Evaluation of instrumentation systems for periodontal mechanical treatment

A major objective in the treatment of periodontitis is to reduce supra-gingival and sub-gingival plaque, dental calculus, and prevent recolonization of periodontal pockets by pathogenic bacteria{{117 Braun,A. 2005; 118 Dragoo,M.R. 1992; 119 Kocher,T. 2000; 120 Loos,B. 1987;}}. It is important for the clinician to achieve a controlled surface free of calculus and an optimal oral hygiene control by patients{{88 Keogh,T.P. 1993; 90 Alves,R.V. 2004; 89 Alves,R.V. 2005;}}. Previous studies have reported beneficial results from scaling and root planning in both clinical and microbiological aspects.{{139 Caffesse,R.G. 1986; 140 Huerzeler,M.B. 1998; 141 Leknes,K.N. 1994; 120 Loos,B. 1987; 143 Quirynen,M. 1990;}} The aim of this study is to provide new and relevant data on scaling and root planing methods in order to value the effectiveness (different changes in plaque index, probing pocket depth, attachment level, and bleeding on probing) and the morbidity of four different instrumentation systems (sensitivity and pain). The main objective is to analyze individually each instrument to analyze the effectiveness and the morbidity; the secondary objective is to compare the various instrumentation systems with the "gold standard" for scaling and root planing (Curettes + Ultrasound). Objectives: The results of this study will provide new relevant data on scaling and root planing methods. Main Objective: The main objective is to analyze the clinical effectiveness of 4 different instrumentation systems and compare the results, in terms of clinical attachment level gain, to non surgical periodontal therapy (periodontal debridement). Secondary Objectives: 1. To analyze the post-treatment morbidity for each method. 2. To analyze the working-time for each method. Focus of the Thesis to achieve the objectives: This in vivo study compared the effectiveness and morbidity of four different instruments using a split mouth design. Patients were chosen at the first visit to the department of Periodontology of the Dental Clinic of the Universitat Internacional de Catalunya UIC. On the first visit patients underwent a comprehensive periodontal examination. The operator carried out an initial examination of the patient and filled out a questionnaire relevant to the patient’s general information. A Periodontal examination was performed with a periodontal probe (HU-Friedy® - Chicago.IL.USA - COD: PCPUNC15 30 - CP15) and a periodontal chart used in the University Dental Clinic . The following parameters were examined: - plaque index (PI) {{171 O'Leary,T.J. 1972;}} - probing pocket depth (PPD) - probing attachment level (PAL) - bleeding on probing (BOP) {{170 Benamghar,L. 1982;}} - gingival recession (REC): measurement from the cementum-enamel junction to the gingival marginal crest - mobility (MOB) (Miller 1950) - furcation involvement (FI) (Hamp et al. 1975) - sensitivity (tested by the operator) After completion of initial screening, each patient (that met the selection criteria) was informed about his/her periodontal status and the clinical study. Each patient agreed to participate by signing a consent form. No patient was admitted to the study until the Informed Consent Form is signed. Twenty (20) patients were selected to obtain the statistical significance of the results and the analyses was performed using a statistical program (Stratigrafics for Windows). A power calculation before the initiation of this study revealed that a sample size of 17 patients was necessary to detect a difference of 1 mm for each clinical parameter, assuming a maximal mean - standard deviation of 1 mm. Inclusion criteria: - Patients with generalized moderate to severe chronic periodontitis - PPD : at least two sites with probing depth ≥4mm per multi-rooted teeth, and at least three sites with probing depth ≥4mm for all remaining teeth, per quadrant. (like in other studies) (44). - Systemically healthy patient Exclusion criteria - Patients who had had antibiotic therapy in the last 2 month or during the study - Patient less of 18 years old - Smokers - Pregnant woman - Remaining dentition of less than 20 teeth - Recent periodontal treatment - Allergies to local anesthetics - Physically handicapped subject and/or with mental disorders, who cannot assume proper plaque control - Aggressive periodontitis - Acute periodontal or endodontic infection - Systemic disease: - Cardiovascular disease: uncontrolled hypertension, stable and unstable angina, recent heart attack (<1 month), heart attack (> 1 month without symptoms), arrhythmias, heart failure. - Lung disease: chronic obstructive pulmonary disease, tuberculosis - Gastrointestinal disease: chronic active hepatitis, cirrhosis, pseudomembranous colitis, renal disease. - Genitourinary disease: chronic renal failure, sexually transmitted diseases (gonorrhea, syphilis, genital herpes, papillomavirus infection). - Endocrine and metabolic disease: diabetes mellitus, renal failure, hypothyroidism and hyperthyroidism, uncontrolled tiroiditis, thyroid cancer, pregnancy and lactation. - Immune disease: HIV infection and related conditions, connective tissue disorders (lupus erythematosus, pemphigus vulgaris, penfogoide, Sjogren's syndrome), organ transplant (heart, liver, kidney, pancreas, bone marrow). - Hematological disorders: Anemia, agranulocytosis, cyclic neutropenia, leukemia, multiple myeloma, lymphomas, thrombocytopenia, vascular wall, hemophilia, von Willebrand disease, disseminated intravascular coagulation, thrombocytopenia, primary fibrinogenolisis. - Oncological disease: patients undergoing radiotherapy and chemotherapy. - Psychiatric illness, disease of the behavior, neurological disease: epilepsy, Parkinson's syndrome, anxiety, eating disorders, delirium, schizophrenia, depression and bipolar disorder untreated. This in vivo study compared four different instruments using a split mouth design. The split mouth design selected for this study is the division of the mouth into 4 parts, each part corresponded to a quadrant. Four groups were formed (one for each instrument) and each quadrant (of each patient) was assigned to one clinically randomized group. The realization of treatment for each patient was made randomly using an informatical function of randomization. Groups Group A: curettes (Hu-Friedy®) Specific curettes were used following this plan: Gracey curettes 5/6 --- anterior teeth Gracey curettes 11/12 --- mesial surface of premolar and molar Gracey curettes 13/14 --- distal surface of premolar and molar Group B: conventional piezoelectric ultrasound (Suprasson P-5 Booster - Satelec®) was applied at a power between 11 and 12 with the insert n.1 (Satelec®). The minute vibration frequency of this ultrasound is 28-36 KHz. Group C: diamond burs 40 µm (Intensiv Perioset®) at 3,000 rpm. Group D: piezoelectric ultrasound - Piezosurgery 3 - Mectron® was applied in On/Mode Periodontics (ROOT) mode with the insert PP1 at a power between 2 and 3. The minute vibration frequency of this ultrasound is 24-36 KHz. One reevaluation visit was performed 1 week after the treatment of each quadrant and a questionnaire was used to analyze the post-treatment morbidity. During this visit only the hypersensibility of each tooth was tested with an air-stimulation by the operator. At 8 weeks a data collection was performed by an expert periodontist (A.S.) who was blinded to the study. All important parameters for this study were recorded (as we mentioned for the Periodontal examination). The pooled data at baseline and two months after instrumentation were then used for the statistical analysis. Each clinical parameter (plaque index, probing pocket depth, probing attachment level, bleeding on probing, gingival recession, mobility, furcation involvement and sensitivity) was analyzed for each group and for a comparison between the groups. The comparison of the four instrumentation systems find out the method that shows better results. Results At 8-week re-evaluation, regarding attachment level gain and probing pocket reduction, Gracey’s curettes, conventional ultrasound, and ultrasound Piezosurgery resulted statistical more effective when compared with diamond burs. Regarding to chair side time, a statistical difference was shown (p<0.001) when suprasson ultrasound and ultrasound Piezosurgery were compared with the others instruments. The post-treatment morbidity after scaling and root planning was not statistical difference for all the analysed instrumentations. The statistical difference was shown between baseline and weeks 1 and 4, and between weeks 1 and 8, and between weeks 4 and 8, when all the results were evaluated together. Better results at 8-week re-evaluation were obtained from the use of conventional ultrasonic device: 3.04 ± 2.39 (SD) but no statistical significance difference was shown (p>0.05) when compared with other groups. Conclusions Conventional Gracey curettes (Hu-Friedy®), conventional ultrasound (P-5 Booster Suprasson Satelec®) and ultrasound Piezosurgery Mectron® are more effective clinically when compared with diamond burs 40 µm (Intensiv Perioset®). The ultrasound instrumentation showed better results in terms of chair side time. Clinical Relevance The use of conventional curettes, conventional ultrasound and ultrasonic piezoelectric Mectron device prove to be more effective than 40 µm diamond burs in the non-surgical periodontal treatment.