Periodontal Therapy, Chlorhexidine, and Surgery Protocols

Chlorhexidine and Chemical Plaque Control

Mechanism of Action of Chlorhexidine (CHX)

• Positive charge: Chlorhexidine has a positive charge, while bacteria have a negative charge.
• Binding: It binds with the phosphate groups of bacterial cell walls.
• Osmotic pressure: It alters osmotic pressure within the bacterial cell.
• Cell lysis: This alteration leads to bacterial cell lysis.

Therapeutic Uses of Chlorhexidine

• Adjunct to mechanical oral hygiene
• Treatment of Acute Necrotizing Gingivitis (ANG)
• Post-operative care after periodontal surgery
• Effective against fungi and viruses

Side Effects of Chlorhexidine

• Brown discoloration (staining) of teeth and restorations
• Bitter taste
• Mucosal erosion

Chemical Control of Subgingival Plaque

• Subgingival irrigation
• Controlled-release devices (local delivery):
  • Actisite: Tetracycline
  • Arestin: Minocycline
  • Atridox: Doxycycline
  • Dentomycin: Minocycline
  • Periochip: Chlorhexidine (CHX)
  • Elyzol: Metronidazole
• Systemic antibiotics:
  • Penicillin
  • Tetracycline
  • Doxycycline
  • Minocycline
  • Metronidazole

Indications for Systemic Antibiotics

• Necrotizing Periodontitis (NP) and Necrotizing Gingivitis (NG)
• Periodontal abscess
• Multiple abscesses
• HIV-associated periodontal diseases
• Stage III and Stage IV periodontitis
• Stage III Grade C periodontitis
• Refractory cases

Host Modulation Therapy

• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Sub-antimicrobial dose doxycycline (SDD)
• Bisphosphonates

Periodontal Surgery Principles

Goals of Periodontal Surgery

• Arrest disease progression
• Prevent recurrence of periodontal disease
• Promote tissue regeneration
• Correct esthetic deformities
• Prepare the dentition to receive restorations

Indications for Periodontal Surgery

• Deep periodontal pockets
• Abnormal gingival morphology
• Mucogingival problems
• Esthetic improvement
• Preprosthetic preparation
• Dental implants placement

Contraindications for Periodontal Surgery

• Uncooperative patients
• Uncontrolled systemic conditions
• Inadequate Scaling and Root Planing (SRP) and poor homecare disease control
• Acute infections
• Hopeless teeth
• Surgery resulting in poor esthetics

Phase I Therapy Before Surgery

• Eliminate active lesions entirely
• Render tissue firm and healthy
• Evaluate tissue response to initial therapy
• Evaluate patient plaque control
• Acquaint the patient with the office and operator

Periodontal Pack Dressings

Advantages of Periodontal Packs

• Prevent infection
• Control hemorrhage
• Protect from pain
• Prevent mechanical trauma

Types of Periodontal Packs

• Zinc oxide eugenol
• Non-eugenol pack (e.g., Coe-Pak)

Desensitizing Agents

Used by Patients

• Fluoride
• Strontium chloride (e.g., Sensodyne)
• Potassium nitrate

Used by Dentists

• To block dentinal tubules:
  • Fluoride compounds
  • Strontium chloride
  • Silver nitrate
• To seal the root surface:
  • Varnish
  • Dentin bonding agents
  • Glass ionomer cement

Furcation Involvement and Management

Furcation Anatomy and Attachment Loss

Complex Anatomical Morphology

• Difficult routine periodontal instrumentation
• Difficult routine home care
• Indicates advanced periodontitis

Factors Influencing Extent of Attachment Loss

• Local anatomical factors
• Local developmental factors
• Traumatic occlusion
• Dental caries
• Pulp death (pulpal necrosis)
• Iatrogenic factors

Cervical Enamel Projections (CEP)

Problems Associated with CEP

• Affects plaque removal
• Complicates Scaling and Root Planing (SRP)
• Acts as a local factor in developing gingivitis and periodontitis

Treatment of Furcation Defects

Treatment Options

• Non-surgical periodontal therapy
• Odontoplasty and furcationplasty
• Open flap debridement
• Regeneration of furcation defects
• Tunneling
• Root resection, hemisection, and bicuspidization
• Extraction

Disadvantages of Tunneling

• Increased risk of root caries
• Hypersensitivity
• Exposure of lateral canals