Full mouth disinfection

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The Full Mouth Disinfection (FMD) is a supplement to the initial periodontal therapy. This counteracts the problem that pathogenic germs otherwise remaining in untreated areas during a treatment over several sessions re- infect the areas already treated and thus endanger the success of the therapy .

indication

Patients who suffer from particularly aggressive forms of periodontitis or who, for genetic or constitutional reasons, offer periodontitis more vulnerable areas (including smokers , diabetics , trisomy 21 ) often cannot be successfully treated with normal periodontal treatment. The full-mouth disinfection is therefore primarily intended for these aggressive and stubborn cases, with the aim of achieving the highest possible degree of sterility in the entire oral cavity - but above all in the entirety of the gum pockets - in a short time . If the initial periodontal therapy does not achieve the required reduction in probing depth of 2.5 mm, the FMD concept is used. It is based on the scientific fact that curetted bags are colonized again with microorganisms from the oral cavity within a few days and that all surfaces of the mouth and throat must be professionally disinfected to avoid such re-infections. A transmission of pathogenic germs from the oral cavity of the partner must also be prevented, which requires a periodontal examination and, if necessary, treatment of the partner.

Basically, periodontal therapy is only considered successful when there are no longer any periodontal pockets larger than 4 mm. Periodontal pockets larger than 4 mm represent microbial or antigenic depots, of which (1) bacteria disseminate in the oral cavity and colonize the hard tooth substances or oral implants again, which means a recurrence of periodontitis and as a result (2) antigens and their inflammation products in enter the circulation and trigger metastatic biofilm infections elsewhere in the body . If the probing depths are initially over 9 mm, it becomes problematic without surgical intervention. Even with probing depths of 7–9 mm, the tissue must be approached more aggressively with curettage in order to achieve the necessary leveling of the pockets. If the initial treatment does not achieve the expected reduction in the probable pocket depth of at least 2.5 mm for pockets larger than 6 mm, FMD is indicated .

Cause biofilm

The vast majority of oral bacteria are protected in biofilms in the oral cavity. In diseases of the periodontium, the biofilm below the gum line is primarily pathogenic, but is influenced by the biofilm above the gum line, whereby the patient's oral hygiene is crucial. Since pockets more than 4 mm deep only allow a lower oxygen content and the conditions are therefore good for the multiplication of periodontal pathogens, gingival pockets must be reduced to below 4 mm. In addition, these bacteria are distributed to other niches in the oral cavity. In these niches it is also possible for periodontopathogenic bacteria in the biofilms to survive for 10-14 days until the next spontaneous tissue desquamation. An effective removal of the biofilm and thus the periodontopathogenic bacteria and their toxins can only be achieved mechanically in combination with disinfection , since the bacteria in the biofilm are largely resistant to antimicrobial and antiseptic therapies.

General health risk

Any chronic inflammation carries the risk of infection not only in the oral cavity, but elsewhere in the body as well. In the various oral biofilms, supragingival periodontal bacteria can also survive for 1–3 weeks and thus enter the bloodstream by way of bacteremia or biofilmemia when chewing on slightly periodontally inflamed teeth .

Paths of bacterial distribution:

  • Aspiration : Since the oral cavity is connected to the respiratory tract ( nose , lungs ), germs can be spread through the air circulation in these regions. It is known that this can lead to an infection or even pneumonia . Therefore, before an operation with endotracheal intubation , a disinfectant mouthwash should be used.
  • Infection via the bloodstream: Bacteremia can result from chewing or small injuries in the oral cavity, for example when using dental floss infrequently or when brushing your teeth . These infections play a subordinate role in the healthy oral cavity. In the presence of gingivitis , periodontitis or peri-implantitis or easily movable teeth, individual bacteria or groups of bacteria (biofilm particles) can spread into the body via the bloodstream.

This results in inflammatory changes in blood vessels ( arteriosclerosis ), heart (heart valves, infarction), brain ( stroke ) and, in pregnant women, premature births as a result of haematogenous spread into the uterus .

Smoke

Smoking , periodontal disease, or any other chronic inflammation are risk factors for a heart attack . Smoking leads to periodontal disease after 20 years due to the normal predominance of catabolic metabolism. This is the reason why open-minded dentists refer their patients, who smoke for a long time and who have periodontitis (also peri-implantitis), to a doctor in order to clarify whether they are at increased risk.

Pretreatment

The usual conservative pretreatment is necessary beforehand:

  • Learning the perfect oral hygiene
  • Perfect removal of all concretions ( tartar above and below the gums on the root and tooth surfaces), hand-held with sharpened instruments under local anesthesia.
  • Adaptation of crowns or filling margins, which can be palpated below the gums, which the patient also does when cleaning with dental floss or when probing (odor formation).
  • Removal of damaged fillings and half- erupted wisdom teeth or niches under overcontoured implants in relation to the tooth crown
  • Eliminate possible other causes of deep pockets (e.g. dead tooth nerve)
  • Elimination of stressors
    • Smoke
    • unbalanced diet
    • Periodontal control on the partner

Health requirements for the FMD

The patient must not be ill; infections of the nose , ears and throat in particular are contraindications for an effective reduction in the number of bacteria in the mouth.

The partner should also be treated if necessary so that cross-contamination can be excluded after the end of therapy. In the case of oral health, it is nevertheless indicated that a healthy partner also treats their hiding places supragingivally with local chlorhexidine rinses for 14 days.

Therapy procedure for full-mouth disinfection

Full Mouth Disinfection Therapy requires strict adherence to all the necessary steps, a very high level of willingness on the part of the patient and an understanding of the use of disinfectants at home during the long wound healing period (8 months for this part of the therapy).

The evening before the FMD meeting

Thoroughly rinse (at least one minute) with a disinfectant mouth rinse (0.1-0.2% chlorhexidine). Thereafter, there should be no rinsing. This reduces the free bacteria in the mouth by approx. 90%.

Re-disinfecting mouth rinse before FMD treatment

Immediately before the treatment, rinsing again with 0.1-0.2% chlorhexidine (CHX) for one minute and gargling briefly in order to reduce the free bacteria in the mouth, to reduce the risk of bacteremia and to effectively lower the number of bacteria in the oral cavity to initiate.

Niche disinfection

Niches such as the palatine arch , pharynx and palatine tonsils , floor of the mouth and folds of the envelope are thoroughly sprayed with a 0.1-0.2% chlorhexidine spray. The chlorhexidine may then be spat out, but not rinsed with water .

Tongue disinfection

The back of the tongue is freed from biofilm with 1% chlorhexidine gel and a rotating brush or with ultrasound / sound.

Biofilm removal around all teeth

Biofilm removal must be performed around all teeth that were not treated with hand instruments in this session. All probing depths <4 mm must be freed from biofilm with the sonic or ultrasonic devices.

Pocket disinfection

Systemic antibiotics

Antibiotics must not be used to bridge negligence in scaling or disinfection . The use of systemic antibiotics only makes sense if the supragingival and subgingival biofilms have been destroyed or removed beforehand. Use is recommended, for example, for patients with additional systemic impairments. The biofilms must be mechanically removed even in shallow pockets up to 4 mm.

Re-disinfection in the 1st and 2nd month after the FMD treatment

The use of a 0.1–0.2% chlorhexidine mouth rinsing solution for daily, careful wound control for two months (rinse the mouth thoroughly twice a day for one minute, after breakfast and before going to bed ) is a clinical and scientific basis after microbiological controls Studies indexed. The partner, even if he is healthy, must also be involved in this first phase and should also flush with chlorhexidine for the first 14 days. In this way, cross-contamination with periodontal pathogens can be prevented. Effective rinsing requires intensive work of the cheek and tongue during this minute in order to press the rinsing fluid back and forth through the interdental spaces. Finally gargle for 10-15 seconds.

Interdental disinfection

Release of 1% chlorhexidine gel for application to the interdental brush. This not only disinfects the endangered interdental space, but even after cleaning, any bacteria will not be able to develop on the bristles of the brush. After the therapy, the tissue shrinks and the interdental spaces gradually become larger. The interdental brushes should be continuously adapted to the size of the interdental spaces and used twice a day.

Subsequent disinfection from 3rd to 8th month after the FMD treatment

For the next 6 months, less strong plaque- inhibiting mouthwashes that can invade biofilms , such as anionic essential oils, triclosan , hexetidine , zinc or quaternary ammonium bases , are sufficient .

Advantages and disadvantages

  • Advantages:
    • does not require expensive equipment
    • Much fewer recessions compared to surgical treatment
  • Disadvantage:
    • time consuming
    • The practitioner must know exactly about the disinfectants used

history

The fact that partial disinfection cannot be successful was first shown in 1995 by the Bern group Lang, Mombelli and Tonetti in several scientific studies. Oosterwaal developed the basics of subgingival disinfection in his master's thesis in the years 1986–1991 in Nijmwegen. Quirynen worked out a concept and his school published several papers in the period from 1995 to 2005. Saxer modified the FMD according to the state of knowledge in 2003 and integrated the consistent subgingival disinfection with various disinfectants , the necessary high concentration (1–2 %), Exposure time and partner control. Many scientific studies were subsequently carried out under the name "Full Mouth Disinfection". However, many studies were carried out without sufficiently thorough pretreatment of all pockets, without including the various niches in the oral cavity, and also with insufficiently long subgingival disinfection. The so-called “split-mouth procedure”, which until then was preferred in traditional periodontal therapy in order to be able to compare the differences in results of various therapy options on one and the same individual, inevitably leads to cross-contamination and is neither suitable for curing periodontal disease, nor for conduct meaningful studies.

The Cochrane Review (Eberhard et al. 2008) and Lang et al. 2008 report from the 6th European Workshop of European Periodontists . In both reviews, methods with effective and ineffective concentrations and insufficient exposure time were formed in different comparison groups, so that no uniform results could be expected for the following reasons: Traditional scaling in several separate sessions over weeks (CSD) was combined with full mouth scaling and root planning ( FMSRP) and FMD with different pretreatments compared. Different disinfections with iodine in the pocket for a few seconds and chlorhexidine with an exposure time of 5 minutes were equated. The use of sufficiently high concentrations and sufficiently long retention times are of great importance in order to achieve disinfection in the sense of an effective reduction in the number of germs . The follow-up treatment in the first two and the following six months requires a very specific protocol according to microbiological studies. Therapies in patients with chronic periodontitis were compared, which could usually be solved conventionally . The FMD concept presented here is intended in particular for patients with aggressive periodontitis. Nevertheless, comparisons of the FMD method in the two reviews mentioned show significantly better results for single-root teeth and in deep pockets, and the BoP - bleeding gums on probing - was also reduced more according to the reviews.

Future study design

Full Mouth Disinfection studies require hygiene pre-treatment so that the patient can maintain the health achieved (BoP <15%) himself afterwards . A perfect scaling of the whole mouth in one or a few sessions close together is a further prerequisite. If several sessions are necessary, the biofilm must be removed again before subgingival disinfection . After scaling has been completed, the mouth must be disinfected with disinfectants that are guaranteed to be effective and have a sufficiently long-term effect. The re-disinfection after two and a further six months must be observed. Medications that do not work according to the FMD concept make no sense and cause significant resistance to develop.

It is important to optimize the concept in terms of time factor and susceptibility to errors. In addition to local highly concentrated disinfection (FMD) with systemic or additional local antibiotic administration, ozone, ozonated water and / or laser disinfection, there are hopeful approaches.

literature

  • S. Zimmer, A. Jordan, University of Witten Herdecke: "Adjuvant Parodontitis Therapy with Chlorhexidine-Xanthan Gel", The introduction of prophylaxis in the dental practice
  • J Clin Periodontology; Eberhard J, Jervøe-Storm PM, Needleman I, Worthington H, Jepsen S: Full-mouth treatment concepts for chronic periodontitis: a systematic review , 2008, No. 35, pp. 591-604. PMID 18498383
  • J Clin Periodontolgy; Lang NP, Tan WC, Krähenmann MA, Zwahlen M: A systematic review of the effects of full-mouth debridementwith and without antiseptics in patients with chronic periodontitis , 2008, No. 35 (Suppl. 8), pp. 8-21 PMID 18724838
  • J Clin Periodontolgy; Quirynen M, Teughels W, van Steenberghe D: Impact of antiseptics on one-stage, full-mouth disinfection , 2006, No. 33, pp. 49-52. PMID 16367856
  • Periodontics; Saxer CM, Quirynen M, Saxer UP: Therapy Concept “Full-Mouth Disinfection” , 2007, No. 18, pp. 331–347.
  • At Heart J; Seinost G, Wimmer G, Skerget M, Thaller E, Brodmann M, Gasser R, Bratschko RO, Pilger E: Periodontal treatment improves endothelial dysfunction in patients with severe periodontitis , 2005, No. 149, pp. 1050-4 PMID 15976787
  • J Periodontology; Teles RP, Patel M, Socransky SS, Haffajee AD: Disease progression in periodontally healthy and maintenance subjects , 2008, No. 79, pp. 784-94. PMID 18454656
  • Periodontology 2000 ; Teughels W., Dekeyser Ch., Van Essche M., Quirynen M .: One-stage, full-mouth disinfection: fiction or reality? , 2009, No. 50, pp. 39-51. PMID 19388952
  • Quintessence 59; Sanderink RB, Zitzmann N., Saxer UP, Schlagenhauf U., Persson R., Erne P .: Periodontitis and peri-implantitis: biofilm infections disseminating in the human body , 2008 No. 3, pp. 273-285.