The cooling spray from your ultrasonic scaler offers a highly effective way to deliver pathogen-destroying agents. Ultrasonic irrigation is inexpensive (you already own most of the required equipment.) It's easy (you chemically irrigate the pockets while you debride the surfaces.) And its extraordinarily effective.

An anecdote with a moral for the 90's.

I have a good friend, and patient who's a professional clarinet player. John is a terrific fellow, who plays a wicked "Sweet Georgia Brown." He suffered from periodontitis so severe, that his periodontist recommended extraction of his lower anteriors.

Now for those of you who don't play a wind instrument, anterior dentition is absolutely essential to controlling the reed. There are no denture wearers among the world's great clarinetists.

Having teeth extracted involves a loss of self-esteem for everybody. But for my friend John, it represented the loss of his career.

Despite the apparently bleak prognosis, we treated him using subgingival ultrasonic therapy supplemented by antimicrobial agents. No extractions. No surgery.

We made no promises. But thirteen years later, he still has his anteriors ... and he's still blowing a storm. (Illustration 1)

First, learn to recognize success.

In my courses I often ask dentists and hygienists what their specific goals are when treating the periodontal patient. I usually get a range of responses:

"3-4mm residual pockets"
"Bone regeneration"
"Eliminate bleeding"
"Achieve pink, stippled gingiva"

Now these are all admirable ambitions. But if you use them as your criteria for success, you're going to feel horribly inadequate, and you may even be in danger of overtreating the patient.

Fact The depth of the residual sulcus is not a valid measure of periodontal health. This is one of the biggest myths in dentistry. Deep pockets are caused by disease, however, they are a contributing factor only if they prevent hygiene or harbor high levels of destructive pathogens. Relatively deep pockets often remain after non-surgical periodontal treatment, when the patient is clearly in a state of health.

Fact: Despite the pictures you see in some magazines, successful periodontal therapy does not necessarily result in bone regeneration.

Fact: Some successfully treated patients may continue to bleed a bit during routine probing. And pink, stippled gingiva may not be a rational objective for many patients suffering moderate to severe periodontitis.

The primary goal of periodontal therapy is very simple:

"To arrest the progression of the disease."

If you can stop further bone and attachment loss, you've fulfilled your duty. Yes, you'll sometimes see osseous regeneration. And if you do, that's wonderful. Just don't count on it.

Different patients ... different immune systems.

With the exception of the intestinal tract, the mouth is the most germ infested place in the body.

It's under constant attack from the widest possible variety of pathogens. So there's an on going immune-system war. If something inhibits the host's resistance, the bugs gain the advantage. (I suspect that’s why immune related problems such as AIDS or cancer chemotherapy often manifest themselves first as diseases of the oral tissues.)

Patients vary widely in their response to periodontal therapy, probably because patients' immune systems vary widely in their ability to resist oral pathogens.

For patients with a robust system, a lecture on oral hygiene plus periodic scaling may be all that's necessary to treat gingivitis. Even mild cases of periodontitis may stop progressing once the level of endotoxins has been reduced by ultrasonic lavage, and sufficient numbers of pathogens have been destroyed and disrupted by the cavitation.

However, many (perhaps most) of my periodontal patients are immune compromised. For them, periodontal health resembles an uneasy truce during a prolonged guerilla war. As soon as their resistance drops even slightly, the pathogens advance, causing flare ups at specific sites ... wherever local factors give them an advantage. These patients may require life-long monitoring and frequent professional intervention to supplement their immune response.

Teetering on the brink of periodontal health.

In my courses, I sometimes describe periodontal therapy as a child's seesaw (Illustration 2).

On the left side of the lever are the forces of evil (periodontal pathogens and the local factors that give them sanctuary) ... on the right side is the treatment armamentarium. The patient's immune system is the fulcrum on which the treatment balances. If the immune system is strong, the fulcrum is positioned far to the left. The pathogens don't exert much leverage ... so normal home care may be all that's necessary to keep them in balance.

But as the immune system weakens, the fulcrum slides to the right. The pathogens exert increasing leverage, so treatment requires increasingly dramatic intervention.

Antimicrobials ... the battle escalates.

As I discussed in my previous article (Special Report #35), a gaggle of studies has shown that simply debriding roots using an ultrasonic scaler equipped with a thin perio tip can often arrest cases of gingivitis and mild periodontitis. The cavitation energy in the water spray blasts bacteria and endotoxins from root surfaces and may mechanically tear apart the bacterial cell walls.

However, in more severe cases (particularly if the patient is immune compromised), subgingival ultrasonic debridement alone may not be enough to halt progression of the disease.

In these cases, it's not unusual to see initial attachment regeneration ... followed by recurrent periodontal lesions.

When pathogens remain entrenched in crevicular epithelial cells or other hard-to-dislodge areas, they can serve as a reservoir of recurrent infection. A tight epithelial attachment coronal to the reservoir may actually make matters worse by preventing drainage.

For these patients you must escalate your attack on the pathogens. And in my opinion one of the best ways is to supplement subgingival ultrasonic debridement with a good antimicrobial agent.

For years my primary treatment for periodontitis has been subgingival ultrasonic scaling combined with antimicrobial irrigation. This one-two punch has proved extraordinarily effective even when treating moderate to severe cases that have resisted traditional therapy. (And I can't remember the last time I received a midnight call from a patient with a post treatment periodontal abscess!)

Rinsing with an antimicrobial won't do it. You have to stick the agent down where the pathogens are entrenched. You can use a cannula or irrigating handpiece (and I use both in my practice.) But my favorite method is to deliver antimicrobials automatically during debridement by running the agent through my scaler handpiece.

Poisoning the bugs while you scale.

In a study described in the Journal of Periodontology several years ago, a team of Army researchers set out to determine just how much of a root's surface is reached by the cooling spray during subgingival ultrasonic debridement.

First, they hooked up their scaler to dye-containing water. Then they activated the tip in pockets around teeth scheduled for extraction. When they later examined the roots, they discovered that the dye covered the surface to the full depth of the tip's penetration. There wasn't a lot of lateral dispersion, but the depth of penetration was excellent. ¹

Since its ultrasonic spray flushes the pocket during subgingival debridement, your scaler offers a fast, easy way to deliver the antimicrobial agent without a separate irrigating step.

This approach (dubbed "ultrasonic bactericidal debridement" by periodontist Robert Genco, DDS, PhD of SUNY Buffalo) has been the subject of a lot of research. And the studies suggest that running antimicrobial solution through a scaler during debridement improves the prognosis. The deeper the pocket, the greater the difference the antimicrobial makes.

For example, back in 1986 a team of researchers compared three methods of treatment: 1.) ultrasonic bactericidal debridement 2.) normal ultrasonic debridement and 3.) periodontal surgery (Modified Widman). When roots received povidone iodine during ultrasonic scaling, they showed attachment gains 50% greater than those receiving either ultrasonic debridement alone or periodontal surgery. 50% greater! (I wonder if the participants who underwent surgery ever learned the results!)²

A similar study described in the Journal of Clinical Periodontology compared the effectiveness of subgingival ultrasonic scaling with and without antimicrobials. For one set of patients, the operators used sterile water as the ultrasonic coolant. For the other, they used a .12% solution of chlorhexidine.

Both sets of patients improved significantly after a single episode of subgingival ultrasonic scaling. The plaque index the, gingival, index and clinical probing depth all improved. However, where the researchers noted differences, it was to the advantage of the antimicrobial agent.

Pockets that originally probed 4-6mm showed a significantly greater reduction at the 14-day and 28-day recall when they received chlorhexidine (Illustration 3).

In other words, subgingival ultrasonic debridement with water was good. But for some patients, simultaneous debridement and antimicrobial irrigation was even better. ³

Another study (this one tracking a mindboggling 5000 pocket sites!) found that antimicrobials plus ultrasonic debridement proved significantly more effective than ultrasonic debridement alone when the pocket was deep ... initially measuring 7 or more millimeters .⁴

And other studies have shown that ultrasonic root debridement using antimicrobial agents reduces final pocket depth during guided tissue regeneration procedures.⁶

The bottom line is this: Clinical research confirms that in severe cases (cases like that of my friend the clarinetist), antimicrobial agents may enhance the therapeutic effect of ultrasonic debridement.

Based on the dramatic results I've seen in my practice, I strongly suspect that an ultrasonic tip doesn't just provide an easy, effective way to deliver the agent to hard to reach pockets. I believe that the cavitation energy it creates in the spray actually makes the agent more lethal ... antimicrobial agents in an ultrasonic lavage kill more bugs than the same agent delivered through a cannula. It may disrupt the protective biofilm, so the bugs are more vulnerable to the chemical agent.

So now the question is ... "Which antimicrobial?"

For most periodontal cases, the decision to use an antimicrobial agent and the method you choose to deliver it into the pocket has more influence on the success of the treatment than the specific antimicrobial you select.

We have a plethora of good pathogen-destroying agents at our disposal. My three favorite irrigating agents are (I call them "The Big Three") ...

1.) Chlorhexidine digluconate
(at least .12%)
2.) Povidone iodine (2.5%)
3.) Stannous fluoride (1.6%)

Illustration 4. A word about ultrasonic spray adjustment. When they adjust their scaler, many dentists and hygienists try to create a fine mist like spray. That’s a mistake. Though a fine spray pattern may have a certain esthetic appeal, it increases the aerosols outside the mouth. Furthermore, it can't deliver enough fluid to achieve our three goals of 1. ) cooling the handpiece, 2.) creating cavitational destruction of bacteria, and 3.) delivering sufficient antimicrobial agent to the pocket.
When properly adjusted, liquid should spray and drip from the tip.

Now a pharmacologist would point out a number of differences between these antimicrobials (Table A). For example, chlorhexidine is highly substantive. It remains active up to 8 hours after irrigation. Iodine, on the other hand, is non-substantive. It's very lethal, but it has little residual effect.

Despite these distinctions, I've found the Big Three to be clinically interchangeable. They all work well. They all destroy a broad range of microflora.

The primary clinical difference between them isn't one of efficacy, it's one of viscosity Stannous is too thick to deliver easily through an ultrasonic handpiece. So when I irrigate with stannous fluoride, I use a cannula rather than my scaler.

In contrast, both chlorhexidine and povidone iodine flow beautifully through an ultrasonic handpiece. I generally use chlorhexidine, because patients tend to find the taste less objectionable and there's less chance of an allergic reaction.

By the way, I don't try to fine tune my irrigating agent. If the patient doesn't respond to one of the Big Three, rather than waste time trying other irrigants, I escalate the battle to the next level.

Topical and systemic antimicrobials.

Systemic drugs are my weapon of last resort. Bathing the entire body with tetracycline or metronidazole simply to reach a periodontal pocket is just plain inefficient. Topical application using ultrasonic irrigation puts much higher concentrations of a medicament right in the face of the offending pathogens.

Furthermore, systemic drugs are more likely to produce toxic side effects and encourage development of resistant strains. And of course, the destructive flora may quickly re-form after the systemic antibiotics are discontinued.

Nevertheless, some of the pathogens involved in severe periodontitis may invade the periodontal tissue so deeply that topical antimicrobials won't reach the culprits.

Here, a shock-treatment using systemic antibiotics (administered for limited periods and carefully monitored) may be necessary to bring the microflora under control.

A discussion of systemic antibiotics is beyond the scope of this report. If you're interested in learning about some of the exciting developments in systemic antibiotics, however, there's an excellent article by Drs. Rams and Slots in the December 1992 issue of the Compendium.6

A general treatment program combining subgingival ultrasonic scaling and antimicrobials.

The candidate for ultrasonic bactericidal debridement is often in bad shape ... deep inflamed pockets, extensive root calculus. Occasionally (as in the case of the clarinetist), the teeth are so loose they wouldn't survive conventional handscaling.

In my practice, the initial treatment involves industrial strength deep ultrasonic debridement using the thin perio tips I discussed in Special Report #35. I generally anesthetize the patient and debride one quadrant at a time in four weekly appointments. Since I'm using my scaler at high power, anesthesia makes these appointments more endurable both for the patient and for me.

During ultrasonic debridement, I run a bactericidal solution (generally chlorhexidine) through the handpiece. If the patient objects to the taste, I'll switch to iodine or stannous fluoride. (Stannous fluoride must be used immediately after mixing and must be applied in a separate procedure using a cannula.)

There should be significant improvement in the first quadrant by the time the patient returns for the third scaling. If I still see a lot of bleeding during probing, I may decide to escalate the treatment and prescribe a systemic drug. A diagnostic test may be appropriate to determine which drug.

After the rigorous initial debridement, the maintenance appointments at 3 or 6 month intervals are easy. Using ultrasonic perio tips, I lightly run over the root surfaces with the scaler on low power while simultaneously irrigating with an antimicrobial. (Incidentally, I use this same maintenance program following periodontal surgery.)

Taking the battle to the bathroom.

In addition to the traditional lecture on brushing and flossing, I generally have the patient apply the same antimicrobial at home using a cannula or oral irrigator equipped with a subgingival tip.

Conventional irrigator tips are not effective subgingivally, but specialized devices like the WaterPik® PikPocket® are easy to use and can deliver solutions as deep as 6mm into the pocket. Beyond that, the patient may use a cannula.

Remember, developing an effective home hygiene program is largely the art of recognizing the possible. A nightly regimen that requires the patient to treat a number of sites with a cannula is doomed to failure. The patient simply won't do it.

So I rarely prescribe nightly irrigation. Use of a cannula once or twice a week (depending on the severity of the case) is probably the best compliance you can expect. And in fact, its probably all that's necessary.

However, on the nights they don't irrigate I suggest that after brushing they use a good antiseptic mouthwash ... Peridex,^® Listerine,^® Viadent,^® or even baking soda. Then before they rinse, they should use floss or Stimudents.^® Any interproximal device (floss, Proxi brush,^® Stimudent^® ) can serve as a subgingival delivery system if it is dipped into an antimicrobial, or used immediately after rinsing with an antiseptic mouthwash. This way, some of the antiseptic will be carried subgingivally.

Obviously, floss-delivered mouthwash won't reach the bottom of deep pockets. But there may be some chemotherapeutic benefit. I suspect it helps. It certainly can't hurt.

Conclusion.

In the old days, when I was treating periodontal disease primarily using curettes, my results were mixed.

Some patients responded nicely to subgingival handscaling. But a disturbing number either suffered recurrent periodontal episodes ... or worse.

"Ultrasonic bactericidal debridement," has been a watershed in the way I treat periodontal disease. In my hands at least, the marriage of subgingival ultrasonic debridement and antimicrobial irrigation has proved faster, much less objectionable to the patient, and (what's most important) far more predictable than traditional therapy. I fully admit that the ultrasonic handpiece isn't a magic wand. I still have occasional failures. But my success rate is up. WAY up. I'm saving teeth that I once would have written off as hopeless. And my referrals for surgery are way down.

References: I Nosal G. at a). The penetration of lavage solution into the periodontal pocket during ultrasonic instrumentation. J Periodontol. 62: 554 557, 91 2 Rosling BG, at al. Topical antimicrobial therapy and diagnosis of subgingival bacteria in the management of inflammatory periodontal disease. J Clin Periodontol 13:975 81, 86 3 Reynolds MA, at al. Clinical effects of simultaneous ultrasonic scaling and subgingival irrigation with chlorhexidine. Mediating influence of periodontal probing depth. J Clin Perlodontol, 19:595 600, 92 4 Christersson LA, at al. Monitoring of subgingival Bacteroides Gingivalis and Actinobacillus Actinomycetemcomltans in the management of advanced periodontitus. Adv Dent Res, 2:2, 382_388, Nov 88 Machtei EE, at al. Effect of tetracycline root preparation on guided tissue regeneration in furcation defects. J Dent Res, 70:Spec, Abstr #1611, 467, 91 8 Rams TE, Slots J. Antibiotics in periodontal therapy. Comp Cont Ed Dent, 13:12, pl 130 1146, Dec 92

About the author ...

A graduate of the Medical College of Virginia School of Dentistry, Dr. Burnett has authored numerous articles and lectured extensively on conservative periodontal therapy throughout the US and Canada. A frequent speaker at both the ADA annual scienific session (1995, 1996, 1997, 1998) and AGD meetings (1994, 1995), he is featured in the new video-based program “Advanced Ultrasonics in General Practice”

Dr. Burnett also conducts hands-on courses for dentist and hygienists.

He can be contacted at: Dr. Larry Burnett, 2221 SW First Ave #1224, Portland, OR 97201 Tel: 503-221-4237, lburnett2@comcast.net

Non-surgical periodontal therapy

Featuring respected lecturer and author Dr. Larry Burnett, this self-study course emphasizes the use of ultrasonics to resolve periodontal disease. The $225 program includes both videotapes and a study manual, and qualifies for 7 hours of CE credit from the ADA CERP and AGD mastership and fellowship programs.

If it sounds interesting contact the producer directly- Perioscope 1-800-888-4941