Treatment for periodontitis


Interventions available to treat periodontitis are categorized as surgical or nonsurgical and may include systemic antibiotics. Tetracyclines are often used to treat periodontitis because they suppress glycation of proteins and reduce the activity of inflammatory mediators such as matrix metalloproteinases.5 Periodontal treatment normally involves the debridement of root surfaces to remove dental plaque and mineralized calculus.4 Scaling and root planing (SRP), the debridement techniques used, may be done nonsurgically or done following surgical reflection of soft tissue flaps to provide visual and physical access to the root surfaces and alveolar bone.4 As shown in Table 1, other interventions used to treat periodontitis include oral hygiene instruction, antiseptic mouth rinses such as chlorhexidine, dentifrices, photodynamic therapy, tooth extraction, subgingival curettage, and gingivectomy.16,17,18


Table 1. Summary of preventive and treatment strategies

Prevention Treatment
Avoidance of sugary foods and beverages Oral hygiene instruction
Smoking cessation Mouth rinses such as chlorhexidine
Use of fluoridated toothpaste Dentrifices
Daily flossing Photodynamic therapy
Brushing teeth twice daily Subgingival curettage
Gingivectomy

Impact of periodontitis treatment
on glycemic control


The consensus of most studies is that the treatment of periodontitis affects diabetes outcomes.1,8,16,18-23 In a randomized controlled trial, Botero et al. compared the effects of nonsurgical intervention plus azithromycin (AZ-Sca; n=33), nonsurgical intervention plus placebo (PB-Sca; n=37), and supragingival prophylaxis plus azithromycin (AZ-Pro; n=35) on glycemic control in patients with diabetes.19 Although the AZ-Sca and PB-Sca groups showed a 0.8% and 0.3% change in A1c levels, respectively, during a nine-month period, the AZ-Pro group did not show any reduction in A1c. In another randomized controlled trial, study participants with chronic periodontitis received SRP plus chlorhexidine mouth rinse at baseline and intermittent supportive therapy at three and six months.21 The researchers found no improvement in A1c. However, in another study, participants who also received SRP and chlorhexidine mouth rinse had an average 0.6% reduction in A1c in six months.17

Regarding SRP and adjuvant antibiotics, differences in A1c levels were noted in two studies that used SRP and doxycycline. In a 2012 study by Gilowski, participants received SRP alone or SRP and doxycycline 20 mg twice daily.22 After three months, there were no changes in A1c results for either group.22 In a 2009 study by Al-Zahrani, participants received SRP alone, SRP plus photodynamic therapy (PDT), or SRP plus doxycycline for three months. An improvement in A1c was noted for all groups but was only significant for the SRP plus doxycycline group.16 In a Turkish-based intervention study in which participants were classified as having both poorly controlled or well-controlled diabetes, Dag et al. investigated the effect of periodontal treatment on TNF-α and A1c levels.20 They found that nonsurgical periodontal treatment reduced TNF-α; however, over a short period of time, it did not reduce A1c without stringent glycemic control in poorly controlled patients with diabetes. Engebretson et al. reported that although periodontal treatment had improved clinical measures of chronic periodontitis in participants with diabetes, their findings did not support the use of nonsurgical periodontal treatment for lowering A1c levels.21

Teeuw, Gerdes, and Loos conducted a systematic review and meta-analysis of five studies with a total of 371 patients with type 2 diabetes in which the subjects in the intervention group received SRP with or without local or systemic antibiotics, while the subjects in the control group did not receive any kind of periodontal intervention.23 From three to nine months, all studies indicated that there was an improvement in glycemic control after periodontal intervention compared with the control group. The meta-analysis indicated that there was a weighted mean difference of −0.40% in A1c before and after treatment. In an intervention review, Simpson et al. assessed the association between periodontal treatment and glycemic control in patients with diabetes.18 Of the seven studies that were assessed, three studies compared interventions with no therapy or usual therapy for three to four months. The researchers also found that there was a mean difference of −0.40% in A1c for SRP and oral hygiene, with or without antibiotic therapy, compared with no treatment or routine treatment. In a meta-analysis of nine controlled trials involving 485 patients with diabetes, Darré and colleagues found that periodontal treatment resulted in a 0.46% A1c reduction, but that it could lead to a 0.79% A1c reduction.1 However, the researchers stated that the findings have to be viewed cautiously, because the controlled trials lacked robustness, and the study designs were flawed.


Table 2. Oral screening

Observation Palpation Record Refer to Dentist
First remove all dentures Mouth Signs of periodontal disease 6-month evaluation
Teeth and odor Neck Presence of plaque Periodontal disease
Palate and gums Erythematous or receded gums
Buccal mucosa Loose teeth
Floor and mouth of tongue
Posterior pharynx
Adapted from Silk H, Douglas A, Douglass J. Adult oral health pocket card. October 2011, Smiles for Life Oral Health Curriculum. Available at www.smilesforlifeoralhealth.org/buildcontent.aspx?pagekey=62954&lastpagekey=62948&userkey=117