The Open Dentistry Journal




ISSN: 1874-2106 ― Volume 13, 2019
REVIEW ARTICLE

Twenty Years of Full-Mouth Disinfection: The Past, the Present and the Future



Ange Désiré Pockpa1, 3, Assem Soueidan1, 2, 4, *, Pauline Louis4, Nadin Thérèse Coulibaly3, Zahi Badran2, 4, 5, Xavier Struillou2, 4
1 Clinical Investigation Unit 11 Odontology, CHU Nantes, Nantes, France
2 Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, F-44042, France
3 Department of Periodontology, Faculty of Dental Surgery, University of Felix Houphouët Boigny, Abidjan, Ivory Coast
4 Department of Periodontology, Faculty of Dental Surgery, University of Nantes, Nantes, France
5 Faculty of Dentistry, McGill University, Montreal, QC, Canada

Abstract

Background:

Conventional periodontal treatment, performed quadrant by quadrant in multiple visits, was re-evaluated in the early 1990s when the full-mouth disinfection concept was introduced. Over the years, several modifications to the full-mouth disinfection approach have been suggested.

Objective:

The purpose of this article is to review the evolution of full-mouth disinfection during the past 20 years, to specify its indications and to consider the prospects for this approach.

Materials and Methods:

An electronic and manual search of the literature, ending in December 2016, was performed by two independent researchers. Only pivotal studies and randomized controlled clinical trials published in the English language that evaluated a new approach to full-mouth disinfection were selected.

Results:

According to the studies included in our analysis (21 articles), several modified full-mouth disinfection protocols have been designed including: full-mouth treatment without chlorhexidine, the extension of hygiene methods and an increase in the duration of post-treatment chlorhexidine use, the replacement of chlorhexidine with other antiseptics, supplementation with antibiotics or probiotics, full-mouth antimicrobial photodynamic therapy and one-stage full-mouth disinfection combined with a periodontal dressing.

Conclusion:

Since 1995, several modifications have been suggested to improve the effectiveness of full-mouth disinfection. The majority of the studies demonstrate that the results obtained with full-mouth disinfection and its variants are equivalent to each other and to those obtained with the conventional quadrant method. Currently, the selection of this technique remains empirical and depends on the preferences of the practitioner and the patient. In the future, a patient-centered approach should be the best indication for the use of this technique.

Keywords: Periodontal disease, Periodontal treatment, Scaling and root planing, Full-mouth disinfection, Chlorhexidine, Antibiotics or probiotics.


Article Information


Identifiers and Pagination:

Year: 2018
Volume: 12
First Page: 435
Last Page: 442
Publisher Id: TODENTJ-12-435
DOI: 10.2174/1874210601812010435

Article History:

Received Date: 13/12/2017
Revision Received Date: 23/4/2018
Acceptance Date: 14/5/2018
Electronic publication date: 31/05/2018
Collection year: 2018

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© 2018 Pockpa et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to the author at the Department of Periodontology, Dental College, Clinical Investigation Unit 11 Odontology, 1 place Alexis –Ricordeau, 44200, CHU Nantes, France; Tel: +33-(0)2-40412923; Portable: +33-(0)6-19112579; E-mail: assem.soueidan@univ-nantes.fr




1. INTRODUCTION

The mechanical treatment of Periodontal Disease (PD) involves scaling and root planing performed quadrant by quadrant in multiple visits spaced over one to two weeks (QSRP) [1Westfelt E, Rylander H, Dahlén G, Lindhe J. The effect of supragingival plaque control on the progression of advanced periodontal disease. J Clin Periodontol 1998; 25(7): 536-41.[http://dx.doi.org/10.1111/j.1600-051X.1998.tb02484.x] [PMID: 9696252] ]. This conventional PD treatment strategy was reevaluated in the early 1990s when the Full-Mouth Disinfection (FMD) concept was introduced. The principle of FMD is based on the scaling and root planning of all pockets and the treatment of all oral niches in two visits within 24 hours [2Quirynen M, Bollen CM, Vandekerckhove BN, Dekeyser C, Papaioannou W, Eyssen H. Full- vs. partial-mouth disinfection in the treatment of periodontal infections: Short-term clinical and microbiological observations. J Dent Res 1995; 74(8): 1459-67.[http://dx.doi.org/10.1177/00220345950740080501] [PMID: 7560400] ]. The aims of the FMD approach are twofold: first, to avoid the potential rapid translocation of periodontal pathogens; and second, to prevent the reinfection of previously treated sites by untreated pockets or by other intraoral niches [3van Winkelhoff AJ, van der Velden U, de Graaff J. Microbial succession in recolonizing deep periodontal pockets after a single course of supra- and subgingival debridement. J Clin Periodontol 1988; 15(2): 116-22.[http://dx.doi.org/10.1111/j.1600-051X.1988.tb01004.x] [PMID: 3279070] , 4Heitz-Mayfield LJA, Lang NP. Surgical and nonsurgical periodontal therapy. Learned and unlearned concepts. Periodontol 2000 2013; 62(1): 218-31.[http://dx.doi.org/10.1111/prd.12008] [PMID: 23574468] ]. The original FMD protocol begins with motivating and instructing the patient in good oral hygiene techniques (Table 1). The protocol proceeds as follows: a) scaling and root planing all teeth under local anesthesia during a 24 hour period spanning two consecutive days; b) brushing the back of the tongue with 1% Chlorhexidine (CHX) gel for a period of 1 minute; c) washing the mouth twice with 10 mL of 0.2% CHX for 1 minute, with gargling for the final 10 seconds; and d) performing the subgingival irrigation of all pockets with 1% CHX gel 3 times for 10 minutes each using a graduated syringe set at 6 and 8 mm immediately after each of the 2 sessions and 8 days later. At home, the patient is to comply with the recommendations of the dental practitioner (for 2 weeks, the patient is to wash the mouth twice daily with 10 mL of 0.2% CHX and use brushing aids) [5Bollen CML, Mongardini C, Papaioannou W, Van Steenberghe D, Quirynen M. The effect of a one-stage full-mouth disinfection on different intra-oral niches. Clinical and microbiological observations. J Clin Periodontol 1998; 25(1): 56-66.[http://dx.doi.org/10.1111/j.1600-051X.1998.tb02364.x] [PMID: 9477021] ] (Table 1). Since 1995, several modifications to the original FMD protocol have been suggested. The purpose of this article is to review the evolution of FMD during the past 20 years, to specify its indications and to consider the prospects for this approach.

Table 1
Initial protocol of FMD (1)


2. MATERIALS AND METHODS

2.1. Review Question

How has the FMD protocol evolved during the past 20 years?

2.2. Search Strategy

This literature review was conducted by two independent reviewers (PZ and LP) using the PubMed/MEDLINE and Cochrane databases. Disagreements were resolved by discussion and third-party review (XS). The final search was performed in December 2016.

The following search terms were used: full mouth, disinfection, scaling and root planning, Quirynen, one-stage FMD, and periodontitis. Abstracts and the corresponding original articles were selected for review from the available titles. All articles that focused on the FMD concept were comprehensively reviewed. The bibliographies of the selected articles were subsequently reviewed to identify additional publications.

This electronic search was supplemented by a manual search of the following journals: Journal of Clinical Periodontology, Journal of Periodontology, Periodontology 2000, Clinical Oral Investigations, and Clinical Oral Implant Research.

2.3. Inclusion and Exclusion Criteria

Only Randomized Controlled Trials (RCTs) in which the original FMD protocol was modified were eligible for inclusion in this review. This study was limited to articles published in the English language.

Interventional studies, retrospective case-control studies, cross-sectional studies, case series, case reports, editorials, reviews, and animal studies were excluded from this review. In addition, studies that used the original FMD protocol and articles not published in English were excluded.

2.4. Data Extraction

The following data were extracted from the selected articles: names of authors, year of publication, number of patients, length of study, type of periodontitis treated, an amendment to the FMD protocol and main outcomes (Table 2).

3. RESULTS

Since the FMD technique was first described, several teams have made changes to the protocol, and we have identified a total of 8 modified protocols: full-mouth treatment without CHX [6Quirynen M, Mongardini C, de Soete M, et al. The rôle of chlorhexidine in the one-stage full-mouth disinfection treatment of patients with advanced adult periodontitis. Long-term clinical and microbiological observations. J Clin Periodontol 2000; 27(8): 578-89.[http://dx.doi.org/10.1034/j.1600-051x.2000.027008578.x] [PMID: 10959784] -9Santos VR, Lima JA, Miranda TS, et al. Full-mouth disinfection as a therapeutic protocol for type-2 diabetic subjects with chronic periodontitis: twelve-month clinical outcomes: A randomized controlled clinical trial. J Clin Periodontol 2013; 40(2): 155-62.[http://dx.doi.org/10.1111/jcpe.12040] [PMID: 23305133] ], the extension of hygiene methods and an increase in the duration of posttreatment CHX use [5Bollen CML, Mongardini C, Papaioannou W, Van Steenberghe D, Quirynen M. The effect of a one-stage full-mouth disinfection on different intra-oral niches. Clinical and microbiological observations. J Clin Periodontol 1998; 25(1): 56-66.[http://dx.doi.org/10.1111/j.1600-051X.1998.tb02364.x] [PMID: 9477021] ], the replacement of CHX with other antiseptics [10Quirynen M, De Soete M, Boschmans G, et al. Benefit of “one-stage full-mouth disinfection” is explained by disinfection and root planing within 24 hours: A randomized controlled trial. J Clin Periodontol 2006; 33(9): 639-47.[http://dx.doi.org/10.1111/j.1600-051X.2006.00959.x] [PMID: 16856902] -13Cortelli SC, Cortelli JR, Holzhausen M, et al. Essential oils in one-stage full-mouth disinfection: Double-blind, randomized clinical trial of long-term clinical, microbial and salivary effects. J Clin Periodontol 2009; 36(4): 333-42.[http://dx.doi.org/10.1111/j.1600-051X.2009.01376.x] [PMID: 19426180] ], supplementation with antibiotics [14Gomi K, Yashima A, Nagano T, Kanazashi M, Maeda N, Arai T. Effects of full-mouth scaling and root planing in conjunction with systemically administered azithromycin. J Periodontol 2007; 78(3): 422-9.[http://dx.doi.org/10.1902/jop.2007.060247] [PMID: 17335364] -22Fonseca DC, Cortelli JR, Cortelli SC, et al. Clinical and microbiologic evaluation of scaling and root planing per quadrant and one-stage full-mouth disinfection associated with azithromycin or chlorhexidine: A Clinical Randomized Controlled Trial. J Periodontol 2015; 86(12): 1340-51.[http://dx.doi.org/10.1902/jop.2015.150227] [PMID: 26252751] ] or probiotics [21Teughels W, Durukan A, Ozcelik O, Pauwels M, Quirynen M, Haytac MC. Clinical and microbiological effects of Lactobacillus reuteri probiotics in the treatment of chronic periodontitis: A randomized placebo-controlled study. J Clin Periodontol 2013; 40(11): 1025-35.[http://dx.doi.org/10.1111/jcpe.12155] [PMID: 24164569] ], full-mouth antimicrobial photodynamic therapy [23Sigusch BW, Engelbrecht M, Völpel A, Holletschke A, Pfister W, Schütze J. Full-mouth antimicrobial photodynamic therapy in Fusobacterium nucleatum-infected periodontitis patients. J Periodontol 2010; 81(7): 975-81.[http://dx.doi.org/10.1902/jop.2010.090246] [PMID: 20350153] ], and the most recent modification, one-stage FMD combined with a periodontal dressing [24Keestra JAJ, Coucke W, Quirynen M. One-stage full-mouth disinfection combined with a periodontal dressing: A randomized controlled clinical trial. J Clin Periodontol 2014; 41(2): 157-63.[http://dx.doi.org/10.1111/jcpe.12199] [PMID: 24255934] ] (Table 2).

Table 2
Characteristics of randomized controlled trial included in review.


3.1. Evolution of the FMD Concept

3.1.1. Full-Mouth Treatment without CHX

In 2000, Quirynen et al. proposed the removal of CHX use from the original protocol, thereby creating the full-mouth scaling approach (FMS). Quirynen et al. conducted a longitudinal study comparing FMS (test group 1) to FMD (test group 2) and Quadrant Scaling and Root Planing (QSRP) (control group) [6Quirynen M, Mongardini C, de Soete M, et al. The rôle of chlorhexidine in the one-stage full-mouth disinfection treatment of patients with advanced adult periodontitis. Long-term clinical and microbiological observations. J Clin Periodontol 2000; 27(8): 578-89.[http://dx.doi.org/10.1034/j.1600-051x.2000.027008578.x] [PMID: 10959784] ] and observed additional benefits in the two test groups in terms of pocket depth reduction (approximately 1.5 mm) and clinical attachment gain (approximately 2 mm). However, no statistically significant differences between the test groups were observed [6Quirynen M, Mongardini C, de Soete M, et al. The rôle of chlorhexidine in the one-stage full-mouth disinfection treatment of patients with advanced adult periodontitis. Long-term clinical and microbiological observations. J Clin Periodontol 2000; 27(8): 578-89.[http://dx.doi.org/10.1034/j.1600-051x.2000.027008578.x] [PMID: 10959784] ]. Additionally, motile microorganisms and spirochetes were significantly decreased in only the FMD group, and this difference lasted for up to 2 months posttreatment. However, this difference was not observed beyond 2 months [6Quirynen M, Mongardini C, de Soete M, et al. The rôle of chlorhexidine in the one-stage full-mouth disinfection treatment of patients with advanced adult periodontitis. Long-term clinical and microbiological observations. J Clin Periodontol 2000; 27(8): 578-89.[http://dx.doi.org/10.1034/j.1600-051x.2000.027008578.x] [PMID: 10959784] ]. In 2009, using a similar methodology, Swierkot et al. observed a greater reduction in pocket depths and gingival bleeding with the FMS protocol than that with the FMD protocol at 2 months. However, at 8 months, no significant difference was observed [8Swierkot K, Nonnenmacher CI, Mutters R, Flores-de-Jacoby L, Mengel R. One-stage full-mouth disinfection versus quadrant and full-mouth root planing. J Clin Periodontol 2009; 36(3): 240-9.[http://dx.doi.org/10.1111/j.1600-051X.2008.01368.x] [PMID: 19236536] ]. Apatzidou et al. compared the FMS group to the QSRP group and observed that patients treated with FMS had more postoperative pain compared to those who received conventional therapy with CHX [7Apatzidou DA, Riggio MP, Kinane DF. Quadrant root planing versus same-day full-mouth root planing. II. Microbiological findings. J Clin Periodontol 2004; 31(2): 141-8.[http://dx.doi.org/10.1111/j.0303-6979.2004.00462.x] [PMID: 15016040] ]. In 2013, Santos et al. investigated the treatment of chronic periodontitis in patients with type II diabetes (FMD compared with FMS + placebo) and observed no significant clinical differences between the results of these treatments for a posttreatment period of up to 12 months [9Santos VR, Lima JA, Miranda TS, et al. Full-mouth disinfection as a therapeutic protocol for type-2 diabetic subjects with chronic periodontitis: twelve-month clinical outcomes: A randomized controlled clinical trial. J Clin Periodontol 2013; 40(2): 155-62.[http://dx.doi.org/10.1111/jcpe.12040] [PMID: 23305133] ].

3.1.2. Extension of Hygiene Methods and Increased Duration of Posttreatment CHX Use

Bollen et al. assessed the use of CHX (mouthwashes and tonsil sprays) for a period of 2 months after treatment instead of 2 weeks [5Bollen CML, Mongardini C, Papaioannou W, Van Steenberghe D, Quirynen M. The effect of a one-stage full-mouth disinfection on different intra-oral niches. Clinical and microbiological observations. J Clin Periodontol 1998; 25(1): 56-66.[http://dx.doi.org/10.1111/j.1600-051X.1998.tb02364.x] [PMID: 9477021] ]. These investigators compared FMD with 2 months of CHX treatment (test group) to QSRP (control group) by evaluating the clinical and microbiological effects of these treatments after 2 and 4 months. Samples of saliva and gingival, lingual, and mucosal plaques were collected. At 2 and 4 months, Bollen et al. observed significantly higher clinical attachment gains in the test group than those in the control group (1.5 mm versus 0.3 mm in deep pockets; 0.9 mm versus 0.1 mm in pockets of moderate depth). In terms of the microbiological effect, they noted a significant decrease in Porphyromonas gingivalis (Pg), Prevotella intermedia (Pi), and spirochetes in the test group. However, at the end of this study, the authors could not demonstrate a direct relationship between the observed results and the increased CHX use. According to the authors, these results could be due to the effectiveness of the full-mouth method compared with that of the quadrant method [5Bollen CML, Mongardini C, Papaioannou W, Van Steenberghe D, Quirynen M. The effect of a one-stage full-mouth disinfection on different intra-oral niches. Clinical and microbiological observations. J Clin Periodontol 1998; 25(1): 56-66.[http://dx.doi.org/10.1111/j.1600-051X.1998.tb02364.x] [PMID: 9477021] ].

3.1.3. Replacement of CHX with other Types of Antiseptics

In 2006, Quirynen et al. considered the possibility of using Amine Fluoride/stannous fluoride (AF) in the original protocol to complement or to substitute for CHX [10Quirynen M, De Soete M, Boschmans G, et al. Benefit of “one-stage full-mouth disinfection” is explained by disinfection and root planing within 24 hours: A randomized controlled trial. J Clin Periodontol 2006; 33(9): 639-47.[http://dx.doi.org/10.1111/j.1600-051X.2006.00959.x] [PMID: 16856902] ]. This study compared these two regimens to the conventional quadrant method. At 8 months posttreatment, no additional benefit was observed with the use of AF either alone or combined with CHX [10Quirynen M, De Soete M, Boschmans G, et al. Benefit of “one-stage full-mouth disinfection” is explained by disinfection and root planing within 24 hours: A randomized controlled trial. J Clin Periodontol 2006; 33(9): 639-47.[http://dx.doi.org/10.1111/j.1600-051X.2006.00959.x] [PMID: 16856902] ]. Using a similar methodology, Wang et al. studied the possibility of using povidone-iodine (Betadine®) in the FMD protocol [11Wang D, Koshy G, Nagasawa T, et al. Antibody response after single-visit full-mouth ultrasonic debridement versus quadrant-wise therapy. J Clin Periodontol 2006; 33(9): 632-8.[http://dx.doi.org/10.1111/j.1600-051X.2006.00963.x] [PMID: 16856899] ] by comparing QSRP (control) to a modified FMD protocol including an irrigation treatment with either water (test 1) or povidone-iodine (test 2). Blood samples were taken before treatment and at 1, 3 and 6 months after treatment. The study aimed to compare the expression of serum antibodies in response to the following periodontal pathogens: Pg, Aggregatibacter actinomycetemcomitans (Aa), and Treponema denticola (Td). Compared to the control group, both test groups showed significant reductions in anti-Pg and anti-Aa antibodies at 1 and 3 months. These authors suggested that povidone-iodine could be a reliable alternative to CHX in the FMD protocol [11Wang D, Koshy G, Nagasawa T, et al. Antibody response after single-visit full-mouth ultrasonic debridement versus quadrant-wise therapy. J Clin Periodontol 2006; 33(9): 632-8.[http://dx.doi.org/10.1111/j.1600-051X.2006.00963.x] [PMID: 16856899] ]. A few years later, in a study investigating the use of essential oils as an adjuvant to or substitute for CHX [12Cavalca Cortelli S, Cavallini F, Regueira Alves MF, Alves Bezerra A Jr, Queiroz CS, Cortelli JR. Clinical and microbiological effects of an essential-oil-containing mouth rinse applied in the “one-stage full-mouth disinfection” protocol: A randomized doubled-blinded preliminary study. Clin Oral Investig 2009; 13(2): 189-94.[http://dx.doi.org/10.1007/s00784-008-0219-3] [PMID: 18716800] , 13Cortelli SC, Cortelli JR, Holzhausen M, et al. Essential oils in one-stage full-mouth disinfection: Double-blind, randomized clinical trial of long-term clinical, microbial and salivary effects. J Clin Periodontol 2009; 36(4): 333-42.[http://dx.doi.org/10.1111/j.1600-051X.2009.01376.x] [PMID: 19426180] ], the authors reported that essential oils were beneficial for the reduction of pocket depth and plaque and gingival indices [12Cavalca Cortelli S, Cavallini F, Regueira Alves MF, Alves Bezerra A Jr, Queiroz CS, Cortelli JR. Clinical and microbiological effects of an essential-oil-containing mouth rinse applied in the “one-stage full-mouth disinfection” protocol: A randomized doubled-blinded preliminary study. Clin Oral Investig 2009; 13(2): 189-94.[http://dx.doi.org/10.1007/s00784-008-0219-3] [PMID: 18716800] , 13Cortelli SC, Cortelli JR, Holzhausen M, et al. Essential oils in one-stage full-mouth disinfection: Double-blind, randomized clinical trial of long-term clinical, microbial and salivary effects. J Clin Periodontol 2009; 36(4): 333-42.[http://dx.doi.org/10.1111/j.1600-051X.2009.01376.x] [PMID: 19426180] ]. However, the results of the microbiological analysis were less clear.

3.1.4. Supplementation with Antibiotics

The hypothesized benefit of adding antibiotics to the FMD protocol has been the subject of several studies [14Gomi K, Yashima A, Nagano T, Kanazashi M, Maeda N, Arai T. Effects of full-mouth scaling and root planing in conjunction with systemically administered azithromycin. J Periodontol 2007; 78(3): 422-9.[http://dx.doi.org/10.1902/jop.2007.060247] [PMID: 17335364] -22Fonseca DC, Cortelli JR, Cortelli SC, et al. Clinical and microbiologic evaluation of scaling and root planing per quadrant and one-stage full-mouth disinfection associated with azithromycin or chlorhexidine: A Clinical Randomized Controlled Trial. J Periodontol 2015; 86(12): 1340-51.[http://dx.doi.org/10.1902/jop.2015.150227] [PMID: 26252751] ]. In 2007, Gomi et al. compared the QSRP protocol (control group) an FMD protocol with Azithromycin (AZT) added (test group) [14Gomi K, Yashima A, Nagano T, Kanazashi M, Maeda N, Arai T. Effects of full-mouth scaling and root planing in conjunction with systemically administered azithromycin. J Periodontol 2007; 78(3): 422-9.[http://dx.doi.org/10.1902/jop.2007.060247] [PMID: 17335364] ]. AZT was administered during the three days preceding the mechanical treatment. The clinical and microbiological parameters were recorded over a 6 month period, and an improvement in the clinical parameters at 2 and 6 months posttreatment was observed in the AZT group [14Gomi K, Yashima A, Nagano T, Kanazashi M, Maeda N, Arai T. Effects of full-mouth scaling and root planing in conjunction with systemically administered azithromycin. J Periodontol 2007; 78(3): 422-9.[http://dx.doi.org/10.1902/jop.2007.060247] [PMID: 17335364] ]. At 2 months, the elimination of periopathogenic bacteria was significantly greater in the test group than that in the control group [14Gomi K, Yashima A, Nagano T, Kanazashi M, Maeda N, Arai T. Effects of full-mouth scaling and root planing in conjunction with systemically administered azithromycin. J Periodontol 2007; 78(3): 422-9.[http://dx.doi.org/10.1902/jop.2007.060247] [PMID: 17335364] ]. The authors concluded their study by claiming that the addition of AZT to the FMD protocol was clinically and microbiologically effective [14Gomi K, Yashima A, Nagano T, Kanazashi M, Maeda N, Arai T. Effects of full-mouth scaling and root planing in conjunction with systemically administered azithromycin. J Periodontol 2007; 78(3): 422-9.[http://dx.doi.org/10.1902/jop.2007.060247] [PMID: 17335364] ]. Similar observations were noted by Yashima et al. [15Yashima A, Gomi K, Maeda N, Arai T. One-stage full-mouth versus partial-mouth scaling and root planing during the effective half-life of systemically administered azithromycin. J Periodontol 2009; 80(9): 1406-13.[http://dx.doi.org/10.1902/jop.2009.090067] [PMID: 19722790] ]. However, recently, Fonseca et al. showed that the addition of AZT did not provide additional clinical benefits compared to the FMD technique alone [22Fonseca DC, Cortelli JR, Cortelli SC, et al. Clinical and microbiologic evaluation of scaling and root planing per quadrant and one-stage full-mouth disinfection associated with azithromycin or chlorhexidine: A Clinical Randomized Controlled Trial. J Periodontol 2015; 86(12): 1340-51.[http://dx.doi.org/10.1902/jop.2015.150227] [PMID: 26252751] ]. In this study, the authors divided the samples into 6 groups and compared different protocols: (a) a full-mouth approach without CHX (FMS), (b) FMD alone, (c) FMD + AZT, d) QSRP without CHX, e) QSRP + CHX, and f) QSRP + AZT. At 3 months, a significant reduction in the depth of deep pockets, gingival inflammation, plaque index, and clinical attachment gain was observed in each group [22Fonseca DC, Cortelli JR, Cortelli SC, et al. Clinical and microbiologic evaluation of scaling and root planing per quadrant and one-stage full-mouth disinfection associated with azithromycin or chlorhexidine: A Clinical Randomized Controlled Trial. J Periodontol 2015; 86(12): 1340-51.[http://dx.doi.org/10.1902/jop.2015.150227] [PMID: 26252751] ]. Compared to the other groups, the group receiving FMD alone exhibited a greater reduction in pocket depth and a lower rate of PD at 6 months [22Fonseca DC, Cortelli JR, Cortelli SC, et al. Clinical and microbiologic evaluation of scaling and root planing per quadrant and one-stage full-mouth disinfection associated with azithromycin or chlorhexidine: A Clinical Randomized Controlled Trial. J Periodontol 2015; 86(12): 1340-51.[http://dx.doi.org/10.1902/jop.2015.150227] [PMID: 26252751] ]. Cionca et al. investigated the addition of Amoxicillin (Amox) and Metronidazole (MTZ) to the FMD protocol using a regimen of 375 mg of Amox and 500 mg of MTZ three times a day for 7 days [16Cionca N, Giannopoulou C, Ugolotti G, Mombelli A. Amoxicillin and metronidazole as an adjunct to full-mouth scaling and root planing of chronic periodontitis. J Periodontol 2009; 80(3): 364-71.[http://dx.doi.org/10.1902/jop.2009.080540] [PMID: 19254119] , 17Cionca N, Giannopoulou C, Ugolotti G, Mombelli A. Microbiologic testing and outcomes of full-mouth scaling and root planing with or without amoxicillin/metronidazole in chronic periodontitis. J Periodontol 2010; 81(1): 15-23.[http://dx.doi.org/10.1902/jop.2009.090390] [PMID: 20059413] ]. At 6 months, Cionca et al. observed a greater reduction in the depth of deep pockets in the test group than that in the control group [16Cionca N, Giannopoulou C, Ugolotti G, Mombelli A. Amoxicillin and metronidazole as an adjunct to full-mouth scaling and root planing of chronic periodontitis. J Periodontol 2009; 80(3): 364-71.[http://dx.doi.org/10.1902/jop.2009.080540] [PMID: 19254119] ]. Moreover, the test group had a smaller number of residual pockets of more than 4 mm in depth than the control group (p = 0.005) and had a significantly reduced need for complementary surgical treatment [16Cionca N, Giannopoulou C, Ugolotti G, Mombelli A. Amoxicillin and metronidazole as an adjunct to full-mouth scaling and root planing of chronic periodontitis. J Periodontol 2009; 80(3): 364-71.[http://dx.doi.org/10.1902/jop.2009.080540] [PMID: 19254119] ]. However, beyond 6 months, no significant differences in these clinical parameters were observed [16Cionca N, Giannopoulou C, Ugolotti G, Mombelli A. Amoxicillin and metronidazole as an adjunct to full-mouth scaling and root planing of chronic periodontitis. J Periodontol 2009; 80(3): 364-71.[http://dx.doi.org/10.1902/jop.2009.080540] [PMID: 19254119] ]. In terms of the microbiological effect, Cionca et al. observed the elimination of Aa in the test group but not in the control group at 3 months posttreatment. Additionally, lower levels of Pg (p = 0.013) and Tannerella forsythia (Tf) (p = 0.007) were observed in the test group than those in the control group [17Cionca N, Giannopoulou C, Ugolotti G, Mombelli A. Microbiologic testing and outcomes of full-mouth scaling and root planing with or without amoxicillin/metronidazole in chronic periodontitis. J Periodontol 2010; 81(1): 15-23.[http://dx.doi.org/10.1902/jop.2009.090390] [PMID: 20059413] ]. However, these results were not confirmed at 6 months [17Cionca N, Giannopoulou C, Ugolotti G, Mombelli A. Microbiologic testing and outcomes of full-mouth scaling and root planing with or without amoxicillin/metronidazole in chronic periodontitis. J Periodontol 2010; 81(1): 15-23.[http://dx.doi.org/10.1902/jop.2009.090390] [PMID: 20059413] ]. Similarly, Varela et al. reported that, at 3 months, an additional clinical benefit in the treatment of aggressive periodontitis was observed with the addition of Amox and MTZ to the FMD protocol (500 mg amoxicillin + 250 mg metronidazole, three times a day for 10 days) [18Varela VM, Heller D, Silva-Senem MX, Torres MCMB, Colombo APV, Feres-Filho EJ. Systemic antimicrobials adjunctive to a repeated mechanical and antiseptic therapy for aggressive periodontitis: A 6-month randomized controlled trial. J Periodontol 2011; 82(8): 1121-30.[http://dx.doi.org/10.1902/jop.2011.100656] [PMID: 21235333] ]. However, according to a similar study by Aimetti et al., the microbiological effects of the addition of Amox and MTZ remained for up to 6 months [19Aimetti M, Romano F, Guzzi N, Carnevale G. One-stage full-mouth disinfection as a therapeutic approach for generalized aggressive periodontitis. J Periodontol 2011; 82(6): 845-53.[http://dx.doi.org/10.1902/jop.2010.100468] [PMID: 21091345] ]. Preus et al. evaluated the efficacy of the addition of MTZ monotherapy to the FMD protocol [20Preus HR, Gunleiksrud TM, Sandvik L, Gjermo P, Baelum V. A randomized, double-masked clinical trial comparing four periodontitis treatment strategies: 1-year clinical results. J Periodontol 2013; 84(8): 1075-86.[http://dx.doi.org/10.1902/jop.2012.120400] [PMID: 23106511] ]. They compared 4 protocols: a) FMD + 400 mg MTZ (three times a day for 10 days), b) FMD + placebo, c) QSRP + 400 mg MTZ (three times a day for 10 days), and d) QSRP + placebo. They reported that the addition of MTZ increased clinical attachment gains and reduced pocket depth [20Preus HR, Gunleiksrud TM, Sandvik L, Gjermo P, Baelum V. A randomized, double-masked clinical trial comparing four periodontitis treatment strategies: 1-year clinical results. J Periodontol 2013; 84(8): 1075-86.[http://dx.doi.org/10.1902/jop.2012.120400] [PMID: 23106511] ]. However, at 12 months, FMD either with or without MTZ did not improve the clinical conditions beyond those obtained by conventional therapy [20Preus HR, Gunleiksrud TM, Sandvik L, Gjermo P, Baelum V. A randomized, double-masked clinical trial comparing four periodontitis treatment strategies: 1-year clinical results. J Periodontol 2013; 84(8): 1075-86.[http://dx.doi.org/10.1902/jop.2012.120400] [PMID: 23106511] ].

3.1.5. Addition of Probiotics

The addition of probiotics (Lactobacillus reuteri (LR) in tablet form) to the FMD protocol has also been considered [21Teughels W, Durukan A, Ozcelik O, Pauwels M, Quirynen M, Haytac MC. Clinical and microbiological effects of Lactobacillus reuteri probiotics in the treatment of chronic periodontitis: A randomized placebo-controlled study. J Clin Periodontol 2013; 40(11): 1025-35.[http://dx.doi.org/10.1111/jcpe.12155] [PMID: 24164569] ]. Teughels et al. compared FMD with the twice daily administration of LR for 12 weeks (test group) to FMD with a placebo (control group). At 12 weeks, the authors observed a significant improvement in clinical and microbiological parameters, including a significant improvement in pocket depth and clinical attachment gain and a reduction in the periopathogenic bacterial load. They concluded that the oral administration of probiotic LR tablets in addition to scaling and surfacing by a comprehensive disinfection method would be useful in the treatment of chronic periodontitis [21Teughels W, Durukan A, Ozcelik O, Pauwels M, Quirynen M, Haytac MC. Clinical and microbiological effects of Lactobacillus reuteri probiotics in the treatment of chronic periodontitis: A randomized placebo-controlled study. J Clin Periodontol 2013; 40(11): 1025-35.[http://dx.doi.org/10.1111/jcpe.12155] [PMID: 24164569] ].

3.1.6. Full-mouth Antimicrobial Photodynamic Therapy

Sigush et al. conducted a study to evaluate the efficacy of dynamic phototherapy in addition to FMD on the eradication of Fusobacterium nucleatum (Fn) [23Sigusch BW, Engelbrecht M, Völpel A, Holletschke A, Pfister W, Schütze J. Full-mouth antimicrobial photodynamic therapy in Fusobacterium nucleatum-infected periodontitis patients. J Periodontol 2010; 81(7): 975-81.[http://dx.doi.org/10.1902/jop.2010.090246] [PMID: 20350153] ]. Patients received either FMD with a photosensitive solution that was activated by a laser (test group) or FMD with the unactivated photosensitive solution (control group). Compared to the control group at 3 months posttreatment, the patients in the test group had a greater reduction in pocket depth, better clinical attachment, and a significant reduction in Fn load [23Sigusch BW, Engelbrecht M, Völpel A, Holletschke A, Pfister W, Schütze J. Full-mouth antimicrobial photodynamic therapy in Fusobacterium nucleatum-infected periodontitis patients. J Periodontol 2010; 81(7): 975-81.[http://dx.doi.org/10.1902/jop.2010.090246] [PMID: 20350153] ].

3.1.7. FMD Combined with a Periodontal Dressing

Keestra et al. evaluated the effects of adding the use of a periodontal dressing (Coe-Pak® type) to the FMD protocol [24Keestra JAJ, Coucke W, Quirynen M. One-stage full-mouth disinfection combined with a periodontal dressing: A randomized controlled clinical trial. J Clin Periodontol 2014; 41(2): 157-63.[http://dx.doi.org/10.1111/jcpe.12199] [PMID: 24255934] ]. This approach resulted in a greater reduction in shallow and moderate-depth periodontal pockets. However, only deep pockets showed a tendency for improvement. According to the authors, this technique would provide additional short-term clinical benefit and would reduce postoperative pain [24Keestra JAJ, Coucke W, Quirynen M. One-stage full-mouth disinfection combined with a periodontal dressing: A randomized controlled clinical trial. J Clin Periodontol 2014; 41(2): 157-63.[http://dx.doi.org/10.1111/jcpe.12199] [PMID: 24255934] ].

4. DISCUSSION

The FMD concept has generated great enthusiasm over the last 20 years due to its many offered advantages. Indeed, FMD reduces both the number of sessions in the dental chair and the duration of the periodontal treatment. The shorter working time limits the risk of intraoral cross-contamination between treated and untreated sites [4Heitz-Mayfield LJA, Lang NP. Surgical and nonsurgical periodontal therapy. Learned and unlearned concepts. Periodontol 2000 2013; 62(1): 218-31.[http://dx.doi.org/10.1111/prd.12008] [PMID: 23574468] ], thereby allowing better control of the transmission of periodontopathogens between the bacterial niches. In addition, the FMD procedure is more comfortable and more economical for the patient and the practitioner. Since 1995, several modifications have been suggested to improve the effectiveness of FMD. These modifications include full-mouth treatment without CHX [6Quirynen M, Mongardini C, de Soete M, et al. The rôle of chlorhexidine in the one-stage full-mouth disinfection treatment of patients with advanced adult periodontitis. Long-term clinical and microbiological observations. J Clin Periodontol 2000; 27(8): 578-89.[http://dx.doi.org/10.1034/j.1600-051x.2000.027008578.x] [PMID: 10959784] -9Santos VR, Lima JA, Miranda TS, et al. Full-mouth disinfection as a therapeutic protocol for type-2 diabetic subjects with chronic periodontitis: twelve-month clinical outcomes: A randomized controlled clinical trial. J Clin Periodontol 2013; 40(2): 155-62.[http://dx.doi.org/10.1111/jcpe.12040] [PMID: 23305133] ], the extension of hygiene methods and an increase in the duration of posttreatment CHX use [5Bollen CML, Mongardini C, Papaioannou W, Van Steenberghe D, Quirynen M. The effect of a one-stage full-mouth disinfection on different intra-oral niches. Clinical and microbiological observations. J Clin Periodontol 1998; 25(1): 56-66.[http://dx.doi.org/10.1111/j.1600-051X.1998.tb02364.x] [PMID: 9477021] ], the replacement of CHX with other antiseptics [10Quirynen M, De Soete M, Boschmans G, et al. Benefit of “one-stage full-mouth disinfection” is explained by disinfection and root planing within 24 hours: A randomized controlled trial. J Clin Periodontol 2006; 33(9): 639-47.[http://dx.doi.org/10.1111/j.1600-051X.2006.00959.x] [PMID: 16856902] -13Cortelli SC, Cortelli JR, Holzhausen M, et al. Essential oils in one-stage full-mouth disinfection: Double-blind, randomized clinical trial of long-term clinical, microbial and salivary effects. J Clin Periodontol 2009; 36(4): 333-42.[http://dx.doi.org/10.1111/j.1600-051X.2009.01376.x] [PMID: 19426180] ], the addition of antibiotics [14Gomi K, Yashima A, Nagano T, Kanazashi M, Maeda N, Arai T. Effects of full-mouth scaling and root planing in conjunction with systemically administered azithromycin. J Periodontol 2007; 78(3): 422-9.[http://dx.doi.org/10.1902/jop.2007.060247] [PMID: 17335364] -22Fonseca DC, Cortelli JR, Cortelli SC, et al. Clinical and microbiologic evaluation of scaling and root planing per quadrant and one-stage full-mouth disinfection associated with azithromycin or chlorhexidine: A Clinical Randomized Controlled Trial. J Periodontol 2015; 86(12): 1340-51.[http://dx.doi.org/10.1902/jop.2015.150227] [PMID: 26252751] ] or probiotics [21Teughels W, Durukan A, Ozcelik O, Pauwels M, Quirynen M, Haytac MC. Clinical and microbiological effects of Lactobacillus reuteri probiotics in the treatment of chronic periodontitis: A randomized placebo-controlled study. J Clin Periodontol 2013; 40(11): 1025-35.[http://dx.doi.org/10.1111/jcpe.12155] [PMID: 24164569] ], the use of photodynamic therapy [23Sigusch BW, Engelbrecht M, Völpel A, Holletschke A, Pfister W, Schütze J. Full-mouth antimicrobial photodynamic therapy in Fusobacterium nucleatum-infected periodontitis patients. J Periodontol 2010; 81(7): 975-81.[http://dx.doi.org/10.1902/jop.2010.090246] [PMID: 20350153] ], and the use of a periodontal dressing [24Keestra JAJ, Coucke W, Quirynen M. One-stage full-mouth disinfection combined with a periodontal dressing: A randomized controlled clinical trial. J Clin Periodontol 2014; 41(2): 157-63.[http://dx.doi.org/10.1111/jcpe.12199] [PMID: 24255934] ]. FMD without CHX reduced the outcomes of the clinical results, suggesting an important but prudently selected use for the protocol [7Apatzidou DA, Riggio MP, Kinane DF. Quadrant root planing versus same-day full-mouth root planing. II. Microbiological findings. J Clin Periodontol 2004; 31(2): 141-8.[http://dx.doi.org/10.1111/j.0303-6979.2004.00462.x] [PMID: 15016040] ]. The use of CHX for longer than 15 days is unnecessary because of the undesirable side effects that are normally associated with prolonged CHX exposure. Similarly, a beneficial clinical effect, especially in the depth of deep periodontal pockets, is obtained when antibiotics are added to the FMD protocol [14Gomi K, Yashima A, Nagano T, Kanazashi M, Maeda N, Arai T. Effects of full-mouth scaling and root planing in conjunction with systemically administered azithromycin. J Periodontol 2007; 78(3): 422-9.[http://dx.doi.org/10.1902/jop.2007.060247] [PMID: 17335364] -22Fonseca DC, Cortelli JR, Cortelli SC, et al. Clinical and microbiologic evaluation of scaling and root planing per quadrant and one-stage full-mouth disinfection associated with azithromycin or chlorhexidine: A Clinical Randomized Controlled Trial. J Periodontol 2015; 86(12): 1340-51.[http://dx.doi.org/10.1902/jop.2015.150227] [PMID: 26252751] ]. However, there is no consensus on the value of supplementing FMD with antibiotic therapy in the treatment of severe chronic periodontitis. The other modifications have shown very good results, although their increased effectiveness does not reach significance when compared to the conventional treatment. According to the articles included in this review, the results obtained with FMD and its variants are not maintained over the long term; the results of the FMD approach and its variants are equivalent to those of the conventional quadrant approach [25Eberhard J, Jepsen S, Jervøe-Storm PM, Needleman I, Worthington HV. Full-mouth disinfection for the treatment of adult chronic periodontitis. Cochrane Database Syst Rev 2008; (1): CD004622.[http://dx.doi.org/10.1002/14651858.CD004622.pub2] [PMID: 18254056] ]. Additionally, with FMD, the number of sessions is reduced, but the sessions are longer and more tiring. Thus, the criteria for choosing the FMD treatment method will depend on the habits and experience of the practitioner, the management of the planning phase and appointments of the practice, and patient availability, compliance, and preference.

CONCLUSION AND PERSPECTIVES

At the end of the 1990s, the FMD concept was considered the best approach for periodontal treatment to avoid the reinfection of the already treated periodontal pockets [3van Winkelhoff AJ, van der Velden U, de Graaff J. Microbial succession in recolonizing deep periodontal pockets after a single course of supra- and subgingival debridement. J Clin Periodontol 1988; 15(2): 116-22.[http://dx.doi.org/10.1111/j.1600-051X.1988.tb01004.x] [PMID: 3279070] , 4Heitz-Mayfield LJA, Lang NP. Surgical and nonsurgical periodontal therapy. Learned and unlearned concepts. Periodontol 2000 2013; 62(1): 218-31.[http://dx.doi.org/10.1111/prd.12008] [PMID: 23574468] ]. Over the years, several modifications to improve the effectiveness of FMD have been suggested. The majority of the studies have demonstrated that the results obtained with FMD and its variants are equivalent to those obtained with the conventional quadrant method. The FMD concept is based on a plausible scientific rationale. Currently, the selection of this technique remains empirical and depends on the preferences of the practitioner and the patient. Indeed, the selection of the FMD technique cannot be based on its greater effectiveness since the majority of the clinical studies have shown it is possible to obtain results equivalent to those obtained with the conventional method with any variant of the FMD technique.

The future of this technique will depend on the progress of research in personalized medicine, microbiology and inflammation. The diversity in the genetic, infectious and immunologic subtypes of periodontal disease argues in favor of personalized therapy. A better knowledge of the oral microbiota and the host response may allow greater precision in defining the indications for FMD. The analysis of the bacterial load, the bacterial composition, and the quality of the inflammatory response will facilitate the design of clinical studies to determine the clinical situations in which this technique could be beneficial. On the other hand, periodontal classification is based almost exclusively on clinical characteristics and offers very limited therapeutic guidance and little evidence of actually improving periodontal care.

In the classification of periodontal disease, it would be interesting to include parameters based on the nature of the periodontal pathology and the general state of health of the patient; such parameters could guide therapeutic choices, for example, the indication for antibiotic therapy as an addition to FMD.

Finally, the concurrent delivery of high-quality periodontal health care and reduction in treatment cost is an obvious challenge, but the FMD technique, which makes it possible to optimize the duration of treatment, could contribute to a reduction in treatment cost and could thus facilitate patient care.

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

The author declared no conflict of interest, financial or otherwise

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

[1] Westfelt E, Rylander H, Dahlén G, Lindhe J. The effect of supragingival plaque control on the progression of advanced periodontal disease. J Clin Periodontol 1998; 25(7): 536-41.[http://dx.doi.org/10.1111/j.1600-051X.1998.tb02484.x] [PMID: 9696252]
[2] Quirynen M, Bollen CM, Vandekerckhove BN, Dekeyser C, Papaioannou W, Eyssen H. Full- vs. partial-mouth disinfection in the treatment of periodontal infections: Short-term clinical and microbiological observations. J Dent Res 1995; 74(8): 1459-67.[http://dx.doi.org/10.1177/00220345950740080501] [PMID: 7560400]
[3] van Winkelhoff AJ, van der Velden U, de Graaff J. Microbial succession in recolonizing deep periodontal pockets after a single course of supra- and subgingival debridement. J Clin Periodontol 1988; 15(2): 116-22.[http://dx.doi.org/10.1111/j.1600-051X.1988.tb01004.x] [PMID: 3279070]
[4] Heitz-Mayfield LJA, Lang NP. Surgical and nonsurgical periodontal therapy. Learned and unlearned concepts. Periodontol 2000 2013; 62(1): 218-31.[http://dx.doi.org/10.1111/prd.12008] [PMID: 23574468]
[5] Bollen CML, Mongardini C, Papaioannou W, Van Steenberghe D, Quirynen M. The effect of a one-stage full-mouth disinfection on different intra-oral niches. Clinical and microbiological observations. J Clin Periodontol 1998; 25(1): 56-66.[http://dx.doi.org/10.1111/j.1600-051X.1998.tb02364.x] [PMID: 9477021]
[6] Quirynen M, Mongardini C, de Soete M, et al. The rôle of chlorhexidine in the one-stage full-mouth disinfection treatment of patients with advanced adult periodontitis. Long-term clinical and microbiological observations. J Clin Periodontol 2000; 27(8): 578-89.[http://dx.doi.org/10.1034/j.1600-051x.2000.027008578.x] [PMID: 10959784]
[7] Apatzidou DA, Riggio MP, Kinane DF. Quadrant root planing versus same-day full-mouth root planing. II. Microbiological findings. J Clin Periodontol 2004; 31(2): 141-8.[http://dx.doi.org/10.1111/j.0303-6979.2004.00462.x] [PMID: 15016040]
[8] Swierkot K, Nonnenmacher CI, Mutters R, Flores-de-Jacoby L, Mengel R. One-stage full-mouth disinfection versus quadrant and full-mouth root planing. J Clin Periodontol 2009; 36(3): 240-9.[http://dx.doi.org/10.1111/j.1600-051X.2008.01368.x] [PMID: 19236536]
[9] Santos VR, Lima JA, Miranda TS, et al. Full-mouth disinfection as a therapeutic protocol for type-2 diabetic subjects with chronic periodontitis: twelve-month clinical outcomes: A randomized controlled clinical trial. J Clin Periodontol 2013; 40(2): 155-62.[http://dx.doi.org/10.1111/jcpe.12040] [PMID: 23305133]
[10] Quirynen M, De Soete M, Boschmans G, et al. Benefit of “one-stage full-mouth disinfection” is explained by disinfection and root planing within 24 hours: A randomized controlled trial. J Clin Periodontol 2006; 33(9): 639-47.[http://dx.doi.org/10.1111/j.1600-051X.2006.00959.x] [PMID: 16856902]
[11] Wang D, Koshy G, Nagasawa T, et al. Antibody response after single-visit full-mouth ultrasonic debridement versus quadrant-wise therapy. J Clin Periodontol 2006; 33(9): 632-8.[http://dx.doi.org/10.1111/j.1600-051X.2006.00963.x] [PMID: 16856899]
[12] Cavalca Cortelli S, Cavallini F, Regueira Alves MF, Alves Bezerra A Jr, Queiroz CS, Cortelli JR. Clinical and microbiological effects of an essential-oil-containing mouth rinse applied in the “one-stage full-mouth disinfection” protocol: A randomized doubled-blinded preliminary study. Clin Oral Investig 2009; 13(2): 189-94.[http://dx.doi.org/10.1007/s00784-008-0219-3] [PMID: 18716800]
[13] Cortelli SC, Cortelli JR, Holzhausen M, et al. Essential oils in one-stage full-mouth disinfection: Double-blind, randomized clinical trial of long-term clinical, microbial and salivary effects. J Clin Periodontol 2009; 36(4): 333-42.[http://dx.doi.org/10.1111/j.1600-051X.2009.01376.x] [PMID: 19426180]
[14] Gomi K, Yashima A, Nagano T, Kanazashi M, Maeda N, Arai T. Effects of full-mouth scaling and root planing in conjunction with systemically administered azithromycin. J Periodontol 2007; 78(3): 422-9.[http://dx.doi.org/10.1902/jop.2007.060247] [PMID: 17335364]
[15] Yashima A, Gomi K, Maeda N, Arai T. One-stage full-mouth versus partial-mouth scaling and root planing during the effective half-life of systemically administered azithromycin. J Periodontol 2009; 80(9): 1406-13.[http://dx.doi.org/10.1902/jop.2009.090067] [PMID: 19722790]
[16] Cionca N, Giannopoulou C, Ugolotti G, Mombelli A. Amoxicillin and metronidazole as an adjunct to full-mouth scaling and root planing of chronic periodontitis. J Periodontol 2009; 80(3): 364-71.[http://dx.doi.org/10.1902/jop.2009.080540] [PMID: 19254119]
[17] Cionca N, Giannopoulou C, Ugolotti G, Mombelli A. Microbiologic testing and outcomes of full-mouth scaling and root planing with or without amoxicillin/metronidazole in chronic periodontitis. J Periodontol 2010; 81(1): 15-23.[http://dx.doi.org/10.1902/jop.2009.090390] [PMID: 20059413]
[18] Varela VM, Heller D, Silva-Senem MX, Torres MCMB, Colombo APV, Feres-Filho EJ. Systemic antimicrobials adjunctive to a repeated mechanical and antiseptic therapy for aggressive periodontitis: A 6-month randomized controlled trial. J Periodontol 2011; 82(8): 1121-30.[http://dx.doi.org/10.1902/jop.2011.100656] [PMID: 21235333]
[19] Aimetti M, Romano F, Guzzi N, Carnevale G. One-stage full-mouth disinfection as a therapeutic approach for generalized aggressive periodontitis. J Periodontol 2011; 82(6): 845-53.[http://dx.doi.org/10.1902/jop.2010.100468] [PMID: 21091345]
[20] Preus HR, Gunleiksrud TM, Sandvik L, Gjermo P, Baelum V. A randomized, double-masked clinical trial comparing four periodontitis treatment strategies: 1-year clinical results. J Periodontol 2013; 84(8): 1075-86.[http://dx.doi.org/10.1902/jop.2012.120400] [PMID: 23106511]
[21] Teughels W, Durukan A, Ozcelik O, Pauwels M, Quirynen M, Haytac MC. Clinical and microbiological effects of Lactobacillus reuteri probiotics in the treatment of chronic periodontitis: A randomized placebo-controlled study. J Clin Periodontol 2013; 40(11): 1025-35.[http://dx.doi.org/10.1111/jcpe.12155] [PMID: 24164569]
[22] Fonseca DC, Cortelli JR, Cortelli SC, et al. Clinical and microbiologic evaluation of scaling and root planing per quadrant and one-stage full-mouth disinfection associated with azithromycin or chlorhexidine: A Clinical Randomized Controlled Trial. J Periodontol 2015; 86(12): 1340-51.[http://dx.doi.org/10.1902/jop.2015.150227] [PMID: 26252751]
[23] Sigusch BW, Engelbrecht M, Völpel A, Holletschke A, Pfister W, Schütze J. Full-mouth antimicrobial photodynamic therapy in Fusobacterium nucleatum-infected periodontitis patients. J Periodontol 2010; 81(7): 975-81.[http://dx.doi.org/10.1902/jop.2010.090246] [PMID: 20350153]
[24] Keestra JAJ, Coucke W, Quirynen M. One-stage full-mouth disinfection combined with a periodontal dressing: A randomized controlled clinical trial. J Clin Periodontol 2014; 41(2): 157-63.[http://dx.doi.org/10.1111/jcpe.12199] [PMID: 24255934]
[25] Eberhard J, Jepsen S, Jervøe-Storm PM, Needleman I, Worthington HV. Full-mouth disinfection for the treatment of adult chronic periodontitis. Cochrane Database Syst Rev 2008; (1): CD004622.[http://dx.doi.org/10.1002/14651858.CD004622.pub2] [PMID: 18254056]

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