CLEAN&SEAL – Therapy for periodontitis, mucostits and periimplantitis

WHY USE CLEAN&SEAL® FOR PERIODONTITIS, MUCOSITIS, AND PERIIMPLANTITIS?

Current established non-surgical subgingival treatments might not show satisfying, long-lasting improvement of clinical parameters in case of severe periodontitis, mucositis and periimplantitis. In recent clinical studies, the non-surgical treatment of deep persistent pockets with the CLEAN&SEAL concept was presented showing rapid improvement of clinical parameters, so that invasive surgical intervention can be delayed or even completely avoided. [4,19, 22,26,27]

8 CHALLENGES OF THERAPIES FOR PERIODONTITIS, MUCOSITIS, AND PERIIMPLANTITIS

Despite careful post-operative oral hygiene protocols, deep periodontal and peri-implant pockets and inflammatory reactions may persist, leading to the resorption of tissues [1] and thus contributing to the risk of bone loss [2]. The challenges to be addressed are :

Removal of the bacterial load from soft tissue and tooth/implant surface without hurting further healthy tissues.

Preserve the root/implant surfaces facilitating cellular adhesion for its proliferation.

Removal of the biofilm composed of a persistent matrix encapsulating a bacterial load.

Restore the bacterial symbiosis.

Remove granulated tissue without impacting healthy tissue and as mini-invasively as possible.

Protect the oral wound from further bacterial aggression during the healing phases.

Accelerate soft and hard tissue regeneration to reduce Pocket Depth, increase Clinical Attachment, limit Gingival Recession, and stop bleeding on probing.

Removal of biofilm and granulated tissue are prerequisites for periodontal and peri-implant wound healing.

CLEAN&SEAL® EXPERTS

CLEAN&SEAL®: THE TWO-STEP PROCESS FOR PERIODONTAL AND PERI-IMPLANT INFECTIONS

CLEANing step with A²H gel (after 60 seconds):

  • In comparison to chlorhexidine, A²H reduces pocket depth (PD) and increases clinical attachment (CAL) to limit tissue recession [17]
  • Facilitates periodontal and peri-implant site decontamination [17]
  • Breaks the biofilm matrix down and reduces the bacterial load [11]
  • Facilitates the separation of the granulated tissues from healthy tissues [18]
  • With a 0.5% concentration, the A²H is gentle to the tissues, tooth- and implant surface and effective against the biofilm [16]

Perisolv Schmidlin et al 2016

SEALing step with xHyA before the patient leaves:

  • Enhances cell adhesion and regeneration of the periodontium leading to shallower pockets (PD) and better clinical attachment (CAL) [4,19,21,22]
  • Bacteriostatic properties protect the decontaminated wound for healing [7,9]
  • Speeding-up pocket closure through blood clot stabilization and growth factor attraction [20]
  • Supports soft tissue and bone regeneration [9–15]
  • Adhesive gel, easy to apply especially in contact with blood

Diehl et al 2022_Clean&Seal

The synergies of CLEAN&SEAL are that A²H and xHyA, both enhance cellular adhesion [16,26] for better regeneration of hard and soft tissues. While SEALing speeds the healing and protects the oral wound, the crosslinked hyaluronic acid (xHyA) enhances the effects of CLEANing: the diluted gel of amino acids with sodium hypochlorite (A²H), is tough against biofilm, bacteria, and granulated tissue while staying gentle to healthy tissues and root/implant surfaces.   

HOW TO APPLY CLEAN&SEAL® ?

CASE REPORT : MODERATE PERI-IMPLANTITIS TREATED WITH CLEAN&SEAL®

Treatment of moderate periimplantitis Dr Thomas Liechti with CLEAN&SEAL

Treatment of severe periimplantitis Dr Thomas Liechti with CLEAN&SEAL

CASE REPORT : MUCOSITIS TREATED WITH CLEAN&SEAL®

Treatment of mucositis by Dr Marisa Roncati with A²H and xHyA

CASE REPORT : SEVERE PERIODONTITIS TREATED WITH CLEAN&SEAL®

Treatment of severe periodontitis by Prof Anton Friedmann with A²H and xHyA

SCIENTIFIC LITERATURE & CLINICAL STUDIES

  1. Page RC, Kornman KS. The pathogenesis of human periodontitis: an introduction. Periodontol 2000. 1997 Jun;14:9-11. doi: 10.1111/j.1600-0757.1997.tb00189.x. PMID: 9567963.
  2. Renvert S, Lessem J, Dahlén G, Lindahl C, Svensson M. Topical minocycline microspheres versus topical chlorhexidine gel as an adjunct to mechanical debridement of incipient peri-implant infections: a randomized clinical trial. J Clin Periodontol. 2006 May;33(5):362-9. doi: 10.1111/j.1600-051X.2006.00919.x. PMID: 16634959.
  3. Sanz M, Herrera D, Kebschull M, Chapple I, Jepsen S, Beglundh T, Sculean A, Tonetti MS; EFP Workshop Participants and Methodological Consultants. Treatment of stage I-III periodontitis-The EFP S3 level clinical practice guideline. J Clin Periodontol. 2020 Jul;47 Suppl 22(Suppl 22):4-60. doi: 10.1111/jcpe.13290. Erratum in: J Clin Periodontol. 2021 Jan;48(1):163. PMID: 32383274; PMCID: PMC7891343.
  4. Diehl, D.; Friedmann, A.; Liedloff, P.; Jung, R.M.; Sculean, A.; Bilhan, H. Adjunctive Application of Hyaluronic Acid in Combination with a Sodium Hypochlorite Gel for Non-Surgical Treatment of Residual Pockets Reduces the Need for Periodontal Surgery—Retrospective Analysis of a Clinical Case Series. Materials 2022, 15, 6508. https://doi.org/10.3390/ma15196508
  5. Jepsen S, Berglundh T, Genco R, Aass AM, Demirel K, Derks J, Figuero E, Giovannoli JL, Goldstein M, Lambert F, Ortiz-Vigon A, Polyzois I, Salvi GE, Schwarz F, Serino G, Tomasi C, Zitzmann NU. Primary prevention of peri-implantitis: managing peri-implant mucositis. J Clin Periodontol. 2015 Apr;42 Suppl 16:S152-7. doi: 10.1111/jcpe.12369. PMID: 25626479.
  6. Costa FO, Takenaka-Martinez S, Cota LO, Ferreira SD, Silva GL, Costa JE. Peri-implant disease in subjects with and without preventive maintenance: a 5-year follow-up. J Clin Periodontol. 2012 Feb;39(2):173-81. doi: 10.1111/j.1600-051X.2011.01819.x. Epub 2011 Nov 23. PMID: 22111654.
  7. Pirnazar P, Wolinsky L, Nachnani S, Haake S, Pilloni A, Bernard GW. Bacteriostatic effects of hyaluronic acid. J Periodontol. 1999 Apr;70(4):370-4. doi: 10.1902/jop.1999.70.4.370. PMID: 10328647.
  8. Jurczyk K, Nietzsche S, Ender C, Sculean A, Eick S. In-vitro activity of sodium-hypochlorite gel on bacteria associated with periodontitis. Clin Oral Investig. 2016 Nov;20(8):2165-2173. doi: 10.1007/s00784-016-1711-9. Epub 2016 Jan 12. PMID: 26759339.
  9. Rajan P et al. Universal Research Journal of Dentistry. 2013;3:113.
  10. King, S.R., Hickerson, W.L. and Proctor, K.G. (1991) Beneficial Actions of Exogenous Hyaluronic Acid on Wound Healing. Surgery, 109, 76-86.
  11. Yıldırım S, Özener HÖ, Doğan B, Kuru B. Effect of topically applied hyaluronic acid on pain and palatal epithelial wound healing: An examiner-masked, randomized, controlled clinical trial. J Periodontol. 2018;89(1):36-45. doi:10.1902/jop.2017.170105
  12. Pilloni A, Schmdlin PR, Sahrmann P, Sculean A, Rojas MA. ‘Effectiveness of adjunctive hyaluronic acid application in coronally advanced flap in Miller class I single gingival recession sites: a randomized controlled clinical trial, Clinical Oral Investigations, 2018 https://doi.org/10.1007/s00784-018-2537-4
  13. Mueller A, Fujioka-Kobayashi M, Mueller HD, Lussi A, Sculean A, Schmidlin PR, Miron RJ. Effect of hyaluronic acid on morphological changes to dentin surfaces and subsequent effect on periodontal ligament cell survival, attachment, and spreading. Clin Oral Investig. 2017 May;21(4):1013-1019. doi: 10.1007/s00784-016-1856-6. Epub 2016 May 19. PMID: 27194052.1
  14. Asparuhova M, Chappuis V, Stähli A, Buser D, Sculean A, ‘Role of hyaluronan in regulating self-renewal and osteogenic differentiation of mesenchymal stromal cells and pre-osteoblasts, Clin Oral Investig. 2020 Mar 31. doi: 10.1007/s00784-020-03259-8.
  15. Asparuhova M, Kiryak D, Eliezer M, Mihov D, Sculean A. ‘Activity of two hyaluronan preparations on primary human oral fibroblasts’.J Periodontal Res 2018 Sep 27. Epub 2018 Sep 27
  16. Schmidlin PR, Fujioka-Kobayashi M, Mueller HD, Sculean A, Lussi A, Miron RJ. Effects of air polishing and an amino acid buffered hypochlorite solution to dentin surfaces and periodontal ligament cell survival, attachment, and spreading. Clin Oral Investig. 2017 Jun;21(5):1589-1598. doi: 10.1007/s00784-016-1950-9. Epub 2016 Sep 5. PMID: 27596604.
  17. Radulescu V, Boariu MI, Rusu D, Roman A, Surlin P, Voicu A, Didilescu AC, Jentsch H, Siciliano VI, Ramaglia L, Vela O, Kardaras G, Sculean A, Stratul SI. Clinical and microbiological effects of a single application of sodium hypochlorite gel during subgingival re-instrumentation: a triple-blind randomized placebo-controlled clinical trial. Clin Oral Investig. 2022 Nov;26(11):6639-6652. doi: 10.1007/s00784-022-04618-3. Epub 2022 Jul 12. PMID: 35829773.
  18. Arvidson A.Thesis (ISBN: 91-628-5882), University of Gothenburg, Sweden. 2003.
  19. Eliezer M, Imber JC, Sculean A, Pandis N, Teich S, ‘Hyaluronic acid as adjunctive to non-surgical and surgical periodontal therapy: a systematic review and meta-analysis’, Clin O Inv 2019; doi: s00784-019-03012-w
  20. Graves DT, Oates T, Garlet GP. Review of osteoimmunology and the host response in endodontic and periodontal lesions. J Oral Microbiol. 2011 Jan 17;3. doi: 10.3402/jom.v3i0.5304. PMID: 21547019; PMCID: PMC3087239.
  21. Iorio-Siciliano V, Ramaglia L, Isola G, Blasi A, Salvi GE, Sculean A. Changes in clinical parameters following adjunctive local sodium hypochlorite gel in minimally invasive nonsurgical therapy (MINST) of periodontal pockets: a 6-month randomized controlled clinical trial. Clin Oral Investig. 2021 Sep;25(9):5331-5340. doi: 10.1007/s00784-021-03841-8. Epub 2021 Mar 9. PMID: 33687555; PMCID: PMC8370947.
  22. Guarnelli ME, Vecchiatini R, Farina R. ‘Professional local administration of chloramine-based treatment in conjunction with ultrasonic mechanical instrumentation: clinical outcomes in patients with deep periodontal pockets persisting following active non-surgical therapy’ Minerva Stomatologia, 2015; 64 suppl.1(2): 158-159
  23. Nobis, B.; Ostermann, T.; Weiler, J.; Dittmar, T.; Friedmann, A. Impact of Cross-Linked Hyaluronic Acid on Osteogenic Differentiation of SAOS-2 Cells in an Air-Lift Model. Materials 2022, 15, 6528. https:// doi.org/10.3390/ma15196528
  24. Husseini B, Friedmann A, Wak R, Ghosn N, Khoury G, El Ghoul T, Abboud CK, Younes R. Clinical and radiographic assessment of cross-linked hyaluronic acid addition in demineralized bovine bone based alveolar ridge preservation: A human randomized split-mouth pilot study. J Stomatol Oral Maxillofac Surg. 2023 Feb 16;124(4):101426. doi: 10.1016/j.jormas.2023.101426. Epub ahead of print. PMID: 36801259.
  25. Bach et al. Implants 2016
  26. Ramanauskaite E, Machiulskiene V, Dvyliene UM, Eliezer M, Sculean A. Clinical Evaluation of a Novel Combination of Sodium Hypochlorite/Amino Acid and Cross-linked Hyaluronic Acid Adjunctive to Non-surgical Periodontal Treatment: A Case Series. Oral Health Prev Dent. 2023 Jul 13;21(1):279-284. doi: 10.3290/j.ohpd.b4347453. PMID: 37724897.
  27. Ramanauskaite E, Machiulskiene V, Shirakata Y, Dvyliene UM, Nedzelskiene I, Sculean A. Clinical evaluation of sodium hypochlorite/amino acids and cross-linked hyaluronic acid adjunctive to non-surgical periodontal treatment: a randomized controlled clinical trial. Clin Oral Investig. 2023 Nov;27(11):6645-6656. doi: 10.1007/s00784-023-05271-0. Epub 2023 Sep 23. PMID: 37740107; PMCID: PMC10630230.