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Dental Tribune Middle East & Africa Edition

11Dental Tribune Middle East & Africa Edition | July - August 2013 RESEARCH P eriodontal diseases, as evi- denced by the groundbrea- king investigations of Loe et al. (1986) and Page (1999), represent infectious diseases of the periodontium which are characte- rized by destruction of the periodon- tal tissues, including the periodontal ligament, the root cementum, the alveolar bone and the gingiva (see Fig. 1). Marginal periodontitis is an opportunistic infection (Fig. 2) which is caused by a gram negative, anaero- bic range of bacteria and is resulting in a chronic inflammation of the pe- riodontal tissues (Socransky und Haf- fajee 1992). The progressive loss of periodontal tissue and attachment can be obser- ved as a consequence of the persistent inflammation. Based on epidemiological studies (Fig. 2), the prevalence of chronic marginal periodontitis in the popula- tion over the age of 35 in Germany is approx. 40-45%, while approx. 53% of this age group suffers from a mode- rately severe, and approx. 21% from a severe form of periodontitis. It has also been possible, however, to obser- ve moderately severe (approx. 13%) and severe (approx. 1%) forms of periodontitis even in 15-year old ado- lescents. In the case of older people (seniors), almost one in two exhibits inflammatory-destructive changes (moderately severe/severe) of the pe- riodontium (DMS, 2006). Causative therapy can prevent the disease from progressing (Sastravaha et al. 2004). Therefore the mecha- nical supragingival and subgingival removal of calculus and plaque is the primary objective of conservative periodontal therapy which is aimed at destroying the subgingival bio- film and minimizing the periodontal pathogenic bacteria (O’Leary 1986, Westfelt 1996). Bacterial biofilms and endotoxins can be effectively remo- ved from the root surfaces by scaling and root planing. Manual, sonic or ul- trasonic scaling instruments are em- ployed (Drisko 1998, Sastravaha et al. 2005, Caruso et al. 2008). According to investigations, the use of mechani- cal scaling systems has become estab- lished because they make cleaning of the root surfaces easier, causing less fatigue and being more efficient for the dental treatment teams (Drisko et al. 1995, Oda et al. 2004). In addition to the decontamination processes already described, the in- tention in this case study is to illust- rate the effectiveness of an innovative method for biofilm removal - low- abrasion air polishing technology - as part of cutting-edge conservative periodontitis therapy. Air polishing instruments have been successfully used for a long time, particularly in professional tooth cleaning. Expansi- on of their use to include subgingival surfaces loaded with biofilm has been associated with significant disadvan- tages as there were no suitable instru- ment attachments available and only sodium bicarbonate powder could be used as the abrasive. This resulted in a less-than-adequate ability to clean the root surfaces. There was also the risk of causing emphysema. The AIR-N-GO PERIO® system replaces the insoluble sodium bicarbonate powder with soluble gly- cine powder which has a less abrasive power. Moreover, in clinical studies (reference literature at www.airngo- concept.com), it could be demonst- rated that the glycine powder exerts no adverse effects on the surrounding soft tissues during the air polishing process. The AIR-N-GO PERIO® in- strument, with its subgingival attach- ment and innovative flow chamber (Fig. 3) developed specifically for working directly in the periodontal pocket, is the result of cutting-edge CFD technology (numerical flow technology). The adjacent anatomical structures are not irritated and thorough remo- val of the subgingival biofilm on the root surface reduces marginal inflam- mation. The initial results presented are part of a clinically and microbio- logically controlled and randomized long-term investigation of the com- parative effectiveness of low-abrasi- on, sonically-assisted air polishing systems and ultrasonically-assisted methods within the scope of conser- vative periodontitis therapy. Material and method 15 patients who had baseline chronic marginal periodontitis were treated and re-examined over a period of three months. The clinical and micro- biological parameters were recorded before starting, immediately after clinical intervention (microbiological investigations only), after six weeks and after three months (Tab.1). After the preparative treatment had been carried out successfully and the patients had received a verbal and written explanation, those included in the study provided an informed consent and written declaration in accordance with the Helsinki Decla- ration (following amendment of the 41st World Medical Assembly, Hong Kong, September 1989). Preparative treatment All patients were involved in prepara- tive treatment following the initial ex- amination. The patients received oral hygiene instruction and professional supragingival debridement as neces- sary. The first phase of the preparative treatment covered a period of at least three and at most five weeks (three to five appointments) depending on the patient. The patients should have had a PI of approximately 1 within this time. The preparative treatment included supragingival scaling and polishing of the tooth surfaces using the AIR-N-GO SUPRA (Fig. 4). This air polisher works with a mixed jet of air and water, added to which is a cleaning powder that has been specially developed to be minimally traumatic to delicate mucosal tissue. The powder’s rounded microstruc- ture and the fineness of the calcium carbonate-based micro-beads protect the tooth enamel and enable gentle and effective cleaning of the tooth surfaces. The spray jet also reaches difficult areas such as tight interpro- ximal spaces. Clinical parameters The clinical attachment level (CAL), bleeding on probing (BOP), probing depth (PD) and gingival recession (GR) were determined as clinical va- riables. Microbiology The bacteriological investigations (Grimm et al. 1990 and 2005) took place prior to the basic examination, immediately after therapeutic inter- vention, six weeks and three months after the conservative periodontal therapy, by selectively detecting the periodontal pathogenic marker bac- teria using gene probe binding (hy- bridization). Subgingival sampling (Fig. 5) was carried out using ste- rile paper points according to Slots (1986). The paper point was inserted down to the base of the pocket, left there for ten seconds, then removed without initiating bleeding and placed imme- diately in the test tube provided for the test. The evaluation was pooled for the patients examined. The test tube contained a buffer which pre- served the amino acids of the bacteria during the transport time. Molecular biology tests, such as the IAI PadoTest 4•5® of the Institute for Applied Im- munology (IAI, Switzerland) used in our investigations, employ small syn- thetic DNAs complementary to the ribosomal RNAs as probes in order to analyze bacteria (such as A. actino- mycetemcomitans/Aa, T. forsythen- sis/ Tf, P. gingivalis/Pg, T. denticola/ Td). Furthermore, the total bacterial load (TBL) represents a good indica- tor for periodontal infection. For pa- tient typing, we additionally used the classification system (cluster) develo- ped by the Institute for Applied Im- munology (IAI, Switzerland). Using statistical methods, the periodontal pockets were classified into five types based on the various bacterial distri- bution patterns. The advantage of this typing of the periodontal pockets is that it records the complexity of the microbiological results using a single classification code thus making it easier to identify their clinical significance. Statistical evaluation When the investigations were com- plete, the mean values of the variab- les: clinical attachment level (CAL), bleeding on probing (BOP), probing depth (PD) and gingival recession (GR), were determined and evaluated descriptively. The Wilcoxon signed- rank test was used to compare the original data with the findings after application of the low-abrasion, so- nically-assisted air polishing system. The statistical tests were carried out using the SPSS statistics program. Results Demographic data All the patients included in the inves- tigation (n = 15) remained in the stu- dy for the entire observation period of three months; there was no change in the number of teeth investigated. 56.6% of the patients recruited were female and 43.4% were male. The proportion of smokers included in the study was 37.5%. All the patients were examined in accordance with the study protocol. Clinical parameters The AIR-N-GO PERIO group (Tab. 2) showed an average gain in clinical at- tachment six weeks post-operatively of 0.30 ± 0.04 mm for all the perio- dontia treated (mean reduction in the probing depth of 0.30 ± 0.02 mm) and for areas on the microbiological study teeth a gain of 0.67 ± 0.01 mm (mean reduction in the probing depth of 1.63 ± 0.06 mm). After three months, the AIR-N-GO PERIO group showed an average gain in clinical attachment for all the periodontia treated of 2.13 ± 0.04 mm (reduction in the probing depth of 0.30 ± 0.03 mm) and for areas on the microbiological study teeth an attachment gain of 2.13 ± 0.14 mm (reduction in the probing depth of 1.34 ± 0.03 mm). Table 3 shows the investigation parameters BOP and GR for all the investigation periods. In the AIR-N-GO PERIO group, the improvement in the BOP (compared to the original findings) after six weeks and three months was statistically significant (p<0.01). The slight increase in the GR compared to the original findings reflects the improved inflammatory situation of the marginal periodontium after the AIR-N-GO PERIO therapy. Microbiological results The results for the four periodontal marker bacteria A. actinomycetem- comitans (Aa), T. forsythensis (Tf), P. gingivalis (Pg), T. denticola (Td) and, in addition, the total number of marker bacteria (TBL) were recorded; the results in each case are given in million pathogens per ml of sulcus fluid. The microbiological results are summarized in Table 4. Aa exhibi- ted the lowest concentration (0.05 x 106) pre-operatively at the time base line of all the species investigated. Six weeks after treatment, the concentra- tion of the bacteria had reduced to 0 and three months post-operatively it had almost reached the original valu- The following case study illustrates the effectiveness of a treatment concept for the decontamination of root surfaces colonized with subgingival biofilm using low-abrasion powder jet technology. The aim of this case study was to evaluate the clinical and microbiological results during conservative periodontitis therapy using a low-abrasion subgingival air polishing system (AIR-N-GO PERIO®). New Methods In Conservative Periodontitis Treatment By Prof. Dr. Wolf-Dieter Grimm ________________________ Fig. 3 AIR-N-GO PERIO® instrument with its subgingival attachment (Fig. 3a) and specially developed flow chamber (Fig. 3b) Fig. 1 REM diagram of the root surface with illustration of the boundary lines of the epithelial attachment, the connective tissue attachment and the intra- alveolar attachment (Gassmann und Grimm, 2006). Fig. 2 Development of the moderately severe and severe periodontal diseases in 35 to 44-year old adults between 1997 and 2007 in percent (cf. Third and Fourth German Oral Health Study [DMS III, IV] of the Institute of German Dentists [IDZ] on behalf of the German Dental Association and the Federal Association Statutory Health Insurance Physicians, November 2006). AIR-N-GO PRIO Species x 106 BASE LINE (BL) Aa 0.05 0.07 0 0.03 2.59 0.23 1.03 0.28 1.67 1.92 0.29 0.18 0.18 87.21 42.81 35.21 29.69 0.23 0.77 0.26 Pg Tf Td TBL AFTER INTERVENTION (AFTERI) AFTER 6 WEEKS (AFT6WKS) AFTER 3 WEEKS (AFT3WKS) AIR-N-GO PRIO BOP (MM) STUDY TOOTH BASE LINE 0.93 ± 0.52 0.32 ± 0.93 2.1 ± 1.91 2.19 ± 1.93 0.2 ± 0.49 0.0027 ± 0.77 2.07 ± 0.54 2.07 ± 0.73 0.27 ± 0.97 0.1727 ± 0.67 2.47 ± 1.93 2.53 ± 0.53 6 WEEKS 3 MONTHS ALL BOP GR (MM) STUDY TOOTH ALL GR AIR-N-GO PRIO PPD (MM) STUDY TOOTH BASE LINE 5.07 ± 0.52 6.00 ± 0.93 8.1 ± 1.91 8.1 ± 1.93 4.40 ± 0.49 5.70 ± 0.29 6.47 ± 0.54 7.8 ± 0.24 3.73 ± 0.97 0.093 3.43 ± 0.77 0.391 6.2 ± 1.93 0.687 5.97 ± 1.53 0.872 6 WEEKS 3 MONTHS P-VALUE ALL PPD CAL (MM) STUDY TOOTH ALL CAL Tab. 1 Chronological treatment scheme Tab. 2 Mean value and standard deviation of the PPD and CAL values for the base line study, six weeks and three months after therapeutic intervention for all periodontia recorded and for the microbiological study tooth Tab. 3 Mean values and standard deviation of the BOP and GR changes to the base line study, after six weeks and after three months for all periodontia and for areas on the microbiological study teeth Tab. 4 Influence of the AIR-N-GO PERIO system on bacterial prevalence PERIOD BASE LINE (BL) CLINICAL EXAMINATION X - X X X X X X X - - - MICROBIOLOGICAL EXAMINATION THERAPY AFTER INTERVENTION (AFTERI) AFTER 6 WEEKS (AFT6WKS) AFTER 3 WEEKS (AFT3WKS)

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