Topical antiseptics and antibiotics in the initial therapy of chronic adult periodontitis: microbiological aspects

Low-cost periodontal therapy

Periodontitis is a complex infectious disease that affects low-income individuals disproportionately. Periodontitis is associated with specific bacterial species and herpesviruses, and successful prevention and treatment of the disease is contingent upon effective control of these pathogens. This article presents an efficacious, highly safe, minimally invasive, practical and low-cost periodontal therapy that involves professional and patient-administered mechanical therapy and antimicrobial agents. The major components are scaling for calculus removal, periodontal pocket irrigation with potent antiseptics, and treatment with systemic antibiotics for advanced disease. Povidone-iodine and sodium hypochlorite have all the characteristics for becoming the first-choice antiseptics in the management of periodontal diseases. Both agents show excellent antibacterial and antiviral properties, are readily available throughout the world, have been safely used in periodontal therapy for decades, offer significant benefits for individuals with very limited financial resources, and are well accepted by most dental professionals and patients. Four per cent chlorhexidine applied with a toothbrush to the most posterior part to the tongue dorsum can markedly reduce or eliminate halitosis in most individuals. Systemic antibiotics are used to treat periodontopathic bacteria that are not readily reached by topical therapy, such as pathogens within gingival tissue, within furcation defects, at the base of periodontal pockets, and on the tongue, tonsils and buccal mucosae. Valuable antibiotic therapies are amoxicillin-metronidazole (250 mg of amoxicillin and 250 mg of metronidazole, three times daily for 8 days) for young and middle-aged patients, and ciprofloxacin-metronidazole (500 mg of each, twice daily for 8 days) for elderly patients and for patients in developing countries who frequently harbor enteric rods subgingivally. Scaling to remove dental calculus and the prudent use of inexpensive antimicrobial agents can significantly retard or arrest progressive periodontitis in the great majority of patients.

A systematic review on the effects of local antimicrobials as adjuncts to subgingival debridement, compared with subgingival debridement alone, in the treatment of chronic periodontitis

AIMS

To update the existing scientific evidence on the efficacy of local antimicrobials as adjuncts to subgingival debridement in the treatment of chronic periodontitis.

MATERIAL AND METHODS

Fifty-six papers were selected, reporting data from 52 different investigations. All the studies reported changes in probing pocket depth (PPD) and clinical attachment level (CAL) and most in plaque index (PlI) and/or bleeding on probing (BOP). Meta-analyses were performed with the data retrieved from the studies fulfilling the inclusion criteria.

RESULTS

The overall effect of the subgingival application of antimicrobials was statistically significant (p = 0.000) for both changes in PPD and CAL with a weighted mean difference (WMD) of -0.407 and -0.310 mm respectively. No significant differences occurred for changes in BOP and PlI. Subgingival application of tetracycline fibres, sustained released doxycycline and minocycline demonstrated a significant benefit in PPD reduction (WMD between 0.5 and 0.7 mm). The rest of the tested outcomes demonstrated a high heterogeneity. The local application of chlorhexidine and metronidazole showed a minimal effect when compared with placebo (WMD between 0.1 and 0.4 mm).

CONCLUSIONS

The scientific evidence supports the adjunctive use of local antimicrobials to debridement in deep or recurrent periodontal sites, mostly when using vehicles with proven sustained release of the antimicrobial.

The application of bone morphogenetic proteins to periodontal and peri-implant tissue regeneration: A literature review

Progress in understanding the role of bone morphogenetic proteins (BMPs) in craniofacial and tooth development and the demonstration of stem cells in periodontal ligament have set the stage for periodontal regenerative therapy and tissue engineering. Furthermore, recent approval by the Food and Drug Administration of recombinant human BMPs for accelerating bone fusion in slow-healing fractures indicates that this protein family may prove useful in designing regenerative treatments in periodontics. In the near term, these advances are likely to be applied to periodontal surgery; ultimately, they may facilitate approaches to regenerating whole lost periodontal structures.

Effect of local drug delivery in chronic periodontitis patients: A meta-analysis

Periodontal diseases are multi-factorial in etiology, and bacteria are one among these etiologic agents. Thus, an essential component of therapy is to eliminate or control these pathogens. This has been traditionally accomplished through mechanical means (scaling and root planing (SRP)), which is time-consuming, difficult, and, sometimes, ineffective. From about the past 30 years, locally delivered, anti-infective pharmacological agents, most recently employing sustained-release vehicles, have been introduced to achieve this goal. This systematic review is an effort to determine the efficacy of the currently available anti-infective agents, with and without concurrent SRP, in controlling chronic periodontitis. Four studies were included, which were all randomized controlled trials, incorporating a total patient population of 80, with 97 control sites and 111 test sites. A meta-analysis completed on these four studies including SRP and local sustained-release agents compared with SRP alone indicated significant adjunctive probing depth (PD) reduction for 10% Doxycycline hycylate (ATRIDOX), minocycline hydrochloride (ARESTIN), tetracycline hydrochloride (PERIODONTAL PLUS AB), and chlorhexidine gluconate (PERIOCHIP). Essentially, all studies reported substantial reductions in gingival inflammation, plaque scores, and bleeding indices, which were similar in both the control and the experimental groups. Use of antimicrobial sustained-release systems as an adjunct to SRP does not result in significant patient-centered adverse events. Local drug delivery combined with SRP appears to provide additional benefits in PD reduction compared with SRP alone.

The effect of various topical peri-implantitis antiseptics on Staphylococcus epidermidis, Candida albicans, and Streptococcus sanguinis

OBJECTIVE

Although peri-implantitis has presented an ever increasing problem in modern dentistry, satisfying therapeutic strategies or scientifically based treatment recommendations are still not available. The main object of the present study was to evaluate the antibacterial efficacy of six different topical antiseptics on three test microorganisms attached to titanium implant specimens.

MATERIAL AND METHODS

For biofilm formation, plane titan specimens were incubated either in Candida albicans, Streptococcus sanguinis, or Staphylococcus epidermidis for 2h. The specimens were then treated with different topical antiseptics for 60s (sodium hypochlorite 1.0%, hydrogen peroxide 3.0%, chlorhexidine gluconate 0.2%, citric acid 40.0%, Plax, or Listerine) and with sterile saline as control. Remaining vital fungi were quantified by means of a bioluminometric assay and the bacterial load and the viability of adhering S. epidermidis and S. sanguinis by live or dead cell labelling in combination with fluorescence microscopy.

RESULTS

Sodium hypochlorite was effective against all three species, whereas hydrogen peroxide was solely effective against C. albicans. CHX and Listerine showed antimicrobial activity against S. sanguinis and C. albicans and citric acid and Plax against both tested bacteria.

CONCLUSIONS

None of the tested antimicrobial agents, except for sodium hypochlorite, showed a significant in vitro effect on all three test microbes. Considering the possible toxicity of sodium hypochlorite, none of the tested - and so far widely used - antiseptics showed any broad-spectrum antimicrobial effect and could therefore not be recommended for the topical disinfection and detoxification of infected implant surfaces.

Periodontal pharmacotherapy - an updated review

Periodontal disease is mainly associated with the activity of bacteria which adhere to the tooth surface and form specific structure of bacterial biofilm. Periodontal bacteria cause inflammation of the gums and aggressive immune response, affecting the periodontium. The first phase of initial therapy - mechanical removal of dental plaque and calculus - is necessary. If this non-surgical therapy has proved to be unsuccessful, an alternative treatment with antimicrobial agents is then considered. Pharmacotherapy is based on systemic or local antibiotics and/or antiseptics, which are applied according to the severity of the disease. A number of recent periodontal studies present some of the pharmacological agents, that are directed against bacteria or a host immune response, are often chosen as an adjunct treatment option, but none of these antimicrobials were established as 'a gold standard' in the periodontal treatment. This review provides some present recommendation of pharmacological strategies, with particular emphasis on systemic and local antimicrobial therapy of periodontal disease.

The antimicrobial effect of Iseganan HCl oral solution in patients receiving stomatotoxic chemotherapy: analysis from a multicenter, double-blind, placebo-controlled, randomized, phase III clinical trial

BACKGROUND

Cytotoxic chemotherapy induces changes in the oral microflora that may cause oral and systemic infections in myelosuppressed cancer patients. These complications prompted us to assess the antimicrobial activity of a topical Iseganan HCl mouthwash vs. placebo on the aerobic and facultatively anaerobic oral flora in these patients.

METHODS

Two hundred and twenty-five chemotherapy patients were recruited into a randomized, double-blind, placebo-controlled trial, conducted at multiple centers. The study compared the antimicrobial efficacy of Iseganan HCl vs. placebo (95% of the Iseganan and 97% of the control group received myeloablative chemotherapy). Iseganan HCl 9 mg/3 ml was administered as a swish and swallow solution, six times daily for 21-28 days. Microbial cultures were made before and after the daily Iseganan mouth rinse on the first and final days of chemotherapy.

RESULTS

The reduction in total microbial load after the first day of treatment was statistically significant (1.59 vs. 0.18 log10 CFU for the Iseganan HCl and placebo groups, respectively, P < 0.0001). Iseganan HCl rinse had a cumulative effect demonstrated by the significant difference between the two groups on the last day of the study (i.e. completion of Iseganan daily treatment) (P < 0.05). The reduction was mainly due to decreased densities of viridans streptococci, non-hemolytic streptococci, and yeasts. The minimal inhibitory concentration (MIC) of Iseganan HCl remained the same throughout the course of treatment.

CONCLUSIONS

Topical Iseganan HCl significantly reduces the total oral aerobic bacterial, streptococcal, and yeast load. Its potential as an oral antimicrobial agent in preventing these types of infections is clear.

Short-term periodontal and microbiological changes following orthognathic surgery

OBJECTIVE

Aim of the present study was to evaluate the influence of orthognathic surgery on the development of periodontal and microbiological changes.

MATERIALS AND METHODS

Fifteen consecutively treated patients with a mean age of 24.9±7.7 years receiving orthognathic surgery were included in the present study. Plaque index (PI) and concentrations of 11 periodonto-pathogenic bacteria were recorded one day prior to surgery (t(0)) and one week (t(1)) and six weeks (t(2)) post-surgery. In addition, a complete periodontal examination including pocket probing depth (PPD), gingival recession (GR), clinical attachment level (CAL), bleeding on probing (BOP) and width of keratinized gingiva (WKG) was conducted at t(0) and t(2). For statistical analysis, general linear model and paired t-test were applied.

RESULTS

A significant increase of PI (t(0)-t(1), p=0.037) was followed by a significant decrease (t(1)-t(2), p=0.017). Apart from Eikenella corrodens (p=0.036), no significant microbiological changes were recorded. PPD significantly increased on oral sites (p=0.045) and GR especially on buccal sites (p=0.001). In the incision area the development of GR was significantly higher on the test (buccal) than on the control sites (oral). Both gingival biotypes were affected by GR.

CONCLUSIONS

Orthognathic surgery causes statistically significant changes of periodontal parameters, but these changes do not necessarily impair the aesthetic appearance of the gingival margin.

Isolation of the new anacardic acid 6-[16'Z-nonadecenyl]-salicylic acid and evaluation of its antimicrobial activity against Streptococcus mutans and Porphyromonas gingivalis

A new anacardic acid, 6-[16'Z-nonadecenyl]-salicylic acid (1), along with seven known compounds, 6-[8'Z-pentadecenyl] salicylic acid (15:1 anacardic acid) (2), 6-nonadecenyl salicylic acid (anacardic acid 19:0) (3), 6-pentadecyl salicylic acid (anacardic acid 15:0) (4), masticadienonic acid (5), 3α-hydroxymasticadienonic acid (6), 3-epi-oleanolic acid (7) and β-sitosterol, were isolated from the bark of Amphipterygium adstringens using a bioassay-guided fractionation method. The structure of the new compound (1) was elucidated by spectroscopic data interpretation. The known compounds (2-7) were identified by comparison of their spectroscopic data with reported values in the literature. Compounds 1-4 exhibited antibacterial activity against Streptococcus mutans and Porphyromonas gingivalis with minimum inhibitory concentrations ranging from 7 to 104 µg mL and from 12 to 126 µg mL, respectively.

Do probiotics offer opportunities to manipulate the periodontal oral microbiota?

BACKGROUND

As in other fields of healthcare, probiotics have been introduced for prevention and treatment of periodontal diseases.

OBJECTIVE

This review was initiated to explore whether the use of probiotics can influence the periodontal microbiota and periodontal health.

MATERIALS AND METHODS

Literature on the mode of action of oral probiotics was reviewed and a systematic review was performed on the microbiological and clinical effects of oral probiotics on periodontal health.

RESULTS

Three animal and 11 in vivo human studies were retrieved. Six studies reported on microbiological effects whereas eight studies report on clinical effects. Seven studies were performed on healthy or gingivitis patients and four studies on periodontitis patients. Many of the retrieved studies are pilot in nature and with low quality. The high degree of heterogeneity between studies hampered analysis.

CONCLUSION

Taking into consideration all limitations, the currently available data indicate an effect of probiotics on the oral microbiota and a more limited effect on clinical periodontal outcome measures. However, there is an urgent need for properly conducted clinical trials where probiotics are used as adjuncts to standard periodontal care, similar to antibiotics, using probiotic strains with, at least at an in vitro level, proven periodontal probiotic effects.

Biofilms: A microbial home

Microbial biofilms are mainly implicated in etiopathogenesis of caries and periodontal disease. Owing to its properties, these pose great challenges. Continuous and regular disruption of these biofilms is imperative for prevention and management of oral diseases. This essay provides a detailed insight into properties, mechanisms of etiopathogenesis, detection and removal of these microbial biofilms.

An 8-week, randomized, controlled, clinical study of the use of a 0.1% chlorhexidine mouthwash by chronic periodontitis patients

AIM

  To evaluate the efficacy of a 2-week administration of a 0.1% chlorhexidine mouthwash in the short-term treatment of chronic periodontitis patients and the impact of this product when administered twice by pocket irrigation.

METHODS

  Sixty patients were enrolled in a single-centre, placebo-controlled, randomized study with the blind allocation of product to two parallel groups. Clinical assessments were performed, and samples from six selected subgingival sites were collected for microbial analysis by culture at baseline, D15 and D56. Three of the six sites were randomly selected and were treated by subgingival irrigation with the same 0.1% chlorhexidine product at D0 and D7. A subsequent statistical analysis was performed using the paired Student's t-test and Wilcoxon rank sum test for within-group analyses; analysis of variance and the Kruskall-Wallis test were used for between-group analyses.

RESULTS

  Two-week treatment with a 0.1% chlorhexidine mouthwash slightly reduced the gingival inflammation associated with periodontitis. We observed a significant decrease in Gram-negative, facultative anaerobes and micro-aerophiles, and a significant increase in Gram-positive cocci. No increase in the treatment effect was demonstrated by irrigation of the periodontal pockets.

CONCLUSION

  The 0.1% chlorhexidine mouthwash showed limited beneficial effects in the treatment of periodontitis patients.

Microbiological findings at tongue piercing sites: implications to oral health

BACKGROUND

Body piercing enjoys a widespread popularity among juveniles and young people. The tongue is the most commonly pierced oral site. Tongue jewellery, however, can damage the teeth and periodontium and may provide an ideal environment for microorganisms. The aim of this report was to investigate if and in case in which amount periodontopathogenic organisms can be found at tongue piercing sites.

METHODS

Patients with tongue piercings visiting the authors' dental office for a dental check-up volunteered. A questionnaire was used to collect data on the type of material used in the piercing, the time the device was in place, oral and piercing hygiene practices and smoking habits. The dental examination included an oral hygiene index and the periodontal screening index. From the surface of the piercing jewellery adjacent to the tongue perforation, microbiological samples were collected and analysed for the presence of 11 periodontopathogenic bacteria.

RESULTS

A total of 12 patients with tongue piercing were asked and examined. Their tongue piercings had been in place between 2 and 8 years. The microbiological analysis showed an increased or substantially increased concentration of periodontopathogenic bacteria in all cases. It became obvious that the longer a piercing had been in place, the more pronounced was the shift from bacteria with a moderate periodontopathogenic potential to bacteria with a high periodontopathogenic potential.

CONCLUSION

Tongue piercing provides a potential reservoir for periodontopathogenic bacteria.

Topical use of a metronidazole gel in the treatment of sites with symptoms of recurring chronic inflammation

BACKGROUND

Bacterial plaque accumulation at the dentogingival junction and in periodontal pockets is the major etiologic factor in all manifestations of periodontal disease. The aim of this study was to evaluate whether a locally delivered 25% metronidazole gel after scaling and root planing (SRP) would enhance the treatment outcome over SRP alone in periodontal pockets with symptoms of recurring chronic inflammation.

METHODS

Twenty-one maintenance-care patients, 10 men and 11 women, having at least one pair of contralateral anatomically matching proximal tooth surfaces showing probing depth > or = 5 mm and bleeding on probing (BOP), were included in the study. The sites were randomized to be treated with SRP plus 25% metronidazole gel (test sites) or with SRP alone (control sites) in a split-mouth design. Clinical evaluations were performed immediately pretreatment (baseline) and at 3 and 6 months post-treatment.

RESULTS

Both treatments yielded a statistically significant (P = 0.001) reduction in probing depth (1.9 and 1.8 mm), gain of attachment level (1.6 and 1.0 mm), and reduction of BOP (38.1% and 33.3%) for test and control sites, respectively, at 6 months. There was no statistically significant difference between the treatments for any of the clinical parameters.

CONCLUSION

This study indicates that a locally applied 25% metronidazole gel does not improve the treatment outcome over SRP alone in sites with recurring chronic inflammation in maintenance-care patients.

Reduction of periodontal pathogens adhesion by antagonistic strains

INTRODUCTION

Periodontitis results from a shift in the subgingival microflora into a more pathogenic direction with Porphyromonas gingivalis, Prevotella intermedia, and Actinobacillus actinomycetemcomitans considered as periodontopathogens. In many cases, treatment procures only a temporary shift towards a less pathogenic microflora. An alternative treatment could be the deliberate colonization of pockets with antagonistic microorganisms to control the adhesion of periodontopathogens. The aim of this study was to identify bacterial strains that reduce adhesion of periodontopathogens to surfaces.

METHODS

Streptococcus sanguinis, Streptococcus crista, Streptococcus salivarius, Streptococcus mitis, Actinomyces naeslundii, and Haemophilus parainfluenzae were evaluated as potential antagonists against P. gingivalis ATCC 33277, P. intermedia ATCC 49046, and A. actinomycetemcomitans ATCC 43718 as periodontopathogens. Adhesion of periodontopathogens to the bottom plate of a parallel plate flow chamber was studied in the absence (control) and the presence of pre-adhering antagonistic strains up to a surface coverage of 5%.

RESULTS

The largest reduction caused by antagonistic strains was observed for P. gingivalis. All antagonistic strains except S. crista ATCC 49999 inhibited the adhesion of P. gingivalis by at least 1.6 cells per adhering antagonist, with the largest significant reduction observed for A. naeslundii ATCC 51655 (3.8 cells per adhering antagonist). Adhering antagonists had a minimal effect on the adhesion of A. actinomycetemcomitans ATCC 43718. Intermediate but significant reductions were perceived for P. intermedia, most notably caused by S. mitis BMS.

CONCLUSION

The adhesion of P. gingivalis was inhibited best by antagonistic strains, while S. mitis BMS appeared to be the most successful antagonist.

Chlorhexidine with an anti discoloration system after periodontal flap surgery: a cross-over, randomized, triple-blind clinical trial

The use of chlorhexidine (CHX) has been recommended for a number of clinical applications including plaque control in the post-operative period. However, the use of CHX is burdened by some side effects that could affect the compliance of the patient. The aim of this clinical trial was to evaluate the side effects, the staining in particular, the patient acceptance, and the efficacy of a 0.2% CHX mouthwash containing an anti discoloration system (ADS) compared with a 0.2% CHX alone, after periodontal flap surgery.

MATERIAL AND METHODS

This single-centre, cross-over, triple-blind randomized clinical trial was carried out on 48 consecutive patients. After periodontal flap surgery, the patients were prescribed to rinse two times per day for 1 min for 1 week with 10 ml of test or control CHX, contained in anonymous bottles coded K or M and assigned randomly. No brushing and interdental cleaning of the surgical area was allowed. At week 1, after suture removal, patients received full-mouth prophylaxis and were given a second anonymous bottle, reversing the products, with the same instructions as at baseline. Patients resumed tooth-brushing but not interdental cleaning. At the end of week 2, prophylaxis was repeated, mouth rinsing was discontinued and patients resumed normal oral hygiene. At weeks 1 and 2, the following variables were recorded: presence of pigmentation, gingival parameters at the surgically treated sites (gingival inflammation, tissue inflammation around the sutures, gingival swelling and presence of granulation tissue), patient perception and acceptance of the 2 mouthwashes.

RESULTS

Forty-seven patients completed the study. The difference between treatments related to gingival variables was not statistically significant. The test CHX caused consistently less pigmentations than the control CHX in all the evaluated areas of the dental surfaces (odds ratio (OR)=0.083 p<0.0001 in the incisal area, OR=0.036 p<0.0001 in the approximal area and OR=0.065 p<0.0001 in the gingival area). The CHX ADS was found to be more tolerated by patients than the control mouthwash and to cause less food alteration, less alterations to the perception of salt and to be less irritant for the oral tissues.

CONCLUSIONS

(1) CHX ADS caused less pigmentation, was burdened by less side effects and was more agreeable than the control CHX; (2) CHX ADS was as effective as CHX without ADS in reducing gingival signs of inflammation in the post-surgical early healing phase; (3) the use of CHX ADS could be of value in treatment protocols in which the patient compliance with a CHX mouthwash prescription is relevant.

Guiding periodontal pocket recolonization: a proof of concept

The complexity of the periodontal microbiota resembles that of the gastro-intestinal tract, where infectious diseases are treatable via probiotics. In the oropharyngeal region, probiotic or replacement therapies have shown some benefit in the prevention of dental caries, otitis media, and pharyngitis, but their effectiveness in the treatment of periodontitis is unknown. Therefore, this study addressed the hypothesis that the application of selected beneficial bacteria, as an adjunct to scaling and root planing, would inhibit the periodontopathogen recolonization of periodontal pockets. Analysis of the data showed, in a beagle dog model, that when beneficial bacteria were applied in periodontal pockets adjunctively after root planing, subgingival recolonization of periodontopathogens was delayed and reduced, as was the degree of inflammation, at a clinically significant level. The study confirmed the hypothesis and provides a proof of concept for a guided pocket recolonization (GPR) approach in the treatment of periodontitis.

Susceptibility to various oral antiseptics of Porphyromonas gingivalis W83 within a biofilm

The origin of chronic periodontal disease is strongly related to the nature and physiology of the subgingival bacterial biofilm, of which Porphyromonas gingivalis is a main protagonist. This study was conducted in vitro, to test the susceptibility of the W83 strain of P gingivalis to several oral antiseptics, bearing in mind its mode of growth as biofilm. To this end, the investigators inoculated a brain-heart infusion broth with Streptococcus gordonii, to which P gingivalis was added before perfusion for 7 d via a closed circuit containing a modified Robbins device. Then, various antiseptics were perfused through the circuit over 30 min, and their bactericidal effects were evaluated after culture by comparison of the mean proportion of bacteria killed. The average proportion of P gingivalis W83 killed after 15 min of contact with antiseptics was 90.51% (+/-4.78) for chlorhexidine 0.2%, 89.87% (+/-6.58) for povidone-iodine 1%, and 98.6% (+/-0.86) for Listerine (McNeil-PPC, Inc., Morris Plains, NJ). After 30 min of contact, survival of P gingivalis was nil, irrespective of the antimicrobial agent used. Preliminary results show that antiseptic mouth rinses, when used in pure concentrations in the traditional way, are effective in killing P gingivalis W83 within a biofilm. Furthermore, in light of these experiments, it appears that the best results are obtained when Listerine is used; however, new trials should be conducted to confirm this observation.

Effects of EDTA Gel Preconditioning of Periodontally Affected Human Root Surfaces on Chlorhexidine Substantivity – An SEM Study

BACKGROUND

Infection control is an important requirement during the early stages of periodontal healing. This study was performed to assess the preconditioning effect of EDTA gel on chlorhexidine (CHX) substantivity to periodontally involved root surfaces.

METHODS

Eighty patients with severe chronic periodontitis were enrolled in this study. Following cause-related therapy, patients were divided randomly into four groups. Each group consisted of 20 subjects with one tooth that was diagnosed as hopeless and designated for extraction. In group 1 (G1), selected periodontal pockets were filled with a placebo gel in a silica base for 2 minutes. Exposed roots in group 2 (G2) were etched for 2 minutes with a neutral EDTA conditioning agent, followed by pocket fill with the placebo gel. Pockets in group 3 (G3) were filled with 0.12% CHX digluconate gel in a silica base. Exposed roots in group 4 (G4) were etched for 2 minutes with a neutral EDTA conditioning agent, followed by pocket fill with the CHX gel. Four teeth from each group were extracted immediately and at 3, 12, 24, and 48 hours for SEM evaluation.

RESULTS

G1 and G2 specimens showed no evidence of silica adherent to any of the examined root surfaces. At 3 hours following CHX gel application, G3 specimens showed marked reduction in CHX-coated silica. At 24 and 48 hours following EDTA and CHX gel application, G4 specimens demonstrated adherent CHX-coated silica particles despite the reclogging of the tubule orifices.

CONCLUSION

EDTA and CHX gel root conditioning is a valuable regimen that improves CHX substantivity to periodontally involved root surfaces.

Subgingival Chlorhexidine Varnish Administration as an Adjunct to Same-Day Full-Mouth Root Planing. I. Clinical Observations

BACKGROUND

Chemo-mechanical treatment concepts have been developed to improve the outcome of non-surgical periodontal therapy. Recently, the clinical additive value of a supersaturated chlorhexidine varnish was shown when used as an adjunct to staged scaling and root planing. The aim of this study was to investigate the clinical effects of a treatment strategy for chronic periodontitis based on a combination of same-day full-mouth root planing and subgingival chlorhexidine varnish administration.

METHODS

A randomized, controlled, single-blind, parallel trial was conducted on 33 non-smoking chronic periodontitis patients. The control group received oral hygiene instructions and same-day full-mouth root planing. The test group received the same instructions and treatment; however, all pockets were disinfected using a chlorhexidine varnish. Clinical response parameters were recorded at baseline and after 1, 3, and 6 months.

RESULTS

Both groups showed significant reductions in probing depth following therapy (P <0.001). There was no significant difference in full-mouth probing depth between the groups at any examination point. However, when a site-specific comparison was made, additive effects were found in the test group; an extra pocket reduction of 0.93 mm (P = 0.044) for initially deep pockets (>or=7 mm) was found at study termination. Additive clinical attachment gains seemed to be temporary. Impermanent extra pocket reductions and clinical attachment gains were found for initially medium-deep pockets (4 to 6 mm).

CONCLUSION

The outcome of same-day full-mouth root planing may benefit from the subgingival administration of a highly concentrated chlorhexidine varnish, at least in terms of pocket reduction in initially deep sites (>or=7 mm).

Microbiological effect of the use of an ultrasonic device and iodine irrigation in patients with severe chronic periodontal disease: a randomized controlled clinical study

OBJECTIVE

Instrumentation of the subgingival area is aimed at removing as much as possible of the bacterial biofilm and subgingival calculus. Since mechanical root debridement is a technically demanding procedure, antiseptics and antibiotics delivered either locally or systemically have been used as adjunct to scaling and root-planning procedures in order to control the subgingival biofilm and thereby enhance the treatment outcome. Our aim was to study the microbiological effect of ultrasonic debridement with or without povidone-iodine (PVP-iodine) in the treatment of severe chronic periodontitis.

MATERIAL AND METHODS

Twenty patients were recruited to the study. Each test site and the related quadrant were randomly assigned to one of four different treatment modalities: ultrasonic scaling+subgingival irrigation with 0.5% PVP-iodine for 5 min/tooth, ultrasonic scaling+subgingival irrigation with sterile saline solution for 5 min/tooth, subgingival irrigation with sterile saline solution for 5 min/tooth and subgingival irrigation with 0.5% PVP-iodine for 5 min/tooth. The individuals were followed longitudinally for 6 months.

RESULTS

The present study showed that non-surgical periodontal therapy with the use of an ultrasonic device was effective in reducing the analyzed putative periodontal bacteria. No statistically significant difference between ultrasonic+saline and ultrasonic+PVP-iodine was found.

CONCLUSIONS

Ultrasonic debridement reduced the periodontal markers in patients with severe chronic periodontitis. The reduction was selective. A concentration of 0.5% PVP-iodine did not add any anti-microbiological effect compared to ultrasonic debridement alone.

The effect of mouthrinses against oral microorganisms

This paper reviews the benefits of the use of antimicrobial mouthrinses for controlling dental biofilm. It is currently known that the human oral cavity is inhabited by approximately 600 to 700 different species of microorganisms, including bacteria, fungi and viruses, organized in biofilms. Biofilm accumulation represents the principal etiologic agent of oral diseases including caries and periodontal diseases. For that reason, prevention of biofilm accumulation has been shown to be associated with the control of diseases. Patient motivation and oral hygiene instruction are claimed to be a major factor influencing the degree of biofilm control. Therefore, mechanical home-care methods, including toothbrushing and flossing, represent the best way for patients to remove biofilm. For many patients, however, the elimination of all biofilm present in the oral cavity through home-care methods could be tedious and time-consuming. Additionally, some local conditions, including malpositioned teeth, presence of bridge-work or orthodontic appliances, among others, may render the mechanical control of biofilm especially difficult. Chemotherapeutic agents, including mouthrinses, could have a key role as adjuncts to daily home care, preventing and controlling supragingival plaque, gingivitis and oral malodor. Indeed, according to the ADA, the active ingredients of mouthwashes must demonstrate a therapeutic effect in vivo and in vitro to be classified as drugs. Several studies included in the present review have demonstrated the effectiveness of mouthrinses containing active ingredients such as chlorhexidine and essential oils in preventing and controlling both supragingival plaque and gingivitis, especially when used adjunctively to regular toothbrushing and flossing procedures.

Healing following ultrasonic debridement and PVP-iodine in individuals with severe chronic periodontal disease: a randomized, controlled clinical study

OBJECTIVE

Antiseptics and antibiotics delivered either locally or systemically have been used as an adjunct to scaling and root planing procedures in order to control the subgingival biofilm and thereby enhancing the treatment outcome. The results presented in the literature are, however, inconclusive. Povidone-iodine (PVP-iodine) has a bactericidal effect and is effective against most bacteria, including putative periodontal pathogens. The aim of the present study was to evaluate the clinical effect of PVP-iodine as an adjunct to ultrasonic scaling in the treatment of severe chronic periodontitis.

MATERIAL AND METHODS

Twenty patients were recruited to the study. Each test site and the related quadrant were randomly assigned to one of four different treatment modalities: ultrasonic scaling + subgingival irrigation with 0.5% PVP-iodine for 5 min/tooth, ultrasonic scaling + subgingival irrigation with sterile saline solution for 5 min/tooth, subgingival irrigation with sterile saline solution for 5 min/tooth, and subgingival irrigation with 0.5% PVP-iodine for 5 min/tooth. The individuals were followed longitudinally for 6 months.

RESULTS

The present study showed that non-surgical periodontal therapy by means of an ultrasonic device was effective in attaining a healthy periodontal status in patients with severe periodontal lesions. No additive effect was found when PVP-iodine was included.

CONCLUSIONS

Ultrasonic debridement using Odontogain is effective in controlling infection in patients with severe chronic periodontitis. PVP-iodine does not add any clinical benefit to the ultrasonic debridement alone under these circumstances.

Interaction of chlorhexidine with smooth and rough types of titanium surfaces

BACKGROUND

Chlorhexidine (CHX) digluconate exerts plaque inhibitory efficacy in the natural dentition environment due to a superior degree of persistence at the tooth surface. The purpose of the present study was to assess the interaction of CHX with titanium surfaces to estimate its antiplaque potential in the peri-implant environment.

METHODS

Saliva-coated machined smooth (S) and sand-blasted acid-etched rough (R) titanium disks were soaked in either 0.1% or 0.2% CHX solution. After 24 hours, CHX amounts that were adsorbed, washed out, and desorbed from the titanium surfaces were determined spectrophotometrically at 230 nm. The antibacterial activity of CHX-treated titanium disks was assessed by measuring bacterial inhibition zones on Streptococcus mutans lawns.

RESULTS

Titanium disks adsorbed 3% to 8% of the available CHX, which was significantly higher with 0.2% CHX (P<0.001) than with 0.1% CHX and two-fold higher on the R titanium disks compared to S titanium surface (P<0.001). After rinsing with water, 2.2% of the adsorbed CHX was washed out. Over 24 hours, S- and R-type disks released 1.1% and 0.6% of the adsorbed agent, respectively. Larger bacterial inhibition zones were obtained with 0.2% CHX and in R disks compared to S disks.

CONCLUSIONS

CHX displayed persistence at the titanium surface. The adsorption level and bacterial growth inhibition were affected by CHX concentration and titanium surface characteristics, with higher levels of adsorption and antibacterial activity with 0.2% CHX and rough titanium surface. The slow CHX release rate suggests persistence of this agent at the titanium-pellicle surface, which can provide a long-term antiplaque effect.

In Vitro, Clinical, and Microbiological Evaluation of a Linear Oscillating Device for Scaling and Root Planing

BACKGROUND

The purpose of this study was to conduct an in vitro and short-term clinical and microbiological evaluation of a linear oscillating device for scaling and root planing (SRP). A comparison was made between conventional ultrasonic scaling (US) and hand scaling (HS) with and without chlorhexidine.

METHODS

In vitro, SRP was carried out on human teeth with calculus. Roots and cross-sections thereof were microscopically examined for the efficacy of calculus removal, hard tissue loss, and surface smoothness. In vivo, 11 patients with chronic periodontitis and single-rooted teeth in all quadrants with probing depths of > or =5 mm were selected. One quadrant was treated with linear oscillation and compared to US with chlorhexidine irrigation in the contralateral site. The other arch was treated with HS and compared to HS followed by laser disinfection. One hundred twenty teeth were assessed for clinical attachment level, probing depth, bleeding on probing, and suppuration at baseline and 7, 28, 90, and 180 days. Microbiologically, total numbers of bacteria and six specific periodontal pathogens were determined by quantitative polymerase chain reaction prior to and 1 and 28 days after SRP. Clinical and microbiological data were analyzed statistically with respect to the SRP method, patient specificity, and time effect.

RESULTS

In vitro, linear oscillation preserved more root tissues but left more calculus (P <0.05). Significant improvements of all clinical and microbiological parameters were observed for all groups. However, 21 out of 24 tests demonstrated that the clinical microbiological correlations between linear oscillation and control groups did not differ (P <0.05).

CONCLUSION

Linear oscillation scaling was clinically acceptable and microbiologically comparable to the control groups despite microscopic remnants of calculus observed in vitro.

A chlorhexidine varnish implemented treatment strategy for chronic periodontitis. Short-term clinical observations

OBJECTIVES

The aim of this study was to investigate the clinical outcome of a subgingivally applied chlorhexidine varnish when used as an adjunct to scaling and root planing (SRP) in the treatment of chronic periodontitis.

MATERIAL AND METHODS

A randomized controlled, single blind, parallel trial was conducted on the basis of 16 volunteers suffering from chronic periodontitis. The control group received oral hygiene instructions and was scaled and root planed in two sessions. The test group received the same instructions and treatment, however, all pockets were additionally disinfected using a chlorhexidine varnish. The gingival index, plaque index, bleeding on probing, probing pocket depth (PPD) and clinical attachment level (CAL) were recorded at baseline and subsequently after 1 and 3 months.

RESULTS

Both treatment strategies showed significant reductions in PPD and CAL at both follow-up visits by comparison with baseline levels (p<0.001). Yet, at study termination, combination therapy resulted in additional pocket reductions between 0.73 and 1.23 mm (p<0.02), and clinical attachment gains between 0.63 and 1.09 mm (p<0.02).

CONCLUSIONS

These findings suggest that a varnish-implemented strategy may improve the clinical outcome for the treatment of chronic periodontitis in comparison with SRP alone.

Dentistry and endocarditis

Bacterial endocarditis (BE), a rare heart infection caused by a bacteremia, has frequently been blamed on but rarely caused by dental procedures. Viridans group streptococci are found abundantly in the mouth and the gingival sulcus but have been surpassed by staphylococci as the leading cause of BE. Antibiotic prophylaxis has been recommended before dental procedures in patients at risk for BE, but it remains controversial because studies have failed to show that antibiotic prophylaxis is an effective preventive for BE or that dental procedures are an important cause of BE. The risks and costs of antibiotic prophylaxis, including antibiotic resistance, cross-reactions with other drugs, allergy, anaphylaxis, and even death, may exceed the benefits in preventing BE. The rationale for the use of antibiotic prophylaxis to prevent BE allegedly caused by dental procedure bacteremias must be seriously reexamined based on recent evidence, particularly the absolute risk rates for endocarditis after a given dental procedure.

Microflora cultivable from minocycline strips placed in persisting periodontal pockets

OBJECTIVE

The microflora that develops on minocycline strips, used as an adjunct in non-surgical periodontal therapy was studied.

DESIGN AND METHODS

Minocycline (1.4 mg in polycaprolactone vehicle) and control strips were applied into all residual pockets (PD > or = 5mm, > or =2 pockets/subject) of patients with chronic periodontitis 1 month after a course of non-surgical periodontal therapy. Strips were inserted and retained for 3 days, changed to new strips for 3 more days and then removed. Strips were recovered from 14 (eight test, six control) of the 34 participants at day 0 (strip inserted, left for 30 s, removed), days 3 and 6, for (i) anaerobic culture, (ii) coliforms culture, using MacConkey agar, (iii) yeast culture, using Sabouraud's dextrose agar.

RESULTS

The mean anaerobic cfu/strip (x10(5); control/test) were 2/6, 24/2, 11/2 at days 0, 3 and 6, respectively (P > 0.05). The corresponding mean proportion of Gram-negative rods and fusiforms were 27%/21%, 27%/15% and 55%/8%. The proportions of Gram-negative rods on test strips by day 6 were significantly reduced (P < 0.05). A significantly increased prevalence of Streptococcus mitis biovar 1 was found on spent test strips (control versus test; 0% versus 38%, Fisher exact test, P = 0.01). Coliform prevalence at days 0, 3 and 6 on control/test strips were 0/13%, 50%/38% and 50%/13%. Yeasts were occasionally isolated.

CONCLUSIONS

The findings indicated that the minocycline strips but not the control strip supported a microbial colonisation compatible with periodontal health by day 6.

In vitro studies on controlled-release cellulose acetate films for local delivery of chlorhexidine, indomethacin, and meloxicam

BACKGROUND

Delivery of medications into periodontal pockets to suppress or eradicate the pathogenic microbiota or modulate the inflammatory response, thereby limiting periodontal tissue destruction, has attracted significant interest with the purpose of effective periodontal treatment. However, no study has previously attempted to develop a controlled-release formulation of anti-inflammatory agents to be used in the field of periodontology. The aim of the present study was to examine the in vitro release profile of chlorhexidine gluconate, indomethacin, and meloxicam from cellulose acetate films.

METHODS

Cellulose acetate films containing chlorhexidine gluconate, indomethacin, and meloxicam were prepared and cut in a form to fit to the periodontal pocket anatomy. The release of active agents was studied in 10 ml artificial saliva at 37 degrees C. Apparatus Vibrax was used at 150 r.p.m. Determinations were carried out spectrophotometrically and the release profiles were plotted as a function of time.

RESULTS

The formulations showed two different release patterns for a total observation period of approximately 120 h. When the formulations of the three active agents were compared, the release patterns of meloxicam and chlorhexidine gluconate were found to be similar, while the indomethacin-containing formulation exhibited the fastest release rate.

CONCLUSIONS

As a conclusion, cellulose acetate may be a suitable inert material for obtaining a prolonged local release of various anti-inflammatory agents like meloxicam. Further in vitro and in vivo studies are required before starting clinical applications of these controlled-release formulations of anti-inflammatory agents.

Clinical and microbiological effects of topical subgingival application of hyaluronic acid gel adjunctive to scaling and root planing in the treatment of chronic periodontitis

BACKGROUND

Hyaluronic acid (HA) has shown anti-inflammatory effects in gingivitis therapy. The potential benefits of local subgingival application of HA adjunctive to scaling and root planing (SRP) were evaluated in this study.

METHODS

Twenty patients with chronic periodontitis were included in this split-mouth study. Sulcus fluid flow rate (SFFR) and sulcus bleeding index were monitored at baseline and after 1, 2, 3, 4, 5, 6, and 12 weeks; probing depth and clinical attachment level were monitored at baseline and 6 and 12 weeks. Subgingival plaque samples were also taken at these same three appointments to determine the presence of Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Tannerella forsythensis, and Treponema denticola. All patients were treated with full-mouth scaling and root planing (SRP); in addition, an HA gel was administered subgingivally in the test sites every week for 6 weeks.

RESULTS

An improvement of all clinical variables was observed (P < 0.05) in both groups. Clinically, no difference between test and control sites could be found. No difference between test and control sites was seen in the tested microorganisms.

CONCLUSIONS

No clinical or microbiological improvement was achieved by the adjunctive use of HA gel compared to SRP alone. Only SFFR was affected by the use of HA in terms of a more rapid reduction of SFFR in the test sites.

Local anti-infective therapy: pharmacological agents. A systematic review

BACKGROUND

It is well recognized that periodontal diseases are bacterial in nature. An essential component of therapy is to eliminate or control these pathogens. This has been traditionally accomplished through mechanical means (scaling and root planing [SRP]), which is time-consuming, difficult, and sometimes ineffective. Over the past 20 years, locally delivered, anti-infective pharmacological agents, most recently employing sustained-release vehicles, have been introduced to achieve this goal.

RATIONALE

This systematic review evaluates literature-based evidence in an effort to determine the efficacy of currently available anti-infective agents, with and without concurrent SRP, in controlling chronic periodontitis.

FOCUSED QUESTION

In patients with chronic periodontitis, what is the effect of local controlled-release anti-infective drug therapy with or without SRP compared to SRP alone on changes in clinical, patient-centered, and adverse outcomes?

SEARCH PROTOCOL

MEDLINE, the Cochrane Central Trials Register, and Web of Science were searched. Hand searches were performed of the Journal of Clinical Periodontology, Journal of Periodontology, and Journal of Periodontal Research. Searches were performed for articles published through April 2002. In addition, investigators contacted editors of the above-mentioned journals and companies sponsoring research on these agents for related unpublished data and studies in progress.

SELECTION CRITERIA

INCLUSION CRITERIA

Studies included randomized controlled clinical trials (RCT), and case-controlled and cohort studies at least 3 months long. Therapeutic interventions had to include 1) SRP alone; 2) local anti-infective drug therapy and SRP; or 3) local anti-infective drug therapy alone. Included studies had to report patient-based mean values and measures of variation for probing depth (PD) and/or clinical attachment levels (CAL) for both test and control groups.

EXCLUSION CRITERIA

Studies were excluded if they: 1) included data from a previously published article; 2) included daily rinsing with chlorhexidine (CHX); or 3) had unclear descriptions of randomization procedures, examiner masking, or concomitant therapies.

DATA COLLECTION AND ANALYSIS

For the meta-analysis, PD and CAL were expressed as summary mean effects with 95% confidence intervals (CI) for the effect, and analyzed using a standardized difference between SRP alone and experimental agent groups. The results were assessed with both fixed-effects and random-effects models. Studies were ranked according to the York system.

MAIN RESULTS

1. Thirty-two studies were included (28 RCT, 2 cohort, and 2 case-control), incorporating a total patient population of 3,705 subjects. 2. Essentially all studies reported substantial reductions in gingival inflammation and bleeding indices, which were similar in both control and experimental groups. 3. A meta-analysis completed on 19 studies that included SRP and local sustained-release agents compared with SRP alone indicated significant adjunctive PD reduction or CAL gain for minocycline (MINO) gel, microencapsulated MINO, CHX chip and doxycycline (DOXY) gel during SRP compared to SRP alone. 4. Use of antimicrobial irrigants or anti-infective sustained-release systems as an adjunct to SRP does not result in significant patient-centered adverse events.

REVIEWERS' CONCLUSIONS

1. In some populations, anti-infective agents in a sustained-release vehicle alone can reduce PD and bleeding on probing (BOP) equivalent to that achieved by SRP alone. 2. No evidence was found for an adjunctive effect on reduction of PD and BOP of therapist-delivered CHX irrigation during SRP compared to SRP alone. 3. Additional RCTs are needed which evaluate the effectiveness of these therapies in all forms of periodontitis. 4. The study protocol for future RCTs should include appropriate statistical analyses and complete data sets to facilitate future evidence-based reviews. 5. Alternative surrogate parameters to PD and CAL need to be identified and validated such as microbial, inflammatory, or tissue-destructive markers that could be used in conjunction with clinical parameters to help determine the patient's response to emerging technologies that target the infectious and/or inflammatory aspects of periodontitis. 6. Future Phase IV clinical trials should be designed that evaluate local anti-infective therapies in conjunction with SRP in a manner consistent with current standards of care and evaluate cost-effectiveness. 7. The use of local anti-infective agents in at-risk patient populations and for the treatment of at-risk disease sites needs to be validated in randomized controlled clinical trials. 8. Several local anti-infective agents combined with SRP appear to provide additional benefits in PD reduction and CAL gain compared to SRP alone. The decision to use local anti-infective adjunctive therapy remains a matter of individual clinical judgment, the phase of treatment, and the patient's status and preferences.

Debridement and local application of tetracycline-loaded fibres in the management of persistent periodontitis: results after 12 months

BACKGROUNDS/AIMS

The aim of our study was to evaluate the clinical, radiological and microbiological response to the local delivery of tetracycline (TE) of sites with persistent periodontal lesions.

MATERIALS AND METHODS

The study was conducted in a split-mouth design. Nineteen patients with at least four bilateral pockets 4-5 mm and bleeding on probing (BOP) were treated with scaling and root planing (SRP) plus TE fibres (test sites) or with SRP alone (control sites). Clinical and radiological measurements were taken at baseline, 6 months and 12 months post-operatively. Subgingival plaque samples were collected at baseline, at fibres removal, 6 and 12 months following treatment and analysed by polymerase chain reaction.

RESULTS

Both treatments yielded a statistically significant (p<0.05) reduction of probing depth (2.05 and 1.21 mm), gain of clinical attachment level (1.71 and 0.53 mm) and reduction of BOP scores (23.68% and 57.89%) for TE and SRP groups, respectively, when comparing 12-month data with baseline. The differences between two groups were significant. The prevalence of Treponema denticola and Bacteroides forsythus decreased after therapy in both groups but only in the test sites Actinobacillus actinomycetemcomitans and Prevotella intermedia were not yield detected. The pathogens could be eliminated from five periodontal pockets by SRP alone, while 21 TE sites were not recolonized at 12 months.

CONCLUSIONS

SRP plus TE fibres gave the greatest advantage in the treatment of periodontal persistent lesions at least 12 months following treatment.

Locally delivered antimicrobials for the treatment of chronic periodontitis

The basic treatment of chronic periodontitis is a mechanical debridement of periodontal pockets by scaling and root planing (S/RP) in combination with efficient plaque control. Locally delivered antiseptics (LDA) have been proposed to practitioners and, while subgingival irrigation of antiseptics is still used in clinical practice, the introduction in our therapy of a slow release and sub-gingival delivery of tetracycline has changed the rationale from a mechanical treatment towards a combined therapy for full mouth/sites disinfection. Various antibiotics, antiseptics and resorbable carriers are now proposed with similar targets to arrest disease progression. In chronic periodontitis, LDA cannot be used routinely in combination with S/RP, because of the limited clinical benefit, even if an increased percentage of deep sites may show an improvement. Prospective multicenter studies considering risk factors for disease progression have to be designed to identify patients who may benefit the most from LDA. For non-responding sites or recurrent pockets, the controversies are limited, because a combined S/RP and LDA may avoid the need for surgery. However, the patient cost/benefit ratio needs to be estimated as well as adverse effects in particular antibiotics.

Penetrating the plaque biofilm: impact of essential oil mouthwash

The interaction between saliva-coated tooth surfaces and pathogenic bacteria is partly governed by electrostatic and hydrophobic interactions, providing a solid rationale for using chemical agents as part of a plaque-control routine. Chlorhexidine works in several ways. For example, it binds to salivary mucins on the bacterial cell membrane, and penetrates the plaque biofilm. Essential oil (EO) mouthwashes kill micro-organisms by disrupting their cell walls and inhibiting their enzymic activity. They prevent bacterial aggregation, slow multiplication and extract endotoxins. Recent studies have shown that bacterial phenotypes are altered when organisms change from a planktonic to a sessile state. This suggests that an effective mouthwash must also penetrate the plaque biofilm. Two studies have demonstrated the ability of an EO mouthwash to penetrate the plaque biofilm.

Selection of antimicrobial agents in periodontal therapy

BACKGROUND

The recognition over the past 3 decades of microbial specificity in periodontitis has afforded dental practitioners the ability to prevent and treat the disease with a variety of antimicrobial drugs. These include systemic antibiotics, topical antibiotics and topical antiseptics.

RESULTS

Systemic antibiotic therapy can be essential in eliminating pathogenic bacteria that invade gingival tissue and in helping control periodontal pathogens residing in various domains of the mouth from where they may translocate to periodontal sites. Frequently used periodontal combination antibiotic therapies are metronidazole-amoxicillin (250-375 mg of each 3 x daily for 8 days) and metronidazole-ciprofloxacin (500 mg of each 2 x daily for 8 days). Microbiological analysis helps determine the optimal antibiotic therapy and effectiveness of treatment. Topical antibiotics that are commercially available as controlled release devices suffer from several potential problems, including insufficient spectrum of antimicrobial activity in some periodontal polymicrobial infections, risks of producing an antibiotic resistant microbiota, and high acquisition costs. Topical antiseptics of relevance in periodontal treatment include 10% povidone-iodine placed subgingivally by a syringe for 5 min, and 0.1% sodium hypochlorite solution applied subgingivally by patients using an irrigation device.

CLINICAL IMPLICATIONS

The present paper recommends periodontal treatment that includes a battery of professionally and patient-administered antimicrobial agents (properly prescribed systemic antibiotics, povidone-iodine and sodium hypochlorite subgingival irrigants, and chlorhexidine mouthrinse). Available chemotherapeutics can provide effective, safe, practical and affordable means of controlling subgingival colonization of periodontal pathogens and various types of periodontal disease.