RU2561890C2 - Method of treating patients with periodontitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to dentistry, and can be applied for treatment of periodontitis in patients. For this purpose, first, removal of supra- and subgingival dental plagues is performed by ultrasonic apparatus "PerioScan" simultaneously with antiseptic processing with solution "Octenisept" in dilution 1:10. Polishing of teeth by sand-blast apparatus "AirnGo" is carried out, with application of glycine-based powder. Teeth polishing and removal of supra- and subgingival dental plagues are carried out one timebefore carrying out first procedure of photodynamic therapy (PDT). After that, 1%. gel Radodent for carrying out of PDT is introduced into 5 or more mm deep periodontal recesses on their entire length. Laser impact is realised by diode laser in pulse mode at wavelength 662 nm, power - 0.3 W, energy density - 75 J/cm². Light guide is submerged for the entire depth of periodontal recesses. Impact is carried out for not more than 2 minutes per one area of inflammation. The total time of procedure constitutes 14-30 minutes. Treatment course includes 3 procedures, carried out every second day. On days between PDT procedures processing of gingival with gel with bactriophages "Phagodent" is carried out twice per day with 8-10 minutes gel exposure. After finishing PDT procedures phage therapy is continued for 5-7 days.

EFFECT: method ensures high efficiency of treatment and durative remission of disease due to suppression of pathogenic microflora as a result of photosensitiser distribution on bottom and walls of periodontal recess and bringing radiation source directly to pathological locus, increase of laser irradiation absorption in deep layers, as well as due to recovery of oral cavity microflora balance with absence of side effects.

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Description

The invention relates to medicine, namely to dentistry, and can be used to treat patients with periodontitis.

Currently, one of the most common treatments for periodontitis patients is photodynamic therapy (PDT).

The method of suppressing pathogenic microflora, developed by the authors Risovannaya ON, Risovannom S.I., Masychev V.I. and protected by patent [RU 2258546, 2004], can be used in the treatment of various inflammatory diseases, including in the treatment of periodontitis. The method consists in photodynamic therapy. Radachlorin is administered in the form of a gel, contacting superficially at a concentration of 0.1% and a dose of 0.1 g of gel / cm ^{2 of the} surface of the pathological lesion or in the form of a solution with a concentration of 56 μM at the rate of 0.5 μg per 1 kg of patient weight inside the pathological lesion min irradiate the focus with a diode laser with an energy density of 100-200 J / cm ² , exposure from 3 to 30 minutes

This method avoids the risk of selection of resistant strains of pathogens and allergization of the patient. However, when using this method for the treatment of periodontitis of moderate and severe degrees of severity, not all patients can achieve the disappearance of all signs of inflammation and prolonged remission. The duration of remission is an average of 5-7 months.

In the method of treating chronic periodontitis, including oral sanitation, removal of dental plaque, selective grinding (polishing) of teeth, curettage of periodontal pockets and PDT, 1% Photoditazine gel is used. The gel "Photoditazine" is applied to the inflamed surfaces of the oral mucosa and periodontal pockets (at the rate of 0.1 ml per 1 cm ² surface) for 8-10 minutes. Then the gel is washed off and laser irradiated, the following laser settings are used: wavelength 662 nm, continuous mode, energy density 80-100 J / cm ² . [Medical technology “Photodynamic therapy of periodontal diseases”, registration certificate FS - 2006/062 dated May 05, 2006, applicant of CJSC “BETA-GRAND”, Authors: Krechina E.K., Efremova N.V. Central Research Institute of Dentistry of Roszdrav, p. 5-7].

The disadvantages of this method include the lack of effectiveness in periodontitis of moderate and severe degrees of severity and insufficient remission (9-10 months). Also, curettage is a surgical procedure that has strict indications and contraindications that do not always allow its conduct.

According to the closest technical essence, the method of treatment of periodontitis is selected as a prototype, which consists in the therapeutic complex treatment of teeth, which includes supragingival ultrasonic treatment of the tooth surface using the Pyezon-Master 400 apparatus, polishing the teeth using the Er-Flo S2 apparatus, subgingival treatment of tooth roots and sanitation of periodontal pockets with low-frequency ultrasound from the Vector apparatus, complete sanitation and closed curettage of periodontal pockets using a Prometey diode laser and phot dynamic therapy. PDT is carried out as follows: the drug Photoditazine (gel 1%) is applied to the inflamed surfaces of the oral mucosa and periodontal pockets for 8-10 minutes, then the gel is washed off and the periodontal pocket is irradiated with laser radiation using a light guide for 1-2 minutes (depending on pocket depth), using the following laser settings: wavelength 660 ± 5 nm, radiation power - 0.2 W, mode - continuous, total procedure time - up to 20-30 minutes. After the therapeutic complex dental treatment, starting from the next day, the patient is given a course of acupuncture, which includes acupuncture points E5 (da-in), E6 (jia-che), J24 (cheng-jian), GI4 (he-gu), E36 ( tsu-san-li). The exposure time for the points is 15-20 minutes. The course of treatment is 10 sessions. After completing the course of acupuncture, the patient is re-treated with subgingival treatment of the roots of the teeth and the sanitation of periodontal pockets with low-frequency ultrasound from the Vector apparatus. The method allows to increase the effectiveness of the treatment of chronic periodontitis, to extend remission from 9-10 to 12-14 months, to dispense with surgical methods of treating periodontitis due to the complex effect on all links of the pathogenesis of the disease [RU 2460491, 2012].

The disadvantages of the method chosen as a prototype include the complexity of the method and its pain associated with the implementation of acupuncture, which requires the consent of the patient, as well as the presence of a certificate allowing this type of activity, as well as a specially equipped office for this procedure. In addition, the implementation of acupuncture has the following contraindications [http://acupuncture-ru.nextohm.com/Meridians/Contraindications-to-acupuncture]:

- Benign and malignant neoplasms.

- Purple and other hemorrhagic disorders.

- Blood coagulation disorders, hereditary hemolytic anemia.

- Pregnancy.

- Acute infectious diseases and febrile conditions of unknown origin.

- Chronic infectious diseases at the time of exacerbation.

- Decompensated diseases of the heart, lungs and other internal organs.

- Active rheumatism.

- Venous thrombosis and embolism in the acute period.

- Physical overstrain.

- Acute inflammatory processes of the musculoskeletal system.

- Congenital malformations of the central nervous system.

- Frostbite and inflammatory processes of the auricle.

There is also an age limit of 75 years and older [http://www.tiensmed.ru/articles/ig55.html].

It is undesirable to combine acupuncture with x-ray therapy. The effect of x-rays on the body reduces the effectiveness of acupuncture for about six months after exposure. In such cases, in order to achieve the desired effect, it is necessary to appoint several times more procedures [http://www.minimumprice.ru/articles/protivopokazaniya_k_igloukaluvaniyu/].

The disadvantages of the prototype should also include the duration of the course of treatment - 10 sessions. It should also be noted that the repeated procedure “Vector” earlier than 21 days later, according to the literature, can contribute to impaired maturation of collagen fibers and the stabilization period after treatment [Herbert F. Wolf, Edith M. Rateytskhak, Klaus Rateytskhak Periodontology, M. "MEDpress-inform", 2008].

The technical result of the invention is the exclusion of acupuncture when performing a method of treating patients with periodontitis, which will make it possible to simplify the method, reduce pain during the procedure and expand the patient population due to the category of persons with contraindications for acupuncture, as well as reduce the number of procedures in the office, while maintaining the high treatment efficiency inherent in the prototype method, in particular the duration of remission.

The technical result of the invention is achieved by the fact that they carry out photodynamic therapy, including applying to the areas of inflammation a gel for photodynamic therapy, followed by exposure to this area of the diode laser of a red spectrum with an exposure time not exceeding 30 minutes. Before the first PDT procedure, removal of supra- and subgingival dental deposits and tooth polishing are performed once. The removal of supra- and subgingival dental deposits is carried out with the PerioScan ultrasound machine simultaneously with antiseptic treatment with Octenisept solution at a 1:10 dilution. Tooth polishing is carried out with an AirnGo sandblasting machine using glycine-based powder. The gel for photodynamic therapy is introduced, and the fiber is immersed to the entire depth of the periodontal pockets, using a 1% gel for PDT Radodent, and the gel is introduced into the periodontal pockets, the depth of which is 5 mm or more. Laser exposure is carried out by a diode laser "ALOD-01" with a power of 0.3 W in a pulsed mode, an energy density of 75 J / cm ² , not more than 2 minutes per area of inflammation. The course of treatment consists of 3 procedures that are carried out every other day, and on the days between PDT procedures, gum gel is independently treated with Fagodent bacteriophages twice a day with gel exposure of 8-10 minutes, and the first phage therapy is carried out the next day after PDT and continues 5 -7 days after completion of PDT procedures.

The method is as follows: after a thorough history taking, conducting additional research methods (determining the hygiene and bleeding index, periodontal pockets depth, performing an X-ray examination, a detailed blood test, determining glucose hemoglobin, Ca level, etc.) and analyzing them, the diagnosis is established - Chronic generalized periodontitis of moderate or severe severity. Once, before the first PDT procedure, a comprehensive dental treatment is carried out, which includes supra- and subgingival surface treatment of the teeth with a PerioScan ultrasound machine, Sirona Dental System GmBh, Germany at the same time as the antiseptic treatment with Octenisept in a 1:10 dilution. All tooth surfaces are polished using an AirnGo sandblasting machine, Satelec Acteon Group, France - Germany, using glycine-based Perio powder. At the same visit, or during the first 24 hours after professional hygiene, the patient undergoes the first procedure of photodynamic therapy. The area where the gel will be injected is isolated from saliva using cotton rolls and a saliva ejector, and is also additionally dried using air from a gun in a dental unit. Then, the first session of photodynamic therapy is carried out using a 1% Radodent gel and an APOD-01 diode laser. Photodynamic therapy is carried out as follows: 1% Radadent gel is introduced into the periodontal pockets, the depth of which is 5 mm or more, to their entire depth and with a slight excess for 20-25 minutes. Then, without washing off the gel, irradiation of periodontal pockets with laser radiation is carried out using a light guide, which is immersed to the entire depth of periodontal pockets and with its constant movement for no more than 2 minutes per section of inflammation. The following laser settings are used: wavelength 662 nm, radiation power - 0.3 W, energy density - 75 J / cm ² , pulse mode (pulse 0.10 s, interval - 0.10 s), total procedure time 14- 30 minutes. After the procedure, the excess gel is removed with a dry cotton swab. The patient is advised to refrain from drinking and eating food for 60 minutes after the procedure.

A syringe with a blunt twisting cannula containing 2 ml of gel with a bacteriophage (at the rate of 0.5-1.0 ml per procedure) is given to the patient’s hands. The day after the photodynamic procedure, the patient begins at home independently treating the gums with gel with bacteriophages "Fagodent" contact-surface from a syringe of the "record" type with a blunt needle in the area of all teeth twice a day for 8-10 minutes, after isolating the cavity mouth from saliva with cotton swabs. The gel is recommended to be stored in the refrigerator. After applying the gel, it is not recommended to drink and eat food for 30 minutes.

Photodynamic therapy is alternated every other day with Fagodent gel treatment, which is carried out at home. After completion of PDT procedures, that is, after the 3rd procedure, phage therapy is continued for 5-7 days.

Repeated supra- and subgingival dental treatment is not required after the course.

Distinctive essential features and a causal relationship between them and the achieved technical result:

- The removal of supra- and subgingival dental deposits is carried out with the PerioScan ultrasound machine simultaneously with antiseptic treatment with Octenisept solution at a 1:10 dilution.

In practice, ultrasonic treatment is carried out with distilled water, a well-known fact of ultrasonic treatment simultaneously with chlorhexidine. Based on the concepts of biofilm and colonization of microorganisms populating periodontal pockets, it is known that only by mechanical means it is possible to destroy the biofilm. Adding a new generation of drug “Octenisept” allows simultaneously with the destruction of the biofilm to conduct antiseptic treatment of this area. The drug "Octenisept" refers to the drugs of the octenidine series. It does not include either amide or ether groups, which leads to its specific properties and the absence of side effects inherent in chlorhexidine (mutagenicity, cytotoxicity, etc.). Also, unlike chlorhexidine, no toxic 4-chloramine is released, which makes it safer for use in patients at risk. The mechanism of action of octenidine preparations on bacterial cells is non-specific, which automatically determines its ability to act on a wide range of microorganisms. Octenidine also surpasses chlorhexidine in its ability to inhibit the enzymes involved in the formation of soft plaque, secreted by Str. Mutans. Since Str. Prevails in the microflora of tooth plaque in the first 2 days of its formation. Mutans, the ability of octenisept to inhibit enzymes secreted by these microorganisms, can inhibit plaque formation, disrupt its structure and, as a result, inhibit the formation of soft plaque. The result of a slowdown in the formation of dental plaque is a more simple structure of microorganisms (complexes) for exposure to subsequent therapy (PDT, phage therapy). An important factor in the use of this particular drug is the fact that selection of multiply resistant strains of pathogens does not occur.

The device for ultrasonic processing “PerioScan” allows you to detect dental deposits in areas inaccessible to the doctor’s eye (subgingival region, furcation) due to the indicator ring located on the tip of the device and the visualizing display.

Also, the detection of dental deposits by the apparatus can reduce the risk of damage to softer tooth structures such as cement and dentin. Depending on the structure of the dental plaque and their location, it is possible to individually select the power of work from 5 to 100%, which also reduces the risk of damage to the tooth structures and pain during the procedure.

- Tooth polishing is carried out with an AirnGo sandblasting machine using glycine-based powder.

The device is designed for supragingival and subgingival processing, it allows to achieve perfect polishing of all surfaces of teeth, which is necessary after using ultrasonic devices. Three types of powder are attached to the device in the kit - based on sodium bicarbonate, calcium carbonate and glycine. The inventors used glycine-based powder.

When using sandblasting machines, there are a number of contraindications that limit the use of powders based on sodium bicarbonate and calcium carbonate, such as: the need for a sodium-free diet; taking drugs that affect salt metabolism, damage to the oral mucosa. If we carry out a comparative analysis and analysis of the powders used, it becomes clear that soda is intended only for supragingival treatment and in the absence of inflammation in the gums, which is associated with the structure of the powder, since when an air-abrasive stream with soda enters soft tissues, they are significantly injured , which is a complication. Today, the only powder that can be used in the supra- and subgingival areas in patients with periodontal disease is glycine.

Due to the specially designed nozzle for subgingival processing of the AirnGo apparatus, it becomes possible to treat the root surface to the entire depth of the periodontal pocket without injuring soft tissues and without creating a microabrasive surface on tooth tissues. The advantage of glycine is the fact that glycine is a water-soluble amino acid in its structure, which dissolves after work in the periodontal pocket. Glycine can also be used in patients taking drugs that affect salt metabolism and are on a salt-free diet, with ceramic designs and implants.

- Subgingival and supragingival tooth treatment and polishing of the roots of the teeth is carried out once, in contrast to the prototype method, before the first PDT procedure.

Repeated sounding of the depth of the periodontal pocket and any invasion after treatment, according to the literature, is recommended to be carried out 21 days after the end. Failure to comply with these terms leads to a violation of epithelial attachment and lengthening the stabilization period [Herbert F. Wolff, Edith M. Rateitzkhak, Klaus Rateitzkhak Periodontology, M. MEDpress-inform, 2008]. Also, based on the properties of the Octenisept preparation, a glycine-based powder for the AirnGo apparatus and clinical observations, patients are not required to re-treat the supra- and subgingival area.

- PDT gel is introduced into periodontal pockets, the depth of which is 5 mm or more.

In periodontal pockets of more than 5 mm, the most aggressive microflora is found. For this reason, it is necessary to influence the focus by a method that is sensitive to all representatives and in close proximity to it. It is not possible to introduce the Fagodent gel at home to the entire depth of the periodontal pocket, and also based on the composition of the gel, we can conclude that it is active against not all microorganisms that are found in periodontal pockets with a depth of more than 5 mm. However, with PDT therapy, both pathogenic microorganisms and normoflora are affected; when using the Fagodent gel, there is no violation of normoflora and biobalance. This can explain the use of PDT only in the area of teeth with the greatest depth of periodontal pockets.

- A gel for photodynamic therapy is introduced, and the light guide is immersed to the entire depth of the periodontal pockets, while using 1% Radodent gel.

The light guide is introduced to the entire depth of the periodontal pockets so that the radiation source is in close proximity to the exposure zone and to avoid radiation scattering into the environment. By immersing the light guide to the entire depth of the periodontal pocket, the photosensitizer is distributed along the bottom and walls of the periodontal pocket. During radiation, the fiber is in constant motion, thereby distributing the photosensitizer, which helps to increase the absorption of laser radiation and its penetration into deeper layers, bringing the radiation source directly to the pathological focus.

- Laser exposure is carried out, in contrast to the prototype method, without washing off the gel.

The photosensitizer was not washed off, assuming that the gel, which did not penetrate the cell structure but remained inside the periodontal pocket, reacted with laser light, would release oxygen inside the periodontal pocket, which, in turn, would serve as an additional factor in the death of the anaerobic flora, which populates periodontal pocket. Also knowing that red radiation is reflected and goes into space by 70%, and that this process can be controlled using vital dye - mutual absorption of colors - green absorbs red well, thus increasing absorption. Almost 100% absorption increases the depth of penetration of laser radiation.

- Laser exposure is carried out by a diode laser with a power of 0.3 W in a pulsed mode, an energy density of 75 J / cm ² , not more than 2 minutes per inflammation site, the total procedure time is 14-30 minutes.

These diode laser settings were selected empirically, based on the feelings of patients during the procedure, which allowed to reduce pain without losing the effectiveness of the procedure.

Changing the continuous mode to pulsed allowed to further reduce the risk of damage to the soft tissues surrounding the tooth, as well as hard tooth tissues.

- The course of treatment consists of 3 procedures that are carried out every other day, and on the days between the photodynamic therapy procedures, the gums are independently treated with gel with bacteriophages “Fagodent” twice a day with gel exposure of 8-10 minutes, after completion of PDT procedures, phagotherapy is continued for 5-7 days .

The inclusion of this gel preparation with bacteriophages "Fagodent" in the treatment of periodontal diseases is explained by the sensitivity of microflora, which populates the periodontal pocket to its components.

The composition of the gel "Phagodent": Bacteriophages (2 ml, concentration 1010 PFU / cm ³ ): Wolinella spp., Actinomyces spp., Actinomyces israelii, Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Campylobacter spp., Bacteroides graphylis, bacteroides graphylis. Streptococcus pyogenes spp., Streptococcus mutans, Streptococcus salivarius, Streptococcus mitis, Pseudomonas aeruginosa spp., Proteus vulgaris spp., Proteus faecalis, Prevotella intermedia, Fusobacterium spp., Treponema denticola. Excipients: carbapol ETD 0.5 g, calendula extract 0.5 g, pH of the finished product 7.0-7.4, purified water to 100.0 g.

Bacteriophages (phages) are viruses that selectively infect bacterial cells. Most often, bacteriophages multiply inside bacteria, cause their lysis and pass into other (young, growing) cells. The entire breeding cycle takes 30-40 minutes, as a result, up to 200 phage particles can form. Bacterial preparations are interesting in connection with the widespread distribution of drug-resistant forms of pathogenic and conditionally pathogenic bacteria.

The advantages of this gel are:

- growth of normoflora is not suppressed;

- bacteria resistance does not develop;

- does not weaken the immune system, has an immunostimulating effect;

- combined with any medications;

- the absence of side effects (toxic effects, the development of allergic reactions, dysbiosis);

- restores the unique individual balance of the microflora of the oral cavity;

- convenient to use;

- has no taste;

- does not contain synthetic fragrances, dyes and preservatives;

- does not stain teeth.

The set of essential distinguishing features is new and eliminates the need for acupuncture when performing a method of treating periodontitis patients, which makes it possible to simplify the method, reduce pain during the procedure and expand the patient population due to the category of people with contraindications for acupuncture, as well as reduce the number of procedures while maintaining the high treatment efficiency inherent in the prototype method, in particular the duration of remission.

Examples of clinical use: Example 1. Patient Yu., 62 years old.

Complaints: bleeding gums when cleaning and eating, unpleasant taste in the mouth in the morning, the presence of discharge with an unpleasant odor.

Diagnosis: Chronic generalized periodontitis of severe severity. Objectively: the teeth of the upper and lower jaws are punctured, the gums are hyperimpaired, edematous, immediately bleeds profusely after probing, there are supra- and subgingival mineralized and demineralized dental deposits, hygiene index - 2.7, PMA index - 74.6, bleeding index - 2, 6, the depth of periodontal pockets 4-7 mm.

The treatment was carried out according to the claimed method of treatment. After treatment, the patient has no complaints.

Objectively: the gum is pink, dense, does not bleed when probed, no dental deposits are detected, it cannot be separated from periodontal pockets, there is no halitosis, the hygiene index is 1.0, the PMA index is 10.7, and the bleeding index is 0.

The achieved result is saved for 15 months.

Example 2. Patient E., 56 years old.

Complaints: tooth mobility, bleeding when cleaning and eating solid food, bad breath.

Objectively: an abundant amount of dental supra- and subgingival dental deposits, tooth mobility of 1-3 degrees, areas of traumatic occlusion, the gum is swollen, hyperemic with a cyanotic hue, the presence of purulent exudate from periodontal pockets, hygiene index - 4.67, PMA index - 78 , 72, the bleeding index is 3, the depth of periodontal pockets is 4-6 mm. Diagnosis: Chronic generalized periodontitis of moderate severity.

The treatment was carried out according to the claimed method of treatment. After treatment, the patient has no complaints. Objectively: the gum has a uniform pink color, fits snugly to the teeth, over- and subgingival dental deposits are not detected, bleeding is absent, tooth mobility is significantly reduced, hygiene index - 1.0, PMA index - 17.4, bleeding index - 0.

Remission is 13 months.

The inventive method was tested in 42 patients with a diagnosis of chronic generalized periodontitis of moderate (25 people) and severe (17 people) degrees of severity, 19 men and 23 women, 4 of all patients suffered from smoking, the average age is 46.7 years.

The treatment results were evaluated on the basis of clinical data and PCR studies of periodontopathogens.

A significant improvement in the clinical picture was obtained in all patients - gums without signs of inflammation, lack of swelling and hyperemia, dense; detachable from periodontal pockets is absent, bleeding during sounding is absent (table. 1).

According to the PCR study, the complete or almost complete disappearance of the main periodontopathogens (Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Treponema denticola, Prevotella intermedia, Tannerella forsythia) was determined. (table 2)

The achieved clinical result lasts for 12-15 months in 100% of patients with moderate periodontitis (25 patients) and 88.2% of severe severity (15 of 17 patients). When using the prototype method, the achieved clinical result is maintained for 12-14 months in 95.5% of patients with moderate periodontitis (43 out of 45 patients).

The prototype method consists of 10 procedures, the inventive method of 3, carried out every other day. In the intervals between the procedures, the patient independently conducts phagotherapy, which lasts 5-7 days after the completion of PDT procedures. Thus, the duration of an outpatient treatment according to the claimed method is 5 days, which is 2 times shorter compared to the prototype.

Thus, the claimed method of treatment of patients with periodontitis excludes acupuncture during the implementation of the method, which allowed to simplify the method, reduce pain during the procedure and expand the patient population due to the category of persons with contraindications for acupuncture, as well as reduce the number of procedures, while maintaining the high treatment efficiency inherent in the prototype method, in particular the duration of remission.

Claims (1)

A method of treating patients with periodontitis, which consists in photodynamic therapy (PDT), including applying to the areas of inflammation of the PDT gel with subsequent exposure to this area of the diode laser of a red spectrum with an exposure time not exceeding 30 minutes, and before PDT, supra-subgingival dental plaque using an ultrasound device and polishing of teeth, characterized in that the removal of supra- and subgingival dental plaque is carried out by the ultrasonic device "PerioScan" simultaneously with antiseptic abotkoy solution "Octenisept" in a 1:10 dilution, and polishing of teeth carried sandblasted «AirnGo», using glycine-based powder, wherein the polishing teeth and removing supra- and subgingival dental plaque performed once before the first PDT procedure; the PDT gel is introduced into the periodontal pockets, the depth of which is 5 mm or more, the PDT gel is introduced, and the fiber is dipped to the entire depth of the periodontal pockets, using 1% Radodent gel; laser exposure is carried out by a diode laser in a pulsed mode at a wavelength of 662 nm, power - 0.3 W, energy density - 75 J / cm ² , not more than 2 minutes per area of inflammation, the total procedure time is 14-30 minutes, the course of treatment is 3 procedures are carried out every other day, and on the days between PDT procedures, gum gel is independently treated with the bacteriophage "Fagodent" twice a day with gel exposure of 8-10 minutes, after completion of PDT procedures, phage therapy is continued for 5-7 days.