FMD

1. Full Mouth Disinfection

2. Contents
Introduction
Disinfection
Rationale
Chlorhexidine
Aim of FMD concept
Advantages
Disadvantages
Evolution of FMD concept
 Full-mouth treatment with CHX
 Full-mouth treatment without CHX,
 The extension of hygiene and duration
of post treatment CHX use
 The replacement of antiseptics
 Supplementation with antibiotics,
 Probiotics
 Full-mouth antimicrobial
photodynamic therapy
 One-stage FMD combined with a
periodontal dressing
Conclusion

3. Introduction :
• The most common periodontal
diseases are plaque-induced
inflammatory condition that arise
as a result of interactions between
bacterial plaque and the host
immune and inflammatory
responses.

4.  The concept of bacterial specificity in periodontal infections has
become largely accepted.
 Three factors are currently considered for the establishment of an
active periodontal infection:
(1) a susceptible host,
(2) the presence of periodontopathogens, and
(3) the absence of beneficial Species.
Slots & Rams 1991

5. These interactions result in:
Loss of connective tissue attachment to the root surface;
Necrosis of root surface cementum;
Apical migration of the junctional epithelium;
Pocket formation; and
Further plaque biofilm developing in the subgingival environment.
Loss of supporting alveolar bone occurs, which may lead to
increased mobility and tooth loss

6. The conventional approach to
periodontal treatment is largely based
around the mechanical removal of
bacterial deposits from the teeth and
root surfaces.
This involves thorough subgingival
debridement to remove plaque and
calculus, decontamination of root
surfaces and disruption of the
subgingival biofilm.

7. What is Disinfection?

8. • Disinfection describes a process that eliminates many or all
pathogenic microorganisms, except bacterial spores, on inanimate
objects
-CDC

9. Rationale of Full Mouth
Disinfection

10. In the presence of adequate supragingival
plaque control, this initial cause-related
therapy allows resolution of inflammation
and a reduction in probing pocket depths.

11.  Pathogenic microrganisms also
colonize other intra-oral niches
such as the tonsils, the tongue, and
other mucous membranes.
 Since most periodontopathogens
colonize several niches in the oral
cavity (Van Winkelhoff et al.,
1986) and can be transmitted from
one site to another (Quirynen et al.,
1995).

12. In periodontitis patients, keypathogens such as
 Actinobacillus actinomycetemcomitans,
 Porphyromonas gingivalis and
 Prevotella intermedia
detected in all of the above mentioned niches existence of an intra-oral
translocation (from one niche to another) of periodontopathogens.
Saliva can be considered a major vehicle of transmission.
(Quirynen et al. 1996).

13.  The degree of elimination of the exogenous periodontopathogens,
was found to have a major impact on the treatment outcome
(Slots and Rams, 1990).Therefore, the target organisms during
periodontal therapy are the exogenous species.
 Also several pathogenic micro-organisms have been found to
spread subgingivally, including at sites without clinical loss of
periodontal attachment (Van Winkelhoff et al., 1994).

14.  Historically, the standard approach for delivering periodontal treatment
has been to undertake scaling and root planing in one quadrant at a time
over a series of appointments.
 A full-mouth disinfection in one session seems logical when compared
with the standard strategy (of quadrant-wise disinfection at several time
intervals).

15.  In QSRP, translocation occurs rapidly, recently scaled and root
planed pockets can be re-colonised by pathogenic bacteria from
remaining untreated pockets, or from other intraoral niches, before a
new and less pathogenic ecosystem has been established

16.  In order to reduce the chance for such a bacterial translocation, and
thereby prevent a re-infection by periodontal pathogens of previously
rootplaned pockets, a ‘‘one stage fullmouth’’ disinfection, obtained by
performing all scaling and root planing within 24 h together with a
repeated application of chlorhexidine to all intraoral niches, has been
introduced

17. Why
CHLORHEXIDINE??

18. Chlorhexidine
Second generation chemical plaque control agent
Highly bacteriostatic in nature
Also used as antiseptic in various specialities
Available in different forms for use

19. HISTORY
Developed in 1940s by Imperial Chemical Industries, England
Marketed in 1954 as antiseptic for skin wounds
 Later, widely used in medicine and surgery including obstetrics,
gynaecology, urology and pre-surgical skin preparation
In dentistry, initially as pre-surgical disinfectant of mouth and in
Endodontics

20. 1969 - Schroeder investigated Plaque inhibition by CHX
1970 - Loe and Schiott did a definitive study on it
Rinsing for 60 sec BD with 10ml of a 0.2% CHX solution
without normal tooth cleaning inhibits plaque regrowth and
development of gingivitis

21. Forms of chlorhexidine
WATER SOLUBLE
Digluconate
Acetate
SPARINGLY SOLUBLE
Hydrochloride

22. ON THE TOOTH SURFACE:
1) CHX gets attached to the salivary proteins and desquamated epithelial cells
Blocks acidic groups on salivary glycoproteins
Reduces glycoprotein adsorption on tooth surface
Prevents pellicle formation

23. 2) Prolonged antiseptic release
Bacteriostatic action that lasts for more than 12 hours
Prevents the adsorption of bacterial cell wall on to the tooth surface
Prevents plaque formation

24. 3) Competes with calcium ions
Blocks agglutination of plaque
Prevents binding of mature plaque

26. ON THE BACTERIAL CELL MEMBRANE:
AT LOW CONCENTRATIONS:
CHX adheres to bacterial cell membrane
Binds to phospholipids in the inner cell membrane
Leakage of lesser molecular weight components
Sub lethal stage – reversible bacteriostatic action

27. Intracellular coagulation
Slows down leakage of intracellular components
Cytoplasmic coagulation
Irreversible cell damage [bactericidal]

28. Pin-cushion effect
 The dicationic CHX molecule, attaches to the tooth surface by one cation, to
the bacteria attempting to colonize the tooth surface with the other. This Is
called the Pin-Cushion effect.
 This prolongs the CHX action
 Its long bacteriostatic action lasting for about 12 hours in the oral cavity
after a single rinse .
 Hence CHX is well known for its substantivity.

29. ADVERSE EFFECTS
a) Extrinsic staining
b) Alteration in taste perception
c) Oral mucosal erosion
d) Enhanced supragingival calculus formation
e) Parotid gland swelling

30. Formulations
• Mouthrinses
• Sprays
• Gel
• Tooth paste
• Varnishes
• Local drug delivery.

31. Full Mouth Disinfection

32. Aim of FMD approach

33.  To avoid the potential rapid translocation of periodontal pathogens;
 To prevent the reinfection of previously treated sites by untreated
pockets or by other intraoral niches
Aim of FMD approach

34.  The reduced probability of an intra-oral transmission of
periodontopathogens from one of their niches to the subgingival
environment of treated teeth.
 A more efficient way of delivering treatment
 Fewer treatment sessions
 Lower cost
 Less surgery needs
Advantages

35. Disadvantages
Carrying out all treatment over one or two sessions for a full-mouth
disinfection procedure does not provide as frequent opportunities for
patient motivation and oral hygiene monitoring as conventional
treatment.
Some patients also find it difficult to tolerate the long appointments
necessary for full-mouth procedures.
Multiple separate review appointments may not always be possible.

36. Evolution of FMD CONCEPT

37. Since the FMD technique was first described, a total of 8 modified protocols:
1) Full-mouth treatment with CHX
2) Full-mouth treatment without CHX,
3) The extension of hygiene methods and an increase in the duration of
posttreatment CHX use
4) The replacement of CHX with other antiseptics
5) Supplementation with antibiotics,
6) Probiotics
7) Full-mouth antimicrobial photodynamic therapy and
8) One-stage FMD combined with a periodontal dressing

38. Full-mouth treatment with CHX

39. For maximal disinfection, the new protocol combined:
(1) The scaling and root planing of all teeth within 24 hours to disrupt and
reduce the number of subgingival pathogenic organisms (Mousques et al.,
1980; Walsh et al., 1986; Loos et at., 1988);

40. (2) Brushing the dorsum of the tongue with a 1% chlorhexidine gel for 1
minute;

41. (3) Rinsing the mouth twice for one min and gargling for final 10 secs
with a 0.2% chlorhexidine solution to reduce the number of bacteria in
the saliva and on the tonsils (Rindom et al., 1976);

42. (4) Irrigating all pockets with a 1% chlorhexidine gel (3x in 10 min to
increase the contact time) immediately after each of the 2 sessions and 8
days later to reduce (up to 99%) the number of remaining bacteria
(oosterwaal et al., 1991);

43. (5) Twice-daily rinsing with 10 ml of 0.2 % chlorhexidine for two weeks
and use brushing aids to retard the subgingival re-establishment of
pathogenic species (Magnusson et al., 1984).

44. FULL MOUTH TREATMENT
WITHOUT CHX

45. FULL MOUTH TREATMENT WITHOUT
CHX
• The question remained, however, whether the benefits of a one stage
full mouth disinfection were
Due to the use of the chlorhexidine (preventing a re-infection from
other intra- oral niches) or
Because of the one stage scaling and root planing (preventing re-
infection from remaining untreated pockets and/or the
immunological consequences of such an approach).

46.  The one stage full-dentition scaling and root planing is the key factor to
the additional clinical and microbiological improvements over a classical
stepwise periodontal therapy.

47.  This might be due to the elimination of the gross of the periodontopathogens
from the pocket with
 Mechanical debridement (indicating that the pockets are important
reservoirs for the colonization of the oral cavity by
periodontopathogens) and/or
 Due to an acute immunological reaction at the second day of the
treatment (a schwartzman or vaccine reaction).
 The adjunctive disinfection with chlorhexidine can be advisable because it
will result in a faster initial healing and offers additional effects in less
complying patients.

48.  Quirynen et al. (2000)
FMD > FMS alone > QRSP:
More reduction of PPD and CAL gain in FMD.
Spirochetes were significantly decreased only in FMD.
 Apatzidou et al. 2004 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

49. Extension of Hygiene Methods

50. Extension of Hygiene Methods and Increased
Duration of Post treatment 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
• 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

51. The extended time of CHX use was associated with adverse events such
as tooth staining, taste changing, and difficulties in patients’ adherence
and side effects over the course of 60 days.

52. Replacement of CHX with other
Types of Antiseptics

53. Replacement of CHX with other Types of
Antiseptics
• Amine fluorides
• Povidone iodine
• Essential oils

54. Full-mouth scaling and root planing (the entire dentition in two visits
within 24 h, i.e. two consecutives mornings) under local anaesthesia.
Followed by rubbing the dorsum of tongue with a sterilized cotton
swab soaked with 0.2 ml of Listerine for 1min.
Mouth rinsing twice with 20 ml of essential oils mouthrinses for 30 s
(during the last 10 s, the subject had to gargle)

55. Subgingival irrigation of all pockets three times within 10 min. with
essential oils mouthrinses (5 ml/ irrigation/pocket) after sessions of
scaling and root planing.
Mouth rinsing at home with 20 ml of essential oils mouthrinses twice
daily for 30 s for the following 2 months.
Oral hygiene instructions including tooth brushing, flossing or inter-
dental cleaning with inter-dental brushes and tongue brushing.

56. Supplementation with Antibiotics

57. Supplementation with Antibiotics
• Azithromicin
• Amoxicillin and metronidazole
• Metronidazole alone

58. AZITHROMYCIN
In 2007, Gomi et al, that the addition of AZT to the FMD protocol
was clinically and microbiologically effective.
The choice of AZ as an adjuvant to the non-surgical periodontal
therapy was based on the following characteristics: its broad spectrum
of action, fast leukocyte and fibroblast absorption, slow release in soft
tissues, and reduced number of days of intake, which can contribute to
patients’ adherence.

59. Metronidazole
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. At 6
months, Cionca et al. observed a greater reduction in the depth of deep
pockets and the elimination of Aa.

60. 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).
Preus et al. evaluated the efficacy of the addition of MTZ
monotherapy (400mg) to the FMD protocol They reported that the
addition of MTZ increased clinical attachment gains and reduced
pocket depth.

61. Addition of Probiotics

62. Addition of Probiotics
The presence of pathogenic bacteria, the absence of so-called
“beneficial bacteria” and the susceptibility of the host are the main
aetiological factors of periodontal diseases.
Teughels et al. Lactobacillus reuteri lozenges twice daily for 12 weeks
difference which could be confirmed at a level of significance was the
lower number P. gingivalis species.
Also, Iniesta et al. (2012) reported this effect.

63. Full-mouth Antimicrobial
Photodynamic Therapy

64. A new, alternative method of adjunctive antimicrobial treatment is
provided by photodynamic therapy (PDT), which involves the use of a
photosensitizer (PS) that is activated by exposure to light of a specific
wavelength in the presence of oxygen.
Full-mouth Antimicrobial Photodynamic
Therapy

65. • The exposure of the PS to light
results in the formation of oxygen
species such as singlet oxygen and
free radicals, the antimicrobial
effects of which are Known PDT
was performed with two chlorine-
based sensitizers and BLC1010,
followed by illumination with a
diode laser (wavelength: 662 nm).

66. Sigush et al in 2010. conducted a study to evaluate the efficacy of
dynamic phototherapy in addition to FMD on the eradication of
Fusobacterium nucleatum.
Compared to the control group at 3 months post treatment, the patients
in the test group had a greater reduction in pocket depth, better clinical
attachment, and a significant reduction in Fn load.

67. • The antimicrobial effect of the PDT method is based on the
combination of a blue PS with laser light with a 660-nmwavelength.
Soft diode laser and a phenothiazine chloride PS solution.
• A fiber-optic applicator with a 0.6-mmdiameter was used as a laser
applicator to direct the laser light into the gingival crevice or the
periodontal pocket.
• The power density measured at the surface of that laser applicator was
60 mW/cm2.

69. The PS solution was applied by placing the cannula tip of the PS
applicator to the bottom of the periodontal pocket and delivered
continuously during the removal of the tip toward the coronal side, and
the upper surface of the tongue was wetted with PS solution.
After an action time of 1 minute, the excess was removed by careful
rinsing of all sites with physiologic saline solution.

70. Immediately thereafter, six sites of each tooth were irradiated. Each site was
exposed to the laser light using the fiber-optic applicator for 10 seconds for
a total of 1 minute per tooth.
This was carried out as a full-mouth treatment that covered all teeth and the
tongue. The tongue was irradiated in six segments, each for 10 seconds.
Control subjects were also treated with the PS solution but without laser
irradiation

71. FMD Combined with a
Periodontal Dressing

72. FMD Combined with a Periodontal Dressing
Keestra et al (2014). evaluated the effects of adding the use of a
periodontal dressing (Coe-Pak® type) for 7 days to the FMD protocol.
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

73. Conclusion
Full-mouth Disinfection carried out within a single day can be a very
efficient way to deliver initial periodontal therapy in patients with
reliable plaque control