Adjunctive Periodontal Therapy: A Review of ... - DentalCEToday

Continuing EducationCourse Number: 127.1Adjunctive PeriodontalTherapy:A Review of Current TechniquesAuthored by Herbert I. Bader, DDSUpon successful completion of this CE activity 1 CE credit hour may be awardedA Peer-Reviewed CE Activity byDentistry Today, Inc, is an ADA CERP Recognized Provider. ADA CERP isa service of the American Dental Association to assist dental professionalsin indentifying quality providers of continuing dental education. ADA CERPdoes not approve or endorse individual courses or instructors, nor does itimply acceptance of credit hours by boards of dentistry. Concerns orcomplaints about a CE provider may be directed to the provider or toADA CERP at ada.org/goto/cerp.Approved PACE Program ProviderFAGD/MAGD Credit Approvaldoes not imply acceptanceby a state or provincial board ofdentistry or AGD endorsement.June 1, 2009 to May 31, 2011AGD Pace approval number: 309062Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention ofspecific product names does not infer endorsement by Dentistry Today. Information contained in CE articles andcourses is not a substitute for sound clinical judgment and accepted standards of care. Participants are urged tocontact their state dental boards for continuing education requirements.

Continuing EducationAdjunctive Periodontal Therapy: A Review of Current Techniquespovidone iodine and others, especially the class ofnonsteroidal anti-inflammatory drugs, can be useful whenapplied topically. 17-20ANTIMICROBIAL THERAPYLocal: Over the past 3 decades a number of sustainedrelease, anti-infective, site-specific vehicles have beendeveloped as a means of improving the efficacy of SRP interms of pocket depth reduction, attachment gain, andinflammatory reduction. Subsequent to Goodson, et al’swork 21,22 with tetracycline impregnated ethylene acetatefibers, a variety of second generation applications wereintroduced in the late 1990s, all of which are biodegradableand do not have to be removed from the site of placement.In 1998, Astra Pharmaceuticals introduced PerioChip, a4 x 5 mm degradable chip in a gelatin matrix, containing 2.5mg of CHX gluconate (Figure 2). The device was approvedfor room temperature storage in 2002. It remains in thepocket for 7 to 10 days, slowly releasing the antiseptic (40%initially), 23 and is fully biodegradable. It may be placedevery 3 months in residual pockets of 5 mm or more indepth. There are numerous published studies on efficacy,showing some gain in attachment level and pocket depthreduction as compared to SRP alone, along with somereduction in inflammatory mediators. 24 The magnitude ofchange of probing depth and attachment gain has beendemonstrated to average about 0.3 mm. 25-28 It has beenshown to be safe with minimal untoward side effects, and iseasily inserted into the pocket.The cost of the chips varies depending on the numberof boxes purchased. Each box contains 20 chips at anaverage of $17.45 per chip. Generally, each surface of thetooth treated requires a single chip.In 1998, Atrix Laboratories introduced Atridox, athixotropic gel containing 10% doxycycline hyclate, a sitespecificantimicrobial adjunct to SRP. The term “thixotropic”refers to the product’s conversion from a gel to a hard,plastic state when it comes in contact with moisture in thepocket. This allows the antibiotic-containing material toremain in place for 7 to 21 days. The flowable nature of thegel allows for the entire defect to be filled with the agent.Atridox is packaged in 2 syringes, which are mixedabFigures 1a and 1b.Site-specific applicationof chlorhexidine (CHX).Figure 2.PerioChip (AstraPharmaceuticals), a4 x 5 mm degradablechip in a gelatin matrix.Figure 3a.Atridox syringes.Figure 3b.Atridox being introducedinto pocket.2

thoroughly and then introduced into the pocket witha disposable cannula (Figures 3a and 3b). Eachsyringe contains enough material to treat 5 to 6sites, making it a very cost effective approach toisolated residual pockets remaining after SRP. A boxof 6 applications averages about $11.38 per site.There is considerable evidence supporting theefficacy of Atridox. The report by Polson andcolleagues 29 on the initial clinical response to asubgingival, biodegradable doxycycline system in1996 was an early study of clinical relevance.Perhaps the most interesting initial studies weremulticenter, 3-armed protocols in which Atridox wascompared to SRP, placebo control, and oral hygiene,and found to be equally effective to SRP, and in asubsequent study was equally effective inmaintenance patients over a 9-month period. 30,31The system has been found to significantly reduce the anaerobicpathogens in the biofilm without an increase inresistant organisms or the development of antibioticresistance. 32 Figure 4 shows the effect on 2 criticalperiodontal pathogens over a 182-day period.A recent study 33 compared the effects of 3 local,sustained delivery systems: doxycycline hyclate 10%(Atridox), CHX gluconate 2.5 mg (PerioChip), andminocycline hydrochloride 1 mg (Arestin) on osteoblasticcell proliferation and differentiation, in terms of periodontalregeneration. The doxycycline hyclate did not have thecytotoxic effect exhibited by the 2 other agents, and in fact,appeared to enhance maturation and differentiation. Theauthors 33 suggested that doxycycline hyclate may have anadditional benefit other than its antimicrobial effect, andmay help enhance periodontal regeneration.The development of a technique for microencapsulatingminocycline hydrochloride in a bioabsorbablepolymer for site-specific subgingival delivery resulted in theintroduction of Arestin in 2001. The system’spharmacokinetics results in gradual hydrolyzation of themicrospheres with sustained release over 14 days. It isdelivered with disposable tips in a sterilizable syringe(Figures 5 and 6).A large 18-site, multicenter study reported that SRP plusContinuing EducationAdjunctive Periodontal Therapy: A Review of Current TechniquesEffect of Atridox on Red Complex BacteriaSample Period (Days)Atridox treatment significantly reduced 2 of the most prevalent pathogens associatedwith periodontal disease (Porphyrmonas gingivalis and Bacteriodes forsythus[Tannellera forsythia]) and sustained the effect after 6 months.Data on File Tolmar, Inc.Figure 4. Effect on red complex from Walker CB, et al. 32Figure 5. Arestin delivery system.Figure 6.Arestin application.minocycline microspheres was more effective than SRPalone in reducing pocket depths in periodontitis patients. 343

Continuing EducationAdjunctive Periodontal Therapy: A Review of Current TechniquesThis confirmed some of thefindings from an earlier, wellcontrolled study. 35Other reports in theliterature attest to improvementin clinical parameters whenusing minocycline microspheresin addition to SRP. Theseinclude evidence that it can bean aid in peri-implantitis and improvingsurgical outcomes. 36-39Arestin is packaged in 2 foilwraps per box, each containing12 disposable tips, for anaverage cost of $19.98 perapplication.A thorough review of localdrug delivery, also called locallyapplied antibiotics, by Greenstein 13 suggests that whilelocally delivered agents have demonstrated clinical efficacy,they are not panaceas, and their use is based on clinicaldecisions taking into account the patient’s specific clinicalsituation. It is generally agreed that due to the nature ofsubgingival plaque biofilm, it must be disrupted byinstrumentation prior to the use of antimicrobials.SYSTEMIC ANTIMICROBIALSThe literature on the use of systemic antimicrobials is quiteextensive, and much of the current use of this modality isbased on the seminal works by Haffajee, Socransky, Teles,and others. 8,40-44 Antibiotics have been used for manyyears based on the accumulated evidence of periodontitisbeing an infectious disease, 44 as an adjunct to improve theresults of SRP. The AAP’s position on systemic antibioticsis: “They may be prescribed for periodontal patients who donot respond to conventional mechanical therapy, forpatients with acute periodontal infections associated withsystemic manifestations, for prophylaxis in medicallycompromised patients, and as an adjunct to surgical andnonsurgical periodontal therapy.” 45 Of the hundreds ofbacterial species identified within periodontal pockets,relatively few have been associated with chronicTable 1. Pathogenicity of bacterial species in periodontalpockets [From: Hafajjee and Socransky, 44 and Slots and Chen 46 ]Very Strong Strong Moderate IndeterminatePorphyrmonas Prevotella Campylobacter Gram-enteric rodsgingivalis intermedia rectusAggregatibacter Eubacterium Peptostreptococcus Pseudomonas speciesactinomycetimcomitans nodatum microsTannerella forsythia Treponema Fusobacterium Staphylococcus speciesdenticola nodatumSpirochetes of acute Dialister Eikenella Enterococcus faecalisnecrotizing gingivitis species corrodensSelenomonas noxiaBeta-hemolyticstreptococciCandida albicansperiodontitis, and the weight of evidence relative to theirpathogenicity has been described (Table 1). 44,46Based on the susceptibility to various antibiotics andantibiotic combinations, a number of different strategies havebeen developed for adjunctive systemic antimicrobialuse. 8,47-50 The most commonly used antibiotics, asdescribed by the AAP paper, 45 are seen in Table 2. Again,they are selected according to bacterial susceptibility. A DNApolymerasechain reaction has been marketed (MyPerioPath[OralDNA Labs]) which provides a clinical laboratory reporton 13 pathogens based on salivary testing, 51 and can beused as a guide for antibiotic selection based on the patient’speriodontal status and medical and family history.As is the case with local antibiotic administration, it isessential that the biofilm be disrupted initially before theadministration of systemic antibiotics.HOST MODULATIONGiven the protective aspects of the host immune system in theperiodontal patient, 3 a major thrust in research for more than2 decades has been aimed at modulating or amelioratingthe release of proinflammatory cytokines such as thematrix metalloproteinases. 52,53 As a result of this work, asubantimicrobial dose doxycycline regimen has been in use for4

Continuing EducationAdjunctive Periodontal Therapy: A Review of Current TechniquesTable 2. Commonly used antibiotics and dosagesAntibiotic Metronidazole Amoxicillin Tetracycline Ciprofloixacin Azithromycin Clindamycin ClarithromycinDoses 500 mg twice a 250 to 500 100 to 200 500 mg 250 to 500 300 mg 500 mg 2day or 3 times mg 3 times mg once 2 times mg once 3 times times a daya day a day a day a day a day a day oronce a dayTime (days) 8 to 10 8 to 10 8 to 14 8 to 10 5 (Z-pack) 8 8some time. Periostat (doxycycline hyclate 20 mg) is given twicedaily to inhibit host-derived matrix metalloproteinases (MMPs),including the collagenases. These results have no relation tothe antimicrobial action of the drug, and in fact, areadministered at levels below that which causes bacteriostasis.By acting to down-regulate the expression of the MMPs andtheir precursors, the collagen-building block of the periodontalconnective tissues are spared. 54A seminal study on the combined effects of hostmodulation and local antibiotic therapy was published in2008. 55 The inclusion of SRP along with Atridox doxycyclinethixotropic gel, and systemic low dose doxycline hyclate, wasshown to provide significantly greater clinical benefits thanSRP alone, perhaps as a result of synergistic actions of theadjunctive antimicrobials.There continues to be a large body of ongoing research onvarious forms of host modulating therapy. 56 Research extendsinto inhibition of osteoclasts with bone sparing agents such asbisphosphonates and cathepsins, 57 affecting prostaglandinformation. 58 With a greater understanding of the sequence ofevents related to inflammation and its resolution, researchersare beginning to look at drugs that may have been heretoforeoverlooked. 59ADJUNCTIVE LASER THERAPYA number of different types of laser engines have been usedin dentistry for many years, and published papers haveexhibited some controversy 60 over usefulness in adjunctivetreatment of periodontitis. A review of the literature byCobb, 61 commissioned by the AAP, is very comprehensiveon this subject. There is current evidence as to the positiveeffect of the Nd:YAG and Er:YAG lasers in reducing probingdepths and altering the subgingival microbiota, 61 and recentwork by Yukna, et al 62,63 describe the laser assisted newattachment procedure with promising results.Photodynamic laser therapy (PDT) is another adjunctivelaser approach that is receiving much attention. PDT isbased on the principle that a photosensitizer (methyleneblue, phenothiazine, tolamine chloride [TBlue; Zila]) isabsorbed onto the surface of the target cell (Gram-negativepathogens), is activated by a diode laser (660 nmwavelength), and is then toxic to the cell. While there isevidence that there is a reduction in inflammatory mediators(TNF-alpha, and crevicular RANKL), the effects are similar toSRP in order of magnitude. 64It is generally agreed that more detailed, controlledclinical research studies are necessary, especially long-termdesigns looking at clinical outcomes, for complete validationof this form of adjunctive therapy.SUMMARYThis paper has reviewed the different types of adjunctivetherapeutic approaches used in the control of periodontitis.While there are many avenues of current clinical use andresearch, it is generally agreed that all of the modalities reviewedare adjunctive to basic mechanical control of the root surfaceenvironment in the form of SRP.5

Continuing EducationAdjunctive Periodontal Therapy: A Review of Current TechniquesREFERENCES1. Haffajee AD, Socransky SS. Introduction to microbialaspects of periodontal biofilm communities, developmentand treatment. Periodontol 2000. 2006;42:7-12.2. Loe H, Theilade E, Jensen SB. Experimental gingivitisin man. J Periodontol. 1965;36:177-187.3. Page RC, Kornman KS. The pathogenesis of humanperiodontitis: an introduction. Periodontol 2000.1997;14:9-11.4. Page RC, Offenbacher S, Schroeder HE, et al.Advances in the pathogenesis of periodontitis: summaryof developments, clinical implications and futuredirections. Periodontol 2000. 1997;14:216-248.5. Drisko CH. Nonsurgical periodontal therapy.Periodontol 2000. 2001;25:77-88.6. Tagge DL, O’Leary TJ, El-Kafrawy AH, et al. Theclinical and histological response of periodontal pocketsto root planing and oral hygiene. J Periodontol.1975;46:527-533.7. Drisko CL, Cochran DL, Blieden T, et al. Research,Science and Therapy Committee of the AmericanAcademy of Periodontology. Position paper: sonic andultrasonic scalers in periodontics. J Periodontol.2000;71:1792-1801.8. Haffajee AD, Teles RP, Socransky SS. The effect ofperiodontal therapy on the composition of thesubgingival microbiota. Periodontol 2000.2006;42:219-258.9. Cobb CM. Non-surgical pocket therapy: mechanical.Ann Periodontol. 1996;1:443-490.10. Jolkovsky DL, Waki MY, Newman MG, et al. Clinicaland microbiological effects of subgingival and gingivalmarginal irrigation with chlorhexidine gluconate.J Periodontol. 1990;61:663-669.11. Ciancio SG, Mather ML, Zambon JJ, et al. Effect of achemotherapeutic agent delivered by an oral irrigationdevice on plaque, gingivitis, and subgingival microflora.J Periodontol. 1989;60:310-315.12. Newman MG, Cattabriga M, Etienne D, et al.Effectiveness of adjunctive irrigation in earlyperiodontitis: multi-center evaluation. J Periodontol.1994;65:224-229.13. Greenstein G; Research, Science and TherapyCommittee of the American Academy of Periodontology.Position paper: The role of supra- andsubgingival irrigation in the treatment of periodontaldiseases. J Periodontol. 2005;76:2015-2027.14. Al-Mubarak S, Ciancio S, Aljada A, et al. Comparativeevaluation of adjunctive oral irrigation in diabetics.J Clin Periodontol. 2002;29:295-300.15. Bader HI, Williams RC. Chlorhexidine efficacyenhancement by local application with powered rotarydevice. J Dent Res (abstract). January 1992.16. Bader HI, Williams RC. Rotary powered brushing withchlorhexidine compared to manual brushing plusirrigation. J Dent Res (abstract). January 1994.17. Paquette DW, Rosenberg A, Lohinai Z, et al.Inhibition of experimental gingivitis in beagle dogswith topical mercaptoalkylguanidines. J Periodontol.2006;77:385-391.18. Johannsen A, Tellefsen M, Wikesjö U, et al. Localdelivery of hyaluronan as an adjunct to scaling and rootplaning in the treatment of chronic periodontitis.J Periodontol. 2009;80:1493-1497.19. Van Dyke TE, Cutler CW, Kowolik M, et al. Effect oftopical cimetidine rinse on gingival crevicular neutrophilleukocyte function. J Periodontol. 2005;76:998-1005.20. Howell TH, Fiorellini J, Weber HP, et al. Effect of theNSAID piroxicam, topically administered, on thedevelopment of gingivitis in beagle dogs. J PeriodontalRes. 1991;26(3 pt 1):180-183.21. Goodson JM, Hogan PE, Dunham SL. Clinicalresponses following periodontal treatment by local drugdelivery. J Periodontol. 1985;56(suppl 11):81-87.22. Goodson JM, Cugini MA, Kent RL, et al. Multicenterevaluation of tetracycline fiber therapy: I. Clinicalresponse. J Periodontal Res. 1991;26:371-379.23. Soskolne WA, Heasman PA, Stabholz A, et al. Sustainedlocal delivery of chlorhexidine in the treatmentof periodontitis: a multi-center study. J Periodontol.1997;68:32-38.24. Jeffcoat MK, Bray KS, Ciancio SG, et al. Adjunctive useof a subgingival controlled-release chlorhexidine chipreduces probing depth and improves attachment levelcompared with scaling and root planing alone.J Periodontol. 1998;69:989-997.25. Jeffcoat MK, Palcanis KG, Weatherford TW, et al. Useof a biodegradable chlorhexidine chip in the treatmentof adult periodontitis: clinical and radiographic findings.J Periodontol. 2000;71:256-262.6

Continuing EducationAdjunctive Periodontal Therapy: A Review of Current Techniques26. Grisi DC, Salvador SL, Figueiredo LC, et al. Effect of acontrolled-release chlorhexidine chip on clinical andmicrobiological parameters of periodontal syndrome.J Clin Periodontol. 2002;29:875-881.27. Azmak N, Atilla G, Luoto H, et al. The effect ofsubgingival controlled-release delivery of chlorhexidinechip on clinical parameters and matrixmetalloproteinase-8 levels in gingival crevicular fluid.J Periodontol. 2002;73:608-615.28. Carvalho J, Novak MJ, Mota LF. Evaluation of the effectof subgingival placement of chlorhexidine chips as anadjunct to scaling and root planing. J Periodontol.2007;78:997-1001.29. Polson AM, Southard GL, Dunn RL, et al. Periodontalpocket treatment in beagle dogs using subgingivaldoxycycline from a biodegradable system. I. Initialclinical responses. J Periodontol. 1996;67:1176-1184.30. Garrett S, Johnson L, Drisko CH, et al. Two multi-centerstudies evaluating locally delivered doxycycline hyclate,placebo control, oral hygiene, and scaling and rootplaning in the treatment of periodontitis. J Periodontol.1999;70:490-503.31. Garrett S, Adams DF, Bogle G, et al. The effect oflocally delivered controlled-release doxycycline orscaling and root planing on periodontal maintenancepatients over 9 months. J Periodontol. 2000;71:22-30.32. Walker CB, Godowski KC, Borden L, et al. The effectsof sustained release doxycycline on the anaerobic floraand antibiotic-resistant patterns in subgingival plaqueand saliva. J Periodontol. 2000;71:768-774.33. Almazin SM, Dziak R, Andreana S, et al. The effectof doxycycline hyclate, chlorhexidine gluconate,and minocycline hydrochloride on osteoblasticproliferation and differentiation in vitro. J Periodontol.2009;80:999-1005.34. Paquette DW, Hanlon A, Lessem J, et al. Clinicalrelevance of adjunctive minocycline microspheres inpatients with chronic periodontitis: secondary analysisof a phase 3 trial. J Periodontol. 2004;75:531-536.35. Williams RC, Paquette DW, Offenbacher S, et al.Treatment of periodontitis by local administration ofminocycline microspheres: a controlled trial.J Periodontol. 2001;72:1535-1544.36. Lu HK, Chei CJ. Efficacy of subgingivally appliedminocycline in the treatment of chronic periodontitis.J Periodontal Res. 2005;40:20-27.37. Persson GR, Salvi GE, Heitz-Mayfield LJ, et al.Antimicrobial therapy using a local drug delivery system(Arestin) in the treatment of peri-implantitis. I:Microbiological outcomes. Clin Oral Implants Res.2006;17:386-393.38. Goodson JM, Gunsolley JC, Grossi SG, et al.Minocycline HCl microspheres reduce red-complexbacteria in periodontal disease therapy. J Periodontol.2007;78:1568-1579.39. Hellström MK, McClain PK, Schallhorn RG, et al. Localminocycline as an adjunct to surgical therapy inmoderate to severe, chronic periodontitis. J ClinPeriodontol. 2008;35:525-531.40. Teles RP, Haffajee AD, Socransky SS. Microbiologicalgoals of periodontal therapy. Periodontol 2000.2006;42:180-218.41. Haffajee AD, Socransky SS, Gunsolley JC. Systemicanti-infective periodontal therapy. A systematic review.Ann Periodontol. 2003;8:115-181.42. Wilson M. Susceptibility of oral bacterial biofilms toantimicrobial agents. J Med Microbiol. 1996;44:79-87.43. van Winkelhoff AJ, Rams TE, Slots J. Systemicantibiotic therapy in periodontics. Periodontol 2000.1996;10:45-78.44. Haffajee AD, Socransky SS. Microbial etiological agentsof destructive periodontal diseases. Periodontol 2000.1994;5:78-111.45. Slots J; Research, Science and Therapy Committee of theAmerican Academy of Periodontology. Systemic antibioticsin periodontics. J Periodontol. 2004;75:1553-1565.46. Slots J, Chen C. The oral microflora and humanperiodontal disease. In: Tannock GW, ed. MedicalImportance of the Normal Microflora. London, England:Kluwer Academic Publishers; 1999:101-127.47. Herrera D, Alonso B, León R, et al. Antimicrobialtherapy in periodontitis: the use of systemicantimicrobials against the subgingival biofilm.J Clin Periodontol. 2008;35(suppl 8):45-66.48. Beikler T, Prior K, Ehmke B, et al. Specific antibiotics inthe treatment of periodontitis—a proposed strategy.J Periodontol. 2004;75:169-175.49. Brook I, Lewis MA, Sándor GK, et al. Clindamycin indentistry: more than just effective prophylaxis forendocarditis? Oral Surg Oral Med Oral Pathol OralRadiol Endod. 2005;100:550-558.7

Continuing EducationAdjunctive Periodontal Therapy: A Review of Current Techniques50. Goodson JM. Antimicrobial strategies for treatment ofperiodontal diseases. Periodontol 2000. 1994;5:142-168.51. Bader HI. Antimicrobial aspects of inflammatorysuppression. Dent Today. 2009;28:142-145.52. Golub LM, Lee HM, Lehrer G, et al. Minocycline reducesgingival collagenolytic activity during diabetes. Preliminaryobservations and a proposed new mechanism of action.J Periodontal Res. 1983;18:516-526.53. Golub LM, Ramamurthy NS, McNamara TF, et al.Tetracyclines inhibit connective tissue breakdown: newtherapeutic implications for an old family of drugs. CritRev Oral Biol Med. 1991;2:297-321.54. Golub LM, Lee HM, Stoner JA, et al. Subantimicrobialdosedoxycycline modulates gingival crevicular fluidbiomarkers of periodontitis in postmenopausalosteopenic women. J Periodontol. 2008;79:1409-1418.55. Novak MJ, Dawson DR III, Magnusson I, et al.Combining host modulation and topical antimicrobialtherapy in the management of moderate to severeperiodontitis: a randomized multicenter trial.J Periodontol. 2008;79:33-41.56. Oringer RJ; Research, Science and TherapyCommittee of the American Academy of Periodontology.Modulation of the host response inperiodontal therapy. J Periodontol. 2002;73:460-470.57. Giannobile WV. Host-response therapeutics forperiodontal diseases. J Periodontol. 2008;79(suppl8):1592-1600.58. Reddy MS, Geurs NC, Gunsolley JC. Periodontal hostmodulation with antiproteinase, anti-inflammatory, andbone-sparing agents. A systematic review. AnnPeriodontol. 2003;8:12-37.59. Bhatavadekar NB, Williams RC. New directions in hostmodulation for the management of periodontal disease.J Clin Periodontol. 2009;36:124-126.60. Karlsson MR, Diogo Löfgren CI, Jansson HM, et al.The effect of laser therapy as an adjunct to nonsurgicalperiodontal treatment in subjects with chronicperiodontitis: a systematic review. J Periodontol.2008;79:2021-2028.61. Cobb CM. Lasers in periodontics: a review of theliterature. J Periodontol. 2006;77:545-564.62. Yukna RA, Evans G, Vastardis S, et al. Humanperiodontal regeneration following the laser assistednew attachment procedure. J Dent Res. Abstract2411; 2004.63. Yukna RA, Carr RL, Evans GH, et al. Histologicevaluation of an Nd:YAG laser-assisted new attachmentprocedure in humans. Int J Periodontics RestorativeDent. 2007;27:577-587.64. de Oliveira RR, Schwartz-Filho HO, Novaes AB, et al.Antimicrobial photodynamic therapy in the non-surgicaltreatment of aggressive periodontitis: cytokine profile ingingival crevicular fluid, preliminary results. JPeriodontol. 2009;80:98-105.8

Continuing EducationAdjunctive Periodontal Therapy: A Review of Current TechniquesPOST EXAMINATION INFORMATIONTo receive continuing education credit for participation inthis educational activity you must complete the programpost examination and receive a score of 70% or better.Traditional Completion Option:You may fax or mail your answers with payment to DentistryToday (see Traditional Completion Information on followingpage). All information requested must be provided in orderto process the program for credit. Be sure to complete your“Payment,” “Personal Certification Information,” “Answers,”and “Evaluation” forms. Your exam will be graded within 72hours of receipt. Upon successful completion of the postexam(70% or higher), a letter of completion will be mailedto the address provided.Online Completion Option:Use this page to review the questions and mark youranswers. Return to dentalcetoday.com and sign in. If youhave not previously purchased the program, select it fromthe “Online Courses” listing and complete the onlinepurchase process. Once purchased the program will beadded to your User History page where a Take Exam linkwill be provided directly across from the program title.Select the Take Exam link, complete all the programquestions and Submit your answers. An immediate gradereport will be provided. Upon receiving a passing grade,complete the online evaluation form. Upon submitting theform your Letter Of Completion will be providedimmediately for printing.General Program Information:Online users may log in to dentalcetoday.com any time inthe future to access previously purchased programs andview or print letters of completion and results.POST EXAMINATION QUESTIONS1. The term “adjunctive therapy” is used to describe:a. Pocket reduction surgery.b. Ancillary or additional means of reducing the inflammatoryburden.c. Osseous regeneration using guided bone regeneration.d. Scaling and root planing.2. Topical application of anti-inflammatory agents hasbeen shown to be effective. These agents include:a. 0.12% chlorhexidine.b. Saline solution.c. Peroxide.d. Chloramphenicol.3. Second generation sustained release systems are:a. Antiseptics.b. Alcohol based.c. Biodegradable.d. Elastomeres.4. Periochip is an:a. Antibiotic.b. Antiseptic.c. Anti-inflammatory cytokine.d. Immune regulator.5. Atridox is doxycycline as a:a. Reversible colloid.b. Irreversible colloid.c. Thixotropic gel.d. Anionic gel.6. The American Academy of Periodontology states thatantibiotics may be prescribed for:a. Pocket depths greater than 5 mm.b. Use instead of SRP.c. Patients older than age 21 years.d. Nonresponsive patients.7. Host modulation refers to:a. Antimicrobial suppression.b. Altering a patient’s genotype.c. Altering the immune response.d. Eliminating the immune response.8. Current literature supports the use of lasers to:a. Regenerate bone.b. Reduce probing depths.c. Create osteotomies for implant placement.d. Increase anti-inflammatory matrix metalloproteinases.9

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