Non-surgical Antimicrobial Treatment of Periodontal Disease

Can periodontitis be treated without surgery?

Periodontal disease affects at least 50 million Americans. This translates to one third of the non-edentulous population over the age of 30 suffering from some form of the disease. When significant oral bone loss, loss of periodontal attachment, and periodontal pocketing occurs, periodontal surgery is usually the treatment of choice to improve periodontal health. In support of surgical treatment, non-surgical antimicrobial agents are now utilized to improve and support periodontal health. These agents are able to address the causes of periodontal disease and are an important part of the dental armamentarium for optimizing oral health.

The current understanding of periodontal disease pathogenesis involves two distinct but related processes: Bacterial infection, and host response. The etiology of periodontal disease is directly linked to infection of the gingival sulcus by pathogenic bacteria. These bacteria excrete acids and toxins which inflame the periodontium, and break down the gingival attachment and alveolar bone. The host response component involves the body's own immune system response (or over-response) to the bacteria. The oral tissues release cytokines that mediate the release of a group of enzymes called matrix metalloproteinases (the most destructive being collagenase) which break down protein compounds in the periodontium. This leads to chronic loss of gingival attachment, periodontal ligament support, and compromised bone levels.

What is a non-surgical treatment for periodontal disease?

Antimicrobial agents can now be locally delivered to help prevent periodontal breakdown. High dosages of specific agents can be placed at the immediate site of the infection, while limiting the systemic circulation of high levels of antibiotics. Among the pharmaceutical agents utilized most frequently in this regard are:

Arestin: Approved by the FDA in 2001 as an adjunctive treatment for adult periodontal disease. Arestin contains the antibiotic minocycline HCl encapsulated in 20-60 micron diameter microspheres for slow release. It is placed directly into periodontal pockets following scaling and root planing. It is highly bioadhesive and is self-retained within the pocket where it kills pathogenic bacteria for 14 days, at which time it is fully dissolved and requires no removal. Clinical studies report reduction in probing depths of 2-3 mm compared with scaling and root planing alone after 9 months.

PerioChip: A small solid chip of resorbable gelatin containing a 2.5 mg dose of chlorhexidine gluconate which is fitted directly into the depth of a periodontal pocket following scaling and root planing. It is only recommended for use in adults, in periodontal pockets of 5 mm or more in depth. It provides a continuous release of chlorhexidine in a far more targeted, sustained manner, and at higher concentrations than is available from rinsing or irrigation with chlorhexidine rinses. The PerioChip completely dissolves in 7-10 days. Studies reveal that actual improvements in probing depths were only in the range of 0.3 mm to 0.5 mm, so the actual level of clinical improvement is in doubt due to the typical 0.5 mm to 0.8 mm margin of error for clinical perio probing.

Atridox: A liquid polymer placement vehicle containing 10% doxycycline hyclate, a broad-spectrum antibiotic which is a synthetic derivative of tetracycline. It is delivered directly into the periodontal pocket and remains active for 1-2 weeks. An important difference in treatment approach between this agent and Arestin and PerioChip is that Atridox studies have been conducted using Atridox as an alternative to scaling and root planing. Atridox is approved by the FDA as a stand-alone therapy for treatment of periodontal pockets in the adult population. For patients who decline scaling and root planing this offers an FDA-approved non-mechanical non-surgical treatment option.  

For an in depth discussion of these agents see the Dental Didactics CE course Antimicrobial Periodontal Therapies