366 endorsements reference manual V 37

366    ENDORSEMENTS

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Gingivitis and periodontitis are the

 

two major forms of in- 

flammatory diseases affecting the periodontium. Their primary 

etiology is bacterial plaque, which can initiate destruction of 

the gingival tissues and periodontal attachment apparatus.

1,2

 

Gingivitis is inflammation of the gingiva that does not result 

in clinical attachment loss. Periodontitis is inflammation of the 

gingiva and the adjacent attachment apparatus and is character-

ized by loss of connective tissue attachment and alveolar bone. 

Each of these diseases may be subclassified based upon etiol- 

ogy, clinical presentation, or associated complicating factors.

3

 

Gingivitis is a reversible disease. Therapy is aimed primarily 

at reduction of etiologic factors to reduce or eliminate inflam-

mation, thereby allowing gingival tissues to heal. Appropriate 

supportive periodontal maintenance that includes personal and 

professional care is important in preventing re-initiation of 

inflammation.

 

Therapeutic approaches for periodontitis fall into two major 

categories: 1) anti-infective treatment, which is designed to halt  

the progression of periodontal attachment loss by removing  

etiologic factors; and 2) regenerative therapy, which includes 

anti-infective treatment and is intended to restore structures 

destroyed by disease. Essential to both treatment approaches is 

the inclusion of periodontal maintenance procedures.

4

 

Inflammation of the periodontium may result from many 

causes (eg, bacteria, trauma). However, most forms of gingivitis 

and periodontitis result from the accumulation of tooth- 

adherent microorganisms.

5-7

 Prominent risk factors for devel-

opment of chronic periodontitis include the presence of 

 

specific subgingival bacteria,

8-10

 tobacco use,

9-13

 diabetes,

9,10,14

 

age,

9,10 

and male gender.

9,10

 Furthermore, there is evidence that 

other factors can contribute to periodontal disease pathogenesis: 

environmental, genetic, and systemic (eg, diabetes).

14,15

  This paper primarily reviews the treatment of plaque-

induced gingivitis and chronic periodontitis, but there might 

be some situations where the described therapies will not 

resolve disease or arrest disease progression. Furthermore, the 

treatments discussed should not be deemed inclusive of all  

possible therapies, or exclusive of methods of care reasonably 

directed at obtaining good results. The ultimate decision re- 

garding the appropriateness of any specific procedure must be  

made by the practitioner in light of the circumstances pre- 

sented by an individual patient.

Plaque-induced gingivitis

Therapy for individuals with chronic gingivitis is initially 

directed at reduction of oral bacteria and associated calcified 

and noncalcified deposits. Patients with chronic gingivitis, but 

without significant calculus, alterations in gingival morphology, 

or systemic diseases that affect oral health, may respond to a 

therapeutic regimen consisting of improved personal plaque 

control alone.

16

 The periodontal literature documents the short- 

and long-term effects following self-treatment of gingivitis by 

personal plaque control.

16-20

 However, while it may be possible 

under controlled conditions to remove most plaque with a 

variety of mechanical oral hygiene aids, many patients lack the 

motivation or skill to attain and maintain a plaque-free state 

for significant periods of time.

21-23

 Clinical trials also indicate 

that self-administered plaque control programs alone, without 

periodic professional reinforcement, are inconsistent in provi-

ding long-term inhibition of gingivitis.

19,24,25

 

Many patients with gingivitis have calculus or other associa-

ted local factors (eg, defective dental restorations) that interfere 

with personal oral hygiene and the ability to remove bacterial 

plaque. An acceptable therapeutic result for these individuals 

is usually obtained when personal plaque control measures are 

performed in conjunction with professional removal of plaque, 

calculus, and other local contributing factors.

26,27

  Removal of dental calculus is accomplished by scaling 

and root planing procedures using hand, sonic, or ultrasonic  

instruments. The therapeutic objective of scaling and root  

planing is to remove plaque and calculus to reduce subgingival  

bacteria below a threshold level capable of initiating clinical  

Originating Group

 

American Academy of Periodontology - Research, Science, and Therapy Committee

Endorsed by the American Academy of Pediatric Dentistry

2004

Copyright © 2004 by the American Academy of Periodontology; all rights reserved. Copyrighted and reproduced with permission from the American Academy of 

Periodontology. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photo- 

copying, or otherwise without written permission of the publisher. Treatment of Plaque-induced Gingivitis, Chronic Periodontitis, and Other Clinical Conditions. J  

Periodontol 2001;72:1790-1800. Available through the American Academy of Periodontology, Department of Scientific, Clinical and Educational Affairs, 737 North 

Michigan Avenue, #800, Chicago, Ill., 60611-2690, Phone: [phone], Fax: [phone].

Treatment of Plaque-induced Gingivitis, Chronic 

Periodontitis, and Other Clinical Conditions

             AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

    ENDORSEMENTS    367

inflammation. The success of instrumentation is determined 

by evaluating the periodontal tissues following treatment and 

during the maintenance phase of therapy.

  The use of topical antibacterial agents to help reduce  

bacterial plaque may be beneficial for the prevention and treat- 

ment of gingivitis in some patients.

28-30

 

A number of these agents in oral rinses and dentifrices 

have been tested in clinical trials.

28

 However, to be accepted by 

the American Dental Association (ADA) Council on Dental 

Therapeutics as an effective agent for the treatment of gingivitis, 

a product must reduce plaque and demonstrate effective reduc-

tion of gingival inflammation over a period of at least 6 months. 

The agent must also be safe and not induce adverse side effects.

  Three medicaments have been given the ADA Seal of 

Acceptance for the control of gingivitis. The active ingredients 

of one product are thymol, menthol, eucalyptol, and methyl 

salicylate.

29

 Active ingredients in the other two are chlorhexi- 

dine digluconate and triclosan.

29

 If properly used, the addition  

of a topical anti-plaque agent to a gingivitis treatment regimen  

for patients with deficient plaque control will likely result 

in reduction of gingivitis.

30

 However, experimental evidence 

indicates that penetration of topically applied agents into the 

gingival crevice is minimal.

31

 Therefore, these agents are useful 

for the control of supragingival, but not subgingival plaque. 

Among individuals who do not perform excellent oral hy- 

giene, supragingival irrigation with and without medicaments  

is capable of reducing gingival inflammation beyond that 

normally achieved by toothbrushing alone. This effect is likely 

due to the flushing out of subgingival bacteria.

32

 

If gingivitis remains following the removal of plaque and 

other contributing local factors, thorough evaluation should be 

undertaken of systemic factors (eg, diabetes, pregnancy, etc.). 

If such conditions are present, gingival health may be attained  

once the systemic problem is resolved and plaque control is  

maintained.

Acute periodontal diseases

Necrotizing ulcerative gingivitis (NUG) is associated with 

specific bacterial accumulations occurring in individuals with 

lowered host resistance.

1

 NUG usually responds rapidly to the 

reduction of oral bacteria by a combination of personal plaque 

control and professional debridement. If lymphadenopathy or 

fever accompanies oral symptoms, administration of systemic 

antibiotics may be indicated. The use of chemotherapeutic 

rinses by the patient may be beneficial during the initial treat-

ment stages. After the acute inflammation of the NUG lesion 

is resolved, additional intervention may be indicated to prevent 

disease recurrence or to correct resultant soft tissue deformities. 

 

Necrotizing ulcerative periodontitis (NUP) manifests as 

rapid necrosis and destruction of the gingiva and periodontal 

attachment apparatus. It may initiate gingival bleeding and pain, 

and it usually represents an extension of necrotizing ulcerative 

gingivitis in individuals with lowered host resistance. NUP has 

been reported among both HIV-positive and negative indi- 

viduals, but its true prevalence is unknown.

33-38

 Management 

of NUP involves debridement which may be combined with 

irrigation with antiseptics (eg, povidone iodine), antimicrobial 

mouth rinses (eg, chlorhexidine), and administration of sys- 

temic antibiotics.

39

 There is also evidence that HIV-immune 

deficiency may be associated with severe loss of periodontal  

attachment that does not necessarily present clinically as an 

ulcerative lesion.

40

 Although not an acute disease, linear gin- 

gival erythema (LGE) occurs in some HIV-infected individuals 

and does not appear to respond to conventional scaling, root 

planing, and plaque control.

39

 Antibiotic therapy should be  

used in HIV-positive patients with caution due to the pos- 

sibility of inducing opportunistic infections.

39,40

 

The oral manifestations of a primary herpes simplex virus 

type I infection often include gingivitis. By the time gingivitis  

is present, patients are usually febrile, in pain, and have lymph-

adenopathy. Diagnosis is generally made from the clinical 

appearance of the oral soft tissues. Although not performed 

routinely, a viral culture may provide definitive identification  

of the infective agent. In otherwise healthy patients, treatment  

for herpetic gingivitis consists of palliative therapy. The infec- 

tion is self-limiting and usually resolves in seven to 10 days.  

Systemic antiviral therapy with acyclovir is appropriate for  

immuno-compromised patients with herpetic gingivitis.

41

Gingival enlargement

Chronic gingival inflammation may result in gingival enlarge-

ment. This overgrowth of gingiva may be exaggerated in patients 

with genetic or drug-related systemic factors (eg, anticonvul-

sants, cyclosporine and calcium channel blocking drugs).

42-46

 

Among individuals taking phenytoin, gingival overgrowth 

may be minimized with appropriate personal oral hygiene and  

professional maintenance.

47,48

 However, root debridement in 

patients with gingival overgrowth often does not return the  

periodontiumto normal contour. The residual overgrowth may  

not only complicate the patient’s ability to adequately clean 

the dentition, but it may also present esthetic and functional 

problems.

49

 

For patients with gingival overgrowth, the modification 

of tissue topography by surgical recontouring may be under- 

taken to create a maintainable oral environment.

47,50

 Postoper- 

ative management following tissue resection is important. 

 

The benefits of surgical reduction may be lost due to rapid  

proliferation of the tissues during the post-therapy phase.

51

 

Recurrence is common in many patients with drug-induced 

gingival overgrowth.

51

 For these patients, consultation with the 

patient’s physician is advisable to determine if it is possible to  

use an alternative drug therapy that does not induce gingival  

overgrowth. If not, then repeated surgical and/or non-surgical  

intervention may be required.

Chronic periodontitis

Appropriate therapy for patients with periodontitis varies 

considerably with the extent and pattern of attachment loss, 

local anatomical variations, type of periodontal disease, and 

therapeutic objectives. Periodontitis destroys the attachment 

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apparatus of teeth resulting in periodontal pocket formation  

and alteration of normal osseous anatomy. The primary ob- 

jectives of therapy for patients with chronic periodontitis 

are to halt disease progression and to resolve inflammation. 

Therapy at a diseased site is aimed at reducing etiologic factors 

below the threshold capable of producing breakdown, thereby  

allowing repair of the affected region. Regeneration of lost 

periodontal structures can be enhanced by specific procedures. 

However, many variables responsible for complete regeneration 

of the periodontium are unknown and research is ongoing in 

this area.

Scaling and root planing

The beneficial effects of scaling and root planing combined  

with personal plaque control in the treatment of chronic peri- 

odontitis have been validated.

52-65

 These include reduction 

of clinical inflammation, microbial shifts to a less pathogenic 

subgingival flora, decreased probing depth, gain of clinical  

attachment, and less disease progression.

52-65

 

Scaling and root planing procedures are technically de- 

manding and time-consuming. Studies show that clinical 

 

conditions generally improve following root planing; nonethe-

less, some sites still do not respond to this therapy.

62,63,66,67

 The 

addition of gingival curettage to root planing in the treatment 

of generalized chronic periodontitis with shallow suprabony 

pockets does not significantly reduce probing depth or gain  

clinical attachment beyond that attained by scaling and root 

planing alone.

68,69

 The following factors may limit the success 

of treatment by root planing: root anatomy (eg, concavities, 

furrows etc.), furcations,

66

 and deep probing depths.

70-72

 

Several weeks following the completion of root planing  

and efforts to improve personal plaque control, re-evaluation 

should be conducted to determine the treatment response.  

Several factors must be considered at sites that continue to  

exhibit signs of disease. If the patient’s daily personal plaque 

control is not adequate to maintain gingival health, then 

additional instruction and motivation in personal plaque 

 

control and/or the use of topical chemotherapeutics (eg, 

 

mouthrinses, local drug delivery devices) may be indicated. 

Anatomical factors that can limit the effectiveness of root 

instrumentation or limit the patient’s ability to perform per- 

sonal plaque control (eg, deep probing depths, root concavities, 

furcations) may require additional therapy including surgery.  

Host response may also have an effect on treatment outcome  

and patients with systemic conditions (eg, diabetes, pregnancy,  

stress, AIDS, immunodeficiencies, and blood dyscrasias) may  

not respond well to therapy that is directed solely at con- 

trolling local factors. In such patients, it is important that  

attempts be made to control the contributing systemic factors.

Pharmacological therapy

Pharmacotherapeutics may have an adjunctive role in the 

management of periodontitis in certain patients.

73

 These ad- 

junctive therapies are categorized by their route of adminis- 

tration to diseased sites: systemic or local drug delivery.

Systemic drug administration

Numerous investigations

73

 have assessed the use of systemic 

antibiotics to halt or slow the progression of periodontitis or to 

improve periodontal status. The adjunctive use of systemically 

delivered antibiotics may be indicated in the following situa- 

tions: patients with multiple sites unresponsive to mechanical 

debridement, acute infections, medically compromised patients,  

presence of tissue-invasive organisms and ongoing disease 

 

progression.

74-77

 The administration of antibiotics for the 

treatment of chronic periodontitis should follow accepted 

 

pharmacological principles including, when appropriate, iden-

tification of pathogenic organisms and antibiotic sensitivity 

testing.

  Considerable research efforts have focused on systemic 

application of host modulating agents such as non-steroidal 

anti-inflammatory drugs (NSAIDS)

78-80

 and subantimicrobial 

dose doxycycline.

81-84

 Investigators have reported some benefit 

when these medications are incorporated into treatment proto-

cols.

78,81-84

 Recently [year 2000], the United States Food and 

Drug Administration (FDA) approved the use of a systemically 

delivered collagenase inhibitor consisting of a 20-mg capsule of 

doxycycline hyclate as an adjunct to scaling and root planing 

for the treatment of periodontitis. Benefits included a statisti-

cally significant reduction in probing depths, a gain in clinical 

attachment levels and a reduction in the incidence of disease 

progression.

82-84

 Overall, the data suggest that use of subantimi-

crobial dose doxycycline as an adjunct to scaling and root planing 

provides defined but limited improvement in periodontal status.

  It is important to consider the potential benefits and 

side effects of systemic pharmacological therapy. Benefits may 

include the ability to treat patients unresponsive to conventional  

therapy or an individual with multiple sites experiencing 

 

recurrent periodonitits. In contrast, potential risks associated 

with systemically administered antibiotics include development 

of resistant bacterial strains,

85

 emergence of opportunistic in- 

fections, and possible allergic sensitization of patients.

73

 With 

regard to the prolonged administration of NSAIDS, harmful 

effects may include gastrointestinal upset and hemorrhage,  

renal and hepatic impairment, central nervous system 

 

disturbances, inhibition of platelet aggregation, prolonged 

 

bleeding time, bone marrow damage, and hypersensitivity  

reactions.

73

 At present, the incidence of negative side effects  

reported after root planing with or without administration  

of subantimicrobial dose doxy-cycline has been similar. In  

general, since patients with chronic periodontitis respond to  

conventional therapy, it is unnecessary to routinely admin- 

ister systemic medications such as antibiotics, NSAIDS, or  

subantimicrobial dosing with doxycycline.

Local delivery

Controlled delivery of chemotherapeutic agents within peri-

odontal pockets can alter the pathogenic flora and improve  

clinical signs of periodontitis.

86-94

 Local drug delivery systems 

provide several benefits; the drug can be delivered to the site  

of disease activity at a bactericidal concentration and it can  

             AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

    ENDORSEMENTS    369

facilitate prolonged drug delivery. The FDA has approved the 

use of an ethylene vinyl acetate fiber that contains tetracy-

cline,

86-91 

a gelatin chip that contains chlorhexidine

93

 and a 

minocycline polymer formulation

92

 as adjuncts to scaling and 

root planing. The FDA has also approved doxycycline hyclate 

in a bioabsorbable polymer gel as a stand-alone therapy for the 

reduction of probing depths, bleeding upon probing, and gain  

of clinical attachment.

94

  Local delivery systems have potential limitations and 

benefits. If used as a monotherapy, problems associated with 

local delivery can include allergic reaction, possible inability to 

disrupt biofilms, and failure to remove calculus.

95

 The benefits 

include the ease of application, selectively targeting a limited 

number of diseased sites that were unresponsive to conventional 

therapy, and possibly enhanced treatment results at specific 

locations. Local delivery modalities have shown beneficial clini-

cal improvements with regard to probing depth reduction and 

gain in clinical attachment.

91-94

 Furthermore, there are limited 

data to suggest that local delivery of antibiotics may also be 

beneficial in preventing recurrent attachment loss in the ab- 

sence of maintenance therapy.

90

 

Utilization of antibiotics at an individual site will depend  

on the discretion of the treating therapist after consultation  

with the patient. The greatest potential of local delivery devices 

may be to enhance therapy at sites that do not respond to  

conventional treatment. Ultimately, the results of local drug  

delivery must be evaluated with regard to the magnitude of 

improvement that can be attained relative to disease severity. A  

more complete review of local drug delivery can be found in  

the American Academy of Periodontology position paper “The  

Role of Controlled Drug Delivery for Periodontitis”.

87