''Efficacy of Locally Delivered Hyaluronic Acid Gel as an Adjunctive to Non-Surgical Management of Stage II or Stage III Periodontitis

Periodontitis is a chronic multifactorial inflammatory disease, associated with the dental plaque biofilms, its distinct feature is destruction of the tooth supporting apparatus. Its main features include: damage of the periodontal tissue, that's manifested by clinical attachment loss, alveolar bone loss, periodontal pocketing and bleeding gum (Armitage, 1999).

A new periodontitis classification scheme has been approved, in which forms of the disease previously known as "chronic" or "aggressive" are now gathered under a single term ("periodontitis") and are more characterized based on a multi-dimensional staging and grading system. Staging is basically reliant on the severity of disease as well as on the difficulty of disease management, on the other hand , grading offers additional information about biological aspects of the disease including a history-based analysis of the rate of periodontitis progression; risk assessment for further progression and analysis of likely poor outcomes of treatment (Caton et al., 2018; Papapanou et al., 2018).

Host-Microbial interaction is having a huge effect on the nature of periodontal disease progression. The microbial biofilm elicits the host to release inflammatory mediators that have a negative effect on the connective tissues. The biofilm or dental plaque is required but not enough to induce periodontitis, since it is the host inflammatory response to this microbial challenge that eventually can be the reason for destruction of the periodontium (Haffajee and Socransky, 1994; Page , 1997; Darveau, 2010).

Physical removal of dental plaque through debridement and/or using antimicrobial agents is the most prevalent management of periodontitis. Initially, scaling and root planing (SRP) is done with the means of hand or ultrasonic instruments to debride the root surface, allowing the development of a long junctional epithelium. Clinically, in case of lack of accessibility like extensive tissue loss, deep periodontal pocket and furcation involvement make it unclear to determine the efficacy of the debridement (Lindhe, 1985).

The use systemic antibiotics (ABs) can contribute in treatment goals without surgical treatment. However, their usage is limited to particular patients for those who have previously two courses of SRP with no improvement in periodontal pocket depth. Additionally, the side effects and rise in AB resistance over time have reduced the number of cases managed in this way (Walters et al., 2015).