INNOVATIONS IN NON SURGICAL PERIODONTAL THERAPY.pptx

Innovations in Non-surgical Periodontal treatments

1. INNOVATIONS IN NON SURGICAL PERIODONTAL THERAPY (NSPT) Dr. Oluwatosin Olonite

2. WACS MEMBERSHIP QUESTION 3, PAPER 2, APRIL 2024 : Several innovations have been employed to improve the efficacy of Non-surgical Periodontal Therapy List TEN various types available (b) Describe how each of these innovations perform the role of Periodontal Therapy

3. OUTLINE Introduction Rationale for Non Surgical Periodontal Therapy Classification of Non-Surgical Periodontal Therapy Innovations in Mechanical Instruments Innovations in Chemotherapeutic approaches Clinical Outcomes of Non-Surgical Periodontal Therapy Conclusion References

4. INTRODUCTION Periodontal disease is an inflammatory condition affecting the periodontium (tooth-supporting tissues), which leads to the destruction of periodontal tissues and eventual tooth loss. The microbial plaque and the host immune responses are important causative factors that are highly responsible for the initiation and progression of the condition. During the development of periodontitis, the oral microbiota converts from facultative gram-positive bacteria to largely anaerobic gram-negative bacteria. There are higher number of disease-causing bacteria than healthy ones in periodontitis.

5. INTRODUCTION Bacterial species known to be strongly implicated in periodontitis include: - Aggregatibacter actinomycetemcomitans (aggressive periodontitis) - Porphyromonas gingivalis (pregnancy gingivitis, chronic periodontitis) - Prevotella intermedia (chronic periodontitis, ANUG ) - Treponema denticola (aggressive periodontitis) - Tannerella forsythia (aggressive periodontitis) - Fusobacterium nucleatum (chronic periodontitis, ANUG) Non-surgical periodontal therapy is effective in removing biofilm, calculus and endotoxins that can induce inflammation from root surfaces and other periodontal tissues Thus it is often the first line of defense against further disease progression

6. INTRODUCTION It is a well established fact that periodontal diseases are multifactorial in nature and one or more risk factors are necessary for disease initiation and progression. These risk factors include: microbial factors, host-related and environmental factors. Presence of poor oral hygiene, poorly controlled diabetes mellitus, persistent stress, habits such as tobacco smoking, genetic susceptibility, extent of alveolar bone loss are some of the risk factors that may influence long term outcomes of periodontal therapy. Thus evaluation of these risk factors are necessary for preferred therapeutic approaches.

7. CRITICAL PROBING DEPTH Critical probing depth indicates the probing pocket depth below which clinical attachment would be lost as a result of the respective treatment procedure and above it would result in clinical attachment gain It is used to determine the therapeutic approach for periodontal conditions. It is marked at 5.4mm which implies that pocket depths below or equal to this will be treated with the non-surgical periodontal therapy while values equal or above it (5.5mm and above) will need both non-surgical and surgical approaches to achieve significant clinical outcomes. ( Heitz-Mayield and Lang)

8. RATIONALE FOR NON-SURGICAL PERIODONTAL TREATMENT Aims of Non-Surgical Treatment: Treatment of periodontitis aims to prevent further disease progression, to minimize symptoms and possibly to restore lost tissues. The overall target of non-surgical treatment is to create an environment that is biologically compatible with healing of the periodontal tissues. This is mostly achieved by: 1. Removal of supra and subgingival calculus 2. Disruption and elimination of biofilm from the root surface 3. Decontamination by removal of endotoxins from the root surface

9. CLASSIFICATION OF NON SURGICAL PERIODONTAL THERAPY(NSPT)

10. CLASSIFICATION OF NON SURGICAL PERIODONTAL THERAPY Nonsurgical periodontal therapy includes mechanical therapy and use of chemotherapeutic agents in treatment of periodontal diseases. Mechanical therapy refers to both supragingival and subgingival scaling and debridement of the roots by use of hand or power-driven instruments to remove deposits such as plaque, calculus and endotoxins. Chemotherapeutic approaches includes antimicrobial agents that can be used systemically or locally to address changes in the microflora as well as host modulation therapy.

11. INNOVATIONS IN NON-SURGICAL PERIODONTAL THERAPY 1)Lasers 2)Photodynamic therapy (PDT) 3)Ozone therapy 4)Probiotics 5)Periodontal vaccine 6)Nanotechnology 7) PerioProtect 8)Pro-resolving mediators 9)Hyperbaric oxygen therapy (HBOT) 10)Full mouth disinfection

12. INNOVATIONS IN MECHANICAL INSTRUMENTS Mechanical periodontal therapy is usually the first line of treatment for most periodontal infections and includes subgingival scaling and root debridement procedures. Conventional mechanical therapy includes use of manual, sonic and ultrasonic instrumentations. However, use of Lasers, Ozone and Photodynamic therapies in Non-surgical periodontal therapy are recent inclusions in mechanical approach.

13. LASERS LASER is an acronym for  Light Amplification by Stimulated Emission of Radiation. Lasers have excellent tissue ablation with strong bactericidal and detoxification effects Unique advantages of lasers are that both soft and hard tissues can be targeted when using lasers for the treatment of periodontal lesions. Examples of lasers in dentistry: Excimer lasers, Diode lasers, CO2, Nd:YAG (Neodymium-doped: yttrium, aluminium , garnet), Er:YAG (Erbium-doped: yttrium, aluminium , garnet). The commonly used high power lasers are CO2 and Nd:YAG (wavelength of 1064nm)

14. LASERS

15. LASERS

16. LASERS A B C D

17. LASERS However, these previous lasers are not useful for treatment of the root surface or alveolar bone, due to carbonization and major thermal side-effects on the target and surrounding tissues. To overcome these side effects, Er : YAG lasers have been introduced. The Erbium family of lasers has been shown to effectively ablate both soft and hard tissues without damaging deeper tissues. In particular, it is preferred for root surface treatment as it’s safe and efficient, especially when used concurrently with water irrigation. 19

18. PHOTODYNAMIC THERAPY (PDT) This is photo inactivation of bacteria. It requires a non-toxic photosensitizer, harmless visible light and oxygen It is based on the principle that the photosensitizer binds to targeted bacterial cells and can be activated by visible light or infrared of the appropriate wavelength in the presence of oxygen. This results in the generation of free radicals, which are extremely toxic to bacterial cells adherent to root surfaces. They have been shown to be effective for pathogen control in planktonic periodontal bacteria

19. PHOTODYNAMIC THERAPY (PDT) Toluidine blue (spectrum:630nm; red laser or LED) and methylene blue (spectrum:661nm; red laser) are the most used photosensitizers in Dentistry. These photosensitizers show peak absorption around 600-700nm and are frequently used in combination with visible or infrared light. The light used for PDT in the treatment of periodontitis is the low-level laser which has shown favorable healing properties. The light intensity used is below the toxicity limit of the host tissues. Scaling and root planing with adjunctive PDT has shown to improve clinical outcomes.

20. PHOTODYNAMIC THERAPY (PDT) Also LED can be used as source of light especially in deep pockets or complex root surfaces. LED devices can give out wavelengths of light in the ultraviolet (UV), visible and infrared regions. The antibacterial effect is based on dose and type of photosensitizer, wavelength and irradiance of light as well as oxygen content in the irradiation field. Methylene blue mediated PDT ( Periowave ®) is an example of PDT employed in periodontics.

21. PHOTODYNAMIC THERAPY Methylene blue mediated PDT with low level laser therapy (LLLT)

22. OZONE THERAPY In year 1932, Dr. E.A. Fisch - a swiss dentist was the first to use ozonated water or gas in his practice. Ozone is a powerful oxidizer - it effectively kills bacteria, fungi, viruses and parasites at a very low concentration with no toxic side effects. It has analgesic, immune stimulant, detoxifying and oxidant effects Ozone causes synthesis of biologically active substances such as interleukins, leukotrienes and prostaglandins which helps to reduce inflammation and promote wound healing.

23. OZONE THERAPY

24. OZONE THERAPY Ozone can be used in the form of Ozonized Water, Ozonized oils or Gaseous Ozone . Similar reduction in bacterial counts and improved probing depths have been seen with ozonized water and therefore merit further investigation in periodontal therapy. Care MUST be taken in using gaseous ozone as it has the consequence of causing respiratory distress.

25. OZONE THERAPY HealOzone ®, OzonyTron ®, Prozone ® are some commercially available appliances used for ozone production in dental treatment

26. INNOVATIONS IN CHEMOTHERAPEUTIC APPROACHES These pharmacological agents can be delivered locally or systemically. Local drug delivery can be further divided into non-controlled and controlled/sustained-release delivery systems. Non-controlled releasing system includes mouth rinses and subgingival irrigation while Controlled/sustained-releasing systems includes Non- resorbable or resorbable ( intrapocket ) delivery systems. Systemic antibiotics can be administered by intraoral or cutaneous (transdermal patch) routes.

27. PROBIOTICS Probiotics are living microorganisms that can have a beneficial effect on the host when taken in sufficient doses. WHO/FAO (2002) Effects of probiotics in periodontology has been researched over the years and currently it been found that probiotics concentrated in the following genera contributes to oral health. Lactobacillus, Bifidobacterium , Streptococcus and Weissella as well as certain species such as Bacillus subtilis and Saccharomyces cerevisiae Strains of Lactobacillus reuteri , Lactobacillus plantarum , Lactobacillus rhamnosus , Lactobacillus casei , Bidifobacterium breve , Bidifobacterium longum , Streptococcus salivarius etc have been commercially produced as oral probiotics.

28. PROBIOTICS They inhibit the release of pro-inflammatory cytokines: IL-1 β , IL-6, IL-8 and TNF- α and stimulates the release of anti-inflammatory cytokines: IL-4, IL-10, IL-11, IL-13. (Guided tissue recolonization ) Also neutralizes volatile sulphur compounds and thus useful in management of halitosis. C linical studies with Lactobacillus reuteri strains (by administering chewing gums and other forms twice a day for 2 weeks) along with scaling and root planning showed improved clinical parameters in the subjects.

29. PROBIOTICS Probiotics can be in powder, lozenges/tablets, mouthwash, toothpaste or granule forms. Examples of Commercially available probiotics for periodontal therapy include Gum Periobalance ®, Prodentis ®, Peribiotic ®, Acilact ®, Vitanar ®.

30. PROBIOTICS

31. PROBIOTICS

32. PROBIOTICS

33. PERIODONTAL VACCINE Edward Jenner devised and established the notion of vaccination in the late 18 th  century. There are three types of vaccinations: Active immunization – A method of stimulating a person’s immune system by giving them killed or live, attenuated products made of microorganisms. Passive immunization – Immunization given passively, in which antibodies produced in one person are passed on to another. DNA immunization – DNA vaccination involves giving a person DNA plasmids that include the genes needed to produce antigens.

34. PERIODONTAL VACCINE The need for vaccine development was brought on by bacteria that are capable of evading host immune responses and invading tissues like  P. gingivalis The availability of a periodontal vaccination would not only prevent or slow the progression of periodontal illnesses but also improve the standard of living for those who cannot easily access periodontal therapy.

35. PERIODONTAL VACCINE Periodontal vaccinations used in the early 20 th  century include pure cultures for  Streptococcus  and other pathogens. Examples include the Inava endocarp vaccine and the Vancott vaccination. Oral, mucosal, sublingual and are various modes of immunization that have been used for periodontal vaccination studies in non-human primates. Human trials of these conducted studies are currently a challenge

36. PERIODONTAL VACCINE

37. PERIODONTAL VACCINE

38. NANOTECHNOLOGY It is the science and technology of relieving pain, improving human health, preventing, diagnosing and treating of diseases and traumatic injury through the use of nanoscale -structured materials, biotechnology and genetic engineering. They are usually measured in the scale of nanometers. They react at molecular level. Timed release of drugs may occur from resorbable nanospheres . Diagnosis and treatment of periodontal conditions can be done via nano -scaled particles

39. NANOTECHNOLOGY The concept of nanotechnology was first introduced by Richard Feynman. The dental nanorobots were first introduced by Robert Freitas in 1994. Nanorobots are able to distinguish different cell types in saliva, gingival crevicular fluid and blood by checking their surface antigens for diagnosis and treatment ( nano -scale biosensors). When the task of nanorobots are completed, they can be removed via the human excretory system.

40. NANOTECHNOLOGY Nanotechnology can be employed in different forms: Hydrogels e.g. Periochip ® - to deliver 2.5mg CHX digluconate Intra pocket microspheres e.g. Arestin ® for local delivery of minocycline antibiotics Nanoscale biosensors (for diagnosis and treatment) Dentrifrobots : devices incorporated in mouthwash or toothpaste that could identify and destroy pathogenic bacteria leaving behind harmless oral flora to flourish.

41. NANOTECHNOLOGY

42. NANOTECHNOLOGY

43. NANOTECHNOLOGY

44. NANOTECHNOLOGY The parts of nanorobots include: CAMERA: for the operator to see what is happening in-vivo PAY LOAD: contains drug dose CAPACITOR: Energy storage unit for the nanorobot SWIMMING TAIL: helps in propulsion inside the body ELECTRODES: that function as battery for the nanorobot LASERS: helps in the destruction of target cell SERVO MOTORS: An important part of any robot which allows the robot to move

45. DENTAL NANOROBOTS

46. NANOTECHNOLOGY

47. NANOTECHNOLOGY Functions may be controlled by an onboard nano -computer carrying out pre-programmed instructions in response to stimuli from the local sensors. Alternatively, the dentist may issue strategic instructions by transmitting his orders directly to in-vivo nanorobots via acoustic signals (e.g. ultrasound). Nanorobotics would be useful in areas of local anaesthesia , tooth repair, dentinal hypersensitivity, nanorobotic dentifrice ( Dentifrobots ) and re-engineering of damaged tissues.

48. PERIOPROTECT PerioProtect ® is a comprehensive therapeutic method customized for individual patients to help manage biofilms growing in periodontal pockets and areas hidden deep below the gums and are extremely difficult to reach with toothbrushes, rinses and floss.  The Perio Protect Method combines in-office procedures with comfortable Perio Tray ®  delivery of medication that patients use at home, between office visits. The chemical therapy involves the delivery of prescribed solutions (1.7% hydrogen peroxide gel of low concentration) in customized trays ( Perio Tray™)to chemically debride biofilms from periodontal pockets. It works by creating a seal to prevent medication from seeping into the mouth. The pressure created by the seal forces the medication into pockets under the gum line

49. PERIOPROTECT The actual frequency and duration will be determined by the dentist based on individual patient needs. Most patients however start with 2-3 Perio Tray applications per day (10-15 minutes per time). Once the infection is under control and the inflammation and bleeding decrease, Perio Tray usage generally drops to one time per day and continues to be used to manage periodontal disease. It alters the pocket's microbiological environment thus disrupting biofilm growth. Used as an adjunct therapy for moderate to advanced periodontitis, it has been shown statistically to have significant outcomes in reducing pocket depths and bleeding when compared with scaling and root planning.

50. PERIOPROTECT

51. PERIOPROTECT

52. PERIOPROTECT The Perio Tray™    delivers medicine deep into perio pockets and holds it there .

53. PRO-RESOLVING MEDIATORS Specialized Pro-resolving Mediators (SPMs) are endogenously biosynthesized chemical mediators that are both pro-resolving and anti-inflammatory. These molecules, namely lipoxins , resolvins , protectins , and maresins . In general, they control the resolution of the inflammation and promote healing. Major findings revealed that these mediators lead to bone gain and consequently bone regeneration by reducing the inflammatory cell infiltration and osteoclastic activity.

54. PRO-RESOLVING MEDIATORS Although these mediators do not have a direct effect on the microbiota , the resulting regulation of the inflammation shifts the composition of the microbiota due to changes in the local environment secondary to the inflammation resolution. Studies suggest that that the chronic periodontal lesion is characterized by hyperactivated neutrophils with resultant activation of lipoxin pathways and that sufficient quantities of lipoxin were capable of preventing tissue destruction in bacterial-induced periodontal disease.

55. PRO-RESOLVING MEDIATORS

56. HYPERBARIC OXYGEN THERAPY (HBOT) HBOT is a method of administering pure (100%)oxygen at high atmospheric pressure (2.4 ATA) within an enclosed chamber to a patient to improve or correct medical conditions. HBOT should be used to compliment conventional therapies and treatments. Studies showed that HBOT combined with supragingival and subgingival scaling therapy had synergistic action on periodontitis. HBOT has good therapeutic effects on severe periodontitis, stimulating the growth of new blood vessels and enhancing oxygen delivery to the affected bone tissues.

57. HYPERBARIC OXYGEN THERAPY (HBOT)

58. FULL-MOUTH DISINFECTION (FMD) FMD technique was described by Quirynen in 1995, with the intention of performing the scaling and root planing in one or two visits in a 24-hour range. The goal is to avoid the possibility of cross contamination between treated and untreated areas. This is to prevent contamination of already treated tissues from microbial translocation from other oral niches such as the tongue, tonsils, interdental spaces.

59. FULL-MOUTH DISINFECTION (FMD) The patient would have been placed on antibiotic coverage starting from 1-2 days before the clinic appointment day for mechanical instrumentation. Scaling and root planning are done, taking approximately one hour in each quadrant with pocket irrigation using 1% chlorhexidine solution. After instrumentation, optimal disinfection is sought by first brushing the back of the tongue for 60 seconds with a 1% chlorhexidine gel. Afterwards, two rinses are made with a 0.2% chlorhexidine solution for one minute (60s gargling during the last 10 seconds to reach the tonsils).

60. FULL-MOUTH DISINFECTION (FMD) This step is repeated eight days after the intervention. Px is to continue the systemic antibiotics e.g. Start dose: Caps Doxycycline 100mg b.d . (1 st day) Then 100mg once daily for the remaining days (20 days) 0.2 % CHX solution (10ml volume) twice daily for 2weeks Oral hygiene motivation is given including interdental plaque control with interdental brushes or flossing, and brushing the back of the tongue twice a day.

61. FULL-MOUTH DISINFECTION

62. CLINICAL OUTCOMES OF NON-SURGICAL THERAPY Significant change in probing depth reduction and gain in clinical attachment occurs within 1–3 months post therapy, although healing and maturation of the periodontium may occur over the following 9–12 months. Thus, evaluation of the response of the periodontium to NSPT should be done after 4 weeks following treatment, to avoid disrupting the healing process.

63. CONCLUSION The introduction of novel adjunctive therapies to enhance the efficacy of existing non-surgical periodontal procedures has contributed favorably to an integrated approach for the long-term clinical management of periodontitis. As the field of periodontology evolves, utilization of these innovative approaches in clinical practice need to be encouraged as well as further extensive researches in the areas that have great therapeutic potentials.

64. REFERENCES Bhansali RS. (2014) Non-surgical periodontal therapy: An update on current evidence.  World J Stomatol   Carranza’s Clinical Periodontology by Newman et al (11 th Edition) Debarghya Pal et al (2021). Non-surgical periodontal therapy (Journal of Dental Panacea) Dr. Dheeraj Khurana . (2014): Photodynamic Therapy- A Ray towards Periodontics (IOSR Journal of Dental and Medical Sciences: Volume 13, Issue 3) Raghavendra Reddy N et al.(2022) Photodynamic therapy: a novel approach for periodontal pathogens

65. REFERENCES Moro MG (2021): Efficacy of aPDT for non-surgical treatment of periodontal diseases, Epub Med www.colgate.com/en-us/oral-health/adult-oral-care/what-is-ozone-dentistry-and-how-does-it-work# Frontiers Journal (March, Vol 12 2022): Probiotic species in the management of periodontal diseases Dr Settu et al (2024): Probiotics in Periodontology- International Journal of Dental Science and Innovative Research Volume 6 (Issue 4) Vaernewyck V, Arzi B, Sanders NN, Cox E, Devriendt B. (2021 Dec)- Mucosal Vaccination Against Periodontal Disease: Current Status and Opportunities. Frontiers Immunology  

66. REFERENCES Saksham Kohli et al (2023): Periodontal vaccines-where we are now and where we can go (Asian Journal of Oral Health and Allied Sciences) Nanotechnology and Periodontics (2023): J Periodontal Sci. www.perioprotect.com Thomas E. Van Dyke , DDS, PhD: Pro-resolving Mediators in the Regulation of Periodontal Disease

67. REFERENCES Shubhra S,Pooja B. Innovations In Non- Surgical Periodontal Therapy https://www.researchgate.net/publication/359685194 Isabella Karina Gutiérrez-de la Garza (2019) Full-mouth disinfection protocol: Applications, techniques and variables in non-surgical periodontal treatment literature review (International Journal of Applied Dental Sciences) Jyotsana Tanwar , Shital A. Hungund , Kiran Dodan - Nonsurgical periodontal therapy: A review Phil Ower . Minimally-invasive non-surgical periodontal therapy PubMed.

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