with other Types of Antiseptics

52. Replacement of CHX with other Types of Antiseptics Amine fluorides Povidone iodine Essential oils

53. Full-mouth scaling and root planing (the entire dentition in two visits within 24 h, i.e. two consecutives mornings) under local anaesthesia . Followed by rubbing the dorsum of tongue with a sterilized cotton swab soaked with 0.2 ml of Listerine for 1min. Mouth rinsing twice with 20 ml of essential oils mouthrinses for 30 s (during the last 10 s, the subject had to gargle)

54. Subgingival irrigation of all pockets three times within 10 min. with essential oils mouthrinses (5 ml/ irrigation/pocket) after sessions of scaling and root planing . Mouth rinsing at home with 20 ml of essential oils mouthrinses twice daily for 30 s for the following 2 months. Oral hygiene instructions including tooth brushing, flossing or inter-dental cleaning with inter-dental brushes and tongue brushing.

55. Supplementation with Antibiotics

56. Supplementation with Antibiotics Azithromicin Amoxicillin and metronidazole Metronidazole alone

57. AZITHROMYCIN In 2007, Gomi et al , that the addition of AZT to the FMD protocol was clinically and microbiologically effective. T he choice of AZ as an adjuvant to the non-surgical periodontal therapy was based on the following characteristics: its broad spectrum of action, fast leukocyte and fibroblast absorption, slow release in soft tissues, and reduced number of days of intake, which can contribute to patients’ adherence.

58. Metronidazole Cionca et al . investigated the addition of Amoxicillin ( Amox ) and Metronidazole (MTZ) to the FMD protocol using a regimen of 375 mg of Amox and 500 mg of MTZ three times a day for 7 days. At 6 months, Cionca et al . observed a greater reduction in the depth of deep pockets and the elimination of Aa .

59. Varela et al . reported that, at 3 months, an additional clinical benefit in the treatment of aggressive periodontitis was observed with the addition of Amox and MTZ to the FMD protocol (500 mg amoxicillin + 250 mg metronidazole, three times a day for 10 days ). Preus et al . evaluated the efficacy of the addition of MTZ monotherapy (400mg) to the FMD protocol They reported that the addition of MTZ increased clinical attachment gains and reduced pocket depth.

60. Addition of Probiotics

61. Addition of Probiotics The presence of pathogenic bacteria, the absence of so-called “beneficial bacteria” and the susceptibility of the host are the main aetiological factors of periodontal diseases. Teughels et al . Lactobacillus reuteri lozenges twice daily for 12 weeks difference which could be confirmed at a level of significance was the lower number P. gingivalis species. Also, Iniesta et al . (2012) reported this effect.

62. Full-mouth Antimicrobial Photodynamic Therapy

63. A new, alternative method of adjunctive antimicrobial treatment is provided by photodynamic therapy (PDT), which involves the use of a photosensitizer ( PS) that is activated by exposure to light of a specific wavelength in the presence of oxygen. Full-mouth Antimicrobial Photodynamic Therapy

64. The exposure of the PS to light results in the formation of oxygen species such as singlet oxygen and free radicals, the antimicrobial effects of which are Known PDT was performed with two chlorine- based sensitizers and BLC1010, followed by illumination with a diode laser (wavelength: 662 nm).

65. Sigush et al in 2010 . conducted a study to evaluate the efficacy of dynamic phototherapy in addition to FMD on the eradication of Fusobacterium nucleatum . Compared to the control group at 3 months post treatment , the patients in the test group had a greater reduction in pocket depth, better clinical attachment, and a significant reduction in Fn load.

66. The antimicrobial effect of the PDT method is based on the combination of a blue PS with laser light with a 660-nmwavelength. Soft diode laser and a phenothiazine chloride PS solution. A fiber-optic applicator with a 0.6-mmdiameter was used as a laser applicator to direct the laser light into the gingival crevice or the periodontal pocket. The power density measured at the surface of that laser applicator was 60 mW /cm2.

67. The PS solution was applied by placing the cannula tip of the PS applicator to the bottom of the periodontal pocket and delivered continuously during the removal of the tip toward the coronal side, and the upper surface of the tongue was wetted with PS solution. After an action time of 1 minute, the excess was removed by careful rinsing of all sites with physiologic saline solution .

68. Immediately thereafter, six sites of each tooth were irradiated. Each site was exposed to the laser light using the fiber-optic applicator for 10 seconds for a total of 1 minute per tooth. This was carried out as a full-mouth treatment that covered all teeth and the tongue. The tongue was irradiated in six segments, each for 10 seconds. Control subjects were also treated with the PS solution but without laser irradiation

69. FMD Combined with a Periodontal Dressing

70. FMD Combined with a Periodontal Dressing Keestra et al (2014) . evaluated the effects of adding the use of a periodontal dressing (Coe-Pak® type) for 7 days to the FMD protocol. This approach resulted in a greater reduction in shallow and moderate-depth periodontal pockets. However , only deep pockets showed a tendency for improvement. According to the authors, this technique would provide additional short-term clinical benefit and would reduce postoperative pain

71. Conclusion Full-mouth Disinfection carried out within a single day can be a very efficient way to deliver initial periodontal therapy in patients with reliable plaque control