Systemic anti-infective periodontal therapy. A systematic review

Effect of gallium aluminium arsenide diode laser therapy on Porphyromonas gingivalis in chronic periodontitis: a randomized controlled trial

OBJECTIVES

The aim of this randomized, controlled trial was to evaluate the effects of 685-nm gallium aluminium arsenide (GaAlAs) diode laser therapy (1.6 J cm^-2 ) as an adjunct to scaling and root planing in the treatment of chronic periodontitis.

METHODS

Thirty-two patients aged 35-60 years old who had chronic periodontitis met the eligibility criteria. They were randomly assigned to two equal groups: scaling and root planing were performed in the SRP group, while scaling, root planing and laser irradiation of periodontal pockets were performed in the SRP + DL group. Subgingival plaque samples were subjected to polymerase chain reaction (PCR) to detect P. gingivalis-colonized sites, and common clinical indices were evaluated before and 2 months after treatment. Clinical examination included gingival index (GI), plaque index (PI), probing depth (PD), clinical attachment level (CAL) and gingival bleeding index (GBI), all of which were recorded.

RESULTS

Data from 30 patients [19 women and 11 men; mean age, 48.4 (5.4) years old] were analysed. There were statistically significant improvements in GI, PD, CAL and GBI for the SRP + DL group compared to SRP group but no significant difference in PI between the groups. Additionally, the percentage of P. gingivalis-positive sites in the SRP + DL group decreased from 80% (12/15) to 20% (3/15) after laser irradiation (P < 0.05). No significant changes were noted in the SRP group.

CONCLUSION

GaAlAs diode laser irradiation of diseased periodontal pockets at 685 nm and 1.6 J cm^-2 seemed to be an effective adjuvant to mechanical instrumentation to treat chronic periodontitis.

Efficacy of Combined Photoablative-Photodynamic Diode Laser Therapy Adjunctive to Scaling and Root Planing in Periodontitis: Randomized Split-Mouth Trial with 4-Year Follow-Up

OBJECTIVE

We previously showed that photoablative laser therapy followed by multiple photodynamic cycles (PAPD) after scaling/root planing (SRP) improved healing of periodontitis patients as compared with conventional SRP after 1-year follow-up. This study reports the favorable results of PAPD plus SRP in patients with chronic periodontitis at a 4-year follow-up.

MATERIALS AND METHODS

Twenty-four patients were studied. Maxillary left or right quadrants were randomly assigned to PAPD laser treatment or sham-treatment and SRP. PAPD consisted of: (1) photoablative intra/extrapocket de-epithelization with diode laser (λ 810 nm, 1 W), and (2) photodynamic treatments (4-10 weekly) with diode laser (λ 635 nm, 100 mW) and 0.3% methylene blue as photoactive antiseptic, performed after SRP. Sham treatment was performed with switched- off laser. Probing depth (PD), clinical attachment level (CAL), and bleeding-on-probing (BOP) were evaluated. Additional disease markers, namely polymorphonuclear leukocytes (PMN), erythrocytes (RBC), damaged epithelial cells (DEC), and bacteria were assayed by cytofluorescence on gingival exfoliative samples.

RESULTS

At 4-year follow-up, PAPD plus SRP significantly improved PD, CAL, and BOP, as well as bacterial contamination and PMN-RBC shedding in the exfoliative samples, compared with sham treatment plus SRP. This effect was greater than that observed at 1-year follow-up.

CONCLUSIONS

PAPD plus SRP provided significant, durable improvement of chronic periodontitis over sham treatment plus SRP alone.

Should Antibiotics Be Prescribed to Treat Chronic Periodontitis?

Although scaling and root planing is a cost-effective approach for initial treatment of chronic periodontitis, it fails to eliminate subgingival pathogens and halt progressive attachment loss in some patients. Adjunctive use of systemic antibiotics immediately after completion of scaling and root planing can enhance the degree of clinical attachment gain and probing depth reduction provided by nonsurgical periodontal treatment. This article discusses the rationale for prescribing adjunctive antibiotics, reviews the evidence for their effectiveness, and outlines practical issues that should be considered before prescribing antibiotics to treat chronic periodontitis.

Maintenance periodontal therapy after systemic antibiotic and regenerative therapy of generalized aggressive periodontitis. A case report with 10-year follow-up

Aggressive periodontitis (AgP) is an inflammatory disease characterized by rapid attachment loss and bone destruction. This case report presents the 10-year results in a subject with generalized AgP treated by a regenerative periodontal therapeutic approach and the adjunctive use of antibiotics, following a systematic maintenance periodontal therapy. The use of enamel matrix derivatives (EMD) and adjunctive antibiotic therapy to treat AgP yielded improvements in clinical parameters and radiographic bony fill. This combined therapeutic approach following a systematic supportive periodontal therapy supports the long-term maintenance of teeth with previous advanced periodontal defects, demonstrating successful stability after 10-years follow-up. Clinical Relevance: The combined treatment protocol using EMD plus adjunctive antibiotic therapy, associated with a systematic supportive periodontal therapy, benefits the long-term maintenance of teeth with previous advanced periodontal defects in subjects presenting AgP, supporting this approach as an alternative in the treatment of AgP.

Systemic moxifloxacin vs amoxicillin/metronidazole adjunct to non-surgical treatment in generalized aggressive periodontitis

Background

The objective of this randomized clinical study was to evaluate the effect of systemic administration of moxifloxacin compared to amoxicillin and metronidazole, combined with non-surgical treatment in patients with generalized aggressive periodontitis (GAgP) in a 6-month follow-up.

Material and Methods

A total of 39 systemically healthy patients with GAgP were evaluated in this randomized clinical trial. Periodontal parameters were recorded at the baseline during the 1st, 3rd and 6th month. Patients received either 400 mg of moxifloxacin per os once daily or 500 mg of metronidazole and 500 mg amoxicillin per os three times daily for 7 days consecutively.

Results

No significant differences between groups were found in any parameters at the baseline. Both groups led to a statistically significant decrease in all clinical periodontal parameters compared to the baseline (PI, p<0.001 and GI, PD, BOP, CAL, p<0.01). There were no differences between the 1st and 3rd months or the 3rd and 6th months for clinical parameters in the groups. Also, no intergroup difference was observed in any parameters at any time, except the gingival index at 6th months.

Conclusions

Systemic administration of moxifloxacin as an adjunct to non-surgical treatment significantly improves clinical outcomes and provides comparable clinical improvement with less adverse events to that of combination of amoxicillin and metronidazole in the treatment of GAgP.

Key words: Aggressive periodontitis, amoxicillin, metronidazole, moxifloxacin, nonsurgical periodontal debridement.

Clinical Factors Influencing the Efficacy of Systemic Moxifloxacin in the Therapy of Patients With Generalized Aggressive Periodontitis: A Multilevel Analysis From a Clinical Trial

Background:

It has been reported that clinical results of mechanical periodontal treatment could differ between subjects and among different sites of the tooth in the patient. The objective of this multilevel analysis is to investigate clinical factors at subject and sites of the tooth that influence variations in clinical attachment (CAL) increase and probing depth (PD) diminution of adjunctive moxifloxacin (MOX) at six months post-treatment in generalized aggressive periodontitis.

Methods:

This clinical trial included 40 patients randomly distributed to two therapy protocols: scaling and root planing alone or combined with MOX. Multilevel linear models for continuous variables were formulated to evaluate the clinical impact of the hierarchical configuration of periodontal data.

Results:

Six months following therapy, the divergences between both protocols were statistically significant in PD diminution and CAL increase, favouring the MOX therapy (p<0.001). Besides, the multilevel analysis revealed that adjunctive MOX at the subject level, non-molar and the interaction non-molar x MOX at the tooth level, interproximal sites and the interaction interproximal sites x MOX at the site level, were statistically significant factors in determining CAL increase and PD diminution.

Conclusions:

The main cause of variability in CAL gain and PD reduction following adjunctive MOX was attributable to the tooth level. Adjunctive MOX and their interactions with non-molar and interproximal sites showed higher clinical benefits at the tooth and site levels which could be essential for PD reduction and CAL gain in generalized aggressive periodontitis subjects.

Non-surgical periodontal therapy supplemented with systemically administered azithromycin: a systematic review of RCTs

BACKGROUND

Azithromycin may be an alternative adjunctive systemic antibiotic in non-surgical periodontal therapy.

OBJECTIVE

This study aims to identify randomized controlled trials evaluating non-surgical periodontal treatment of chronic and/or aggressive periodontitis supplemented with systemically administered azithromycin.

MATERIALS AND METHODS

A systematic literature search was performed for publications published by 31 March 2014 using electronic databases and hand search. Randomized controlled trials published in English or German language, with a follow-up ≥6 months were included. From 231 titles identified, nine publications were eligible for inclusion.

RESULTS

Among the studies included, showing some risk of bias, seven reported on patients with chronic periodontitis and two with aggressive periodontitis. Minor adverse events were described in five studies. A synthesis of results using a vote counting method was applied. Significant (p < 0.05) beneficial effects of azithromycin were shown in six studies for probing depth changes and in five studies for clinical attachment level changes.

CONCLUSION

In contrast to aggressive periodontitis patients, data from this analysis indicate a potential benefit of systemic azithromycin as adjunctive to non-surgical periodontal therapy in chronic periodontitis patients.

CLINICAL RELEVANCE

When contraindications for the standard antibiotics are present, azithromycin (AZM) may be considered as alternative systemically administered antibiotic drug in selected cases of chronic periodontitis.

Comparison of an essential-oil-based oral rinse and chlorhexidine as adjuncts to scaling and root planing in the treatment of periodontal inflammation

OBJECTIVE

The aim of the present short-term follow-up study was to compare the effects of an essential oil (EO)-based oral rinse and chlorhexidine as adjuncts to scaling and root planing (SRP) in the treatment of periodontal inflammation.

METHODS

In Group-1, SRP was performed and participants were instructed to rinse with EO-based oral rinse; in Group-2, SRP was performed and participants were instructed to rinse with chlorhexidine; and in Group-3, SRP was performed and participants were instructed to rinse with water. Periodontal parameters (plaque index [PI], bleeding-on-probing [BOP], and probing pocket depth [PPD] ≥ 4 mm) were assessed at baseline and after 7 and 30 days.

RESULTS

In all groups, periodontal parameters (PI, BOP, and PPD ≥ 4 mm) were comparable at baseline. In Groups-1 and -2, there was a significant reduction in PI (P < 0.01), BOP (P < 0.01), and PD ≥ 4 mm after 7 days and 30 days of follow-up than baseline. In Group-3, there was a significant reduction in PI (P < 0.01) and BOP (P < 0.01) after 7 days of follow-up compared to baseline. There was no difference in periodontal parameters after 7 days and 30 days of follow-up in Groups-1 and -2.

CONCLUSION

EO-based oral rinses and chlorhexidine digluconate (CHX) are acceptable adjuncts to SRP in the treatment of periodontal inflammation.

Long-term evaluation of the antimicrobial susceptibility and microbial profile of subgingival biofilms in individuals with aggressive periodontitis

This study evaluates the antimicrobial susceptibility and composition of subgingival biofilms in generalized aggressive periodontitis (GAP) patients treated using mechanical/antimicrobial therapies, including chlorhexidine (CHX), amoxicillin (AMX) and metronidazole (MET). GAP patients allocated to the placebo (C, n = 15) or test group (T, n = 16) received full-mouth disinfection with CHX, scaling and root planning, and systemic AMX (500 mg)/MET (250 mg) or placebos. Subgingival plaque samples were obtained at baseline, 3, 6, 9 and 12 months post-therapy from 3–4 periodontal pockets, and the samples were pooled and cultivated under anaerobic conditions. The minimum inhibitory concentrations (MICs) of AMX, MET and CHX were assessed using the microdilution method. Bacterial species present in the cultivated biofilm were identified by checkerboard DNA-DNA hybridization. At baseline, no differences in the MICs between groups were observed for the 3 antimicrobials. In the T group, significant increases in the MICs of CHX (p < 0.05) and AMX (p < 0.01) were detected during the first 3 months; however, the MIC of MET decreased at 12 months (p < 0.05). For several species, the MICs significantly changed over time in both groups, i.e., Streptococci MICs tended to increase, while for several periodontal pathogens, the MICs diminished. A transitory increase in the MIC of the subgingival biofilm to AMX and CHX was observed in GAP patients treated using enhanced mechanical therapy with topical CHX and systemic AMX/MET. Both protocols presented limited effects on the cultivable subgingival microbiota.

Microbial flora in chronic periodontitis: study at a tertiary health care center from north karnataka

Background and Objective:

Periodontitis is a major public health problem in India with a prevalence of 60–80%. If untreated it acts as a risk factor for systemic diseases. Data on anaerobic periodontal microflora in the Indian population is very scarce. Hence, this study was undertaken to know the nature of oral microbiota in chronic periodontitis in this region of India and also the semiquantitative study in pre- and post-treatment group and to determine antibiotic susceptibility pattern for aerobic isolates.

Materials and Methods:

The present study was conducted on 60 cases. Material was collected from the subgingival pockets in patients with chronic periodontitis attending the Periodontology, Outpatient Department. Clinical samples were transported to the laboratory in fluid thioglycollate medium. Initially Gram's stain and Fontana stains were done. Aerobic, anaerobic, and microaerophilic culture were put up. Antibiotic sensitivity test was done for aerobic isolates.

Results:

Sixty samples yielded 121 isolates of which 78.34% were polymicrobial, 11.66% were monomicrobial and oral commensals were grown in 10% cases. Out of 121 isolates 91.74% were anaerobic, 7.43% were aerobic and 0.83% were microaerophilic. Fusobacterium species was the most common isolate among anaerobes. Using “paired t-test” “P” value was significant indicating significant reduction in colony count after phase-I periodontal therapy.

Conclusion:

This study has shown that anaerobic bacteria are important cause of chronic periodontitis, along with aerobes and microaerophilic organisms. Fusobacterium spp, Bacteroides fragilis, Porphyromonas spp and Prevotella intermedia are the most common anaerobic pathogens. Bacterial culture methods are still economical and gold standard.

Adjunctive use of antibiotics in periodontal therapy

Periodontal diseases are infectious diseases with a mixed microbial aetiology and marked inflammatory response leading to destruction of underlying tissue. Periodontal therapy aims to eliminate pathogens associated with the disease and attain periodontal health. Periodontitis is generally treated by nonsurgical mechanical debridement and regular periodontal maintenance care. Periodontal surgery may be indicated for some patients to improve access to the root surface; however, mechanical debridement alone may not be helpful in all cases. In such cases, adjunctive systemic antibiotic therapy remains the treatment of choice. It can reach microorganisms at the base of the deep periodontal pockets and furcation areas via serum, and also affects organisms residing within gingival epithelium and connective tissue. This review aims to provide an update on clinical issues regarding when and how to prescribe systemic antibiotics in periodontal therapy. The points discussed are the mode of antibiotic action, susceptible periodontal pathogens, antibiotic dosage, antibiotic use in treatment of periodontal disease, and mechanism of bacterial resistance to each antibiotic.

Clinical effect of locally delivered gel containing green tea extract as an adjunct to non-surgical periodontal treatment

Green tea catechins had an in vitro antibacterial effect against periodontopathic bacteria and were able to inhibit destruction of the periodontal tissue. In this study, we aimed to evaluate the effect of locally delivered gel containing green tea extract as an adjunct to non-surgical periodontal treatment. Forty-eight subjects who had teeth with probing pocket depth of 5-10 mm were randomly allocated into the test or control group. Probing pocket depth, clinical attachment level, gingival index (GI), bleeding on probing (BOP) and full mouth plaque score were measured at baseline. Subjects received oral hygiene instruction, single episode of scaling and root planing and subgingival application of the green tea gel (test group) or the placebo gel (control group). The gel was repeatedly applied at 1 and 2 weeks later. The parameters were recorded again at the 1st, 3rd and 6th month after the last gel application. The results showed that all parameters were improved in both groups compared to baseline. The test group exhibited significantly higher reduction in BOP at the 3rd month (p = 0.003) and significantly lower GI at the 1st month (p < 0.001) and 3rd month (p < 0.001) when compared with the control group. Thus, green tea gel could provide a superior benefit in reducing bleeding on probing and gingival inflammation when used as an adjunct to non-surgical periodontal treatment. (

TRIAL REGISTRATION

MU-IRB 2008/153.0511, ClinicalTrials.gov NCT00918060).

Periodontal status among patients with diabetes in Nuuk, Greenland

Background

Diabetes is becoming more common in the Greenlandic population. Patients with diabetes are more prone to periodontal disease. Periodontal status may have an effect on metabolic control.

Objective

The aim of this study was to estimate the prevalence of periodontitis amongst patients with diabetes in Nuuk, Greenland, and secondly, to observe if dental care was associated with improved periodontal status and metabolic control.

Study design

Observational cross-sectional study and a pilot study of a dental care intervention.

Methods

Sixty-two Greenlandic patients with diabetes were included in the study. Data were collected from the Electronic Medical Records (EMR), in addition to a telephone interview. Patients were offered 3 dental examinations with a 3-month interval. The dental examinations consisted of a full-mouth assessment of number of remaining teeth and assessment of periodontal status. Patients received scaling and root planing, together with information and instructions on oral hygiene. Information on glycated haemoglobin (HbA_1C) values was collected from the EMR at each dental examination.

Results

In this study, 21.0% (13/62) of patients with diabetes had periodontitis. About 42% had less than 20 teeth. The association between diabetes and periodontitis was known by 20 out of the 62 patients. Over half of the patients had been to a dental examination within the last year. The prevalence of periodontitis decreased significantly from 21.0 to 0% (p<0.001) after 3 dental examinations. No change in HbA_1C levels was observed (p=0.440).

Conclusion

Periodontitis was common among patients with diabetes in Nuuk. Dental health status based on Periodontal Screening Index (PSI) and bleeding on probing (BOP) seemed to improve after dental health care, indicating a need for increased awareness among patients and health care professionals. HbA_1C levels were not improved among the patients.

Non-surgical periodontal therapy: An update on current evidence

Periodontal disease is an inflammatory condition that involves a complex interaction between pathogenic bacteria, environmental and acquired factors and host related factors. Till recently periodontal treatment was directed primarily towards reduction of bacterial load by subgingival debridement of root surfaces and modification of environmental risk factors. The current paradigm of periodontal disease stresses greater role of host-mediated inflammatory response in tissue destruction characteristic of periodontal disease. Various therapeutic modalities have been developed adjuvant to mechanical periodontal therapy. The use of laser and photodynamic therapy show great promise but their effectiveness has still not been conclusively proven. Chemotherapeutic agents, either systemic and local antimicrobials or host modulating drugs, played pivotal role in better and more predictable management of periodontal disease. The present review focuses on the best available evidence, for the current management of the chronic periodontal patients, gathered from systematic reviews and meta-analysis of mechanical non surgical periodontal therapy (NSPT) (subgingival debridement, laser therapy and photodynamic therapy) and the adjunctive chemotherapeutic approaches such as systematic and local antibiotics and antiseptics, subgingival pocket irrigation and host modulation therapies. The review also attempts to briefly introduce future developments in some of these modalities. At the end, the review summarizes the analysis of the current evidence that suggests that thorough subgingival debridement remains the mainstay of NSPT and that adjunct use of chemotherapeutic agents may offer better management of clinical parameters in periodontitis patients.

Structure and mechanism of cysteine peptidase gingipain K (Kgp), a major virulence factor of Porphyromonas gingivalis in periodontitis

Cysteine peptidases are key proteolytic virulence factors of the periodontopathogen Porphyromonas gingivalis, which causes chronic periodontitis, the most prevalent dysbiosis-driven disease in humans. Two peptidases, gingipain K (Kgp) and R (RgpA and RgpB), which differ in their selectivity after lysines and arginines, respectively, collectively account for 85% of the extracellular proteolytic activity of P. gingivalis at the site of infection. Therefore, they are promising targets for the design of specific inhibitors. Although the structure of the catalytic domain of RgpB is known, little is known about Kgp, which shares only 27% sequence identity. We report the high resolution crystal structure of a competent fragment of Kgp encompassing the catalytic cysteine peptidase domain and a downstream immunoglobulin superfamily-like domain, which is required for folding and secretion of Kgp in vivo. The structure, which strikingly resembles a tooth, was serendipitously trapped with a fragment of a covalent inhibitor targeting the catalytic cysteine. This provided accurate insight into the active site and suggested that catalysis may require a catalytic triad, Cys(477)-His(444)-Asp(388), rather than the cysteine-histidine dyad normally found in cysteine peptidases. In addition, a 20-Å-long solvent-filled interior channel traverses the molecule and links the bottom of the specificity pocket with the molecular surface opposite the active site cleft. This channel, absent in RgpB, may enhance the plasticity of the enzyme, which would explain the much lower activity in vitro toward comparable specific synthetic substrates. Overall, the present results report the architecture and molecular determinants of the working mechanism of Kgp, including interaction with its substrates.

Non-surgical periodontal therapy with systemic antibiotics in patients with untreated chronic periodontitis: a systematic review and meta-analysis

OBJECTIVE

The purpose of this meta-analysis is to evaluate the effectiveness of different systemic antibiotics in combination with scaling and root planing (SRP) when compared to SRP alone in patients with untreated chronic periodontitis.

BACKGROUND

Although chronic periodontitis is mostly treated without adjunctive systemic antibiotics, some recent meta-analyses have shown clinical benefit for some systemic antibiotics when used as an adjunct to SRP. However, there is a wide variety of systemic antibiotic regimens used today. It remains unclear if the selected type of systemic antibiotic influences the magnitude of clinical benefit.

MATERIAL AND METHODS

The MEDLINE-PubMed database was searched from their earliest records through May 16, 2013. Several journals were hand searched and some authors were contacted for additional information. Outcome measures analysed were mean bleeding on probing change, mean clinical attachment level gain and mean probing pocket depth reduction. Extracted data were pooled using a random effect model. Weighted mean differences were calculated and heterogeneity was assessed.

RESULTS

The search yielded 281 abstracts. Ultimately, 95 studies were selected, describing 43 studies meeting the eligibility criteria. Systemic antibiotics showed a significant (p < 0.05) additional pocket depth reduction for moderate (at 3 mo 0.27 mm ± 0.09, at 6 mo 0.23 mm ± 0.10 and at 12 mo 0.25 mm ± 0.27) and deep pockets (at 3 mo 0.62 mm ± 0.17, at 6 mo 0.58 mm ± 0.16 and at 12 mo 0.74 mm ± 0.30). Statistically, no specific type of antibiotic was superior over another. However, when analysing the clinical data for initially moderate pockets or deep pockets, some trends became apparent.

CONCLUSION

Systemic antibiotics combined with SRP offer additional clinical improvements compared to SRP alone. Although there were no statistically significant differences, there was a trend that for initially moderate and deep pockets, metronidazole or metronidazole combined with amoxicillin, resulted in clinical improvements that were more pronounced over doxycycline or azithromycin. Additionally, there was a trend that the magnitude of the clinical benefit became smaller over time (1 year).

Pathogenicity of the highly leukotoxic JP2 clone of Aggregatibacter actinomycetemcomitans and its geographic dissemination and role in aggressive periodontitis

For decades, Aggregatibacter actinomycetemcomitans has been associated with aggressive forms of periodontitis in adolescents. In the middle of the 1990s, a specific JP2 clone of A. actinomycetemcomitans, belonging to the cluster of serotype b strains of A. actinomycetemcomitans and having a number of other characteristics, was found to be strongly associated with aggressive forms of periodontitis, particularly in North Africa. Although several longitudinal studies still point to the bacterial species, A. actinomycetemcomitans as a risk factor of aggressive periodontitis, it is now also widely accepted that the highly leukotoxic JP2 clone of A. actinomycetemcomitans is implicated in rapidly progressing forms of aggressive periodontitis. The JP2 clone strains are highly prevalent in human populations living in Northern and Western parts of Africa. These strains are also prevalent in geographically widespread populations that have originated from the Northwest Africa. Only sporadic signs of a dissemination of the JP2 clone strains to non-African populations have been found despite Africans living geographically widespread for hundreds of years. It remains an unanswered question if a particular host tropism exists as a possible explanation for the frequent colonization of the Northwest African population with the JP2 clone. Two exotoxins of A. actinomycetemcomitans are known, leukotoxin (LtxA) and cytolethal distending toxin (Cdt). LtxA is able to kill human immune cells, and Cdt can block cell cycle progression in eukaryotic cells and thus induce cell cycle arrest. Whereas the leukotoxin production is enhanced in JP2 clone strains thus increasing the virulence potential of A. actinomycetemcomitans, it has not been possible so far to demonstrate such a role for Cdt. Lines of evidence have led to the understanding of the highly leukotoxic JP2 clone of A. actinomycetemcomitans as an aetiological factor of aggressive periodontitis. Patients, who are colonized with the JP2 clone, are likely to share this clone with several family members because the clone is transmitted through close contacts. This is a challenge to the clinicians. The patients need intense monitoring of their periodontal status as the risk for developing severely progressing periodontal lesions are relatively high. Furthermore, timely periodontal treatment, in some cases including periodontal surgery supplemented by the use of antibiotics, is warranted. Preferably, periodontal attachment loss should be prevented by early detection of the JP2 clone of A. actinomycetemcomitans by microbial diagnostic testing and/or by preventive means.

Antibiotics in the treatment of periodontal disease: a guide for the general dental practitioner

The objective of the present paper is to discuss the appropriate use of systemic and local adjunctive antibiotics/antimicrobials in the management of periodontal diseases using a number of case studies to illustrate an evidence-based approach to treatment.

Clinical and microbiological effects of systemic azithromycin in adjunct to nonsurgical periodontal therapy in treatment of Aggregatibacter actinomycetemcomitans associated periodontitis: a randomized placebo-controlled clinical trial

OBJECTIVE

This study aimed to evaluate clinical and microbiological effects of systemic azithromycin (AZM) in adjunct to nonsurgical periodontal therapy (NSPT; or scaling root planing - SRP) in treatment of Aggregatibacter actinomycetemcomitans associated periodontitis (AAAP).

METHODS AND MATERIALS

Seventy individuals with moderate to severe periodontitis and subgingival detection of A. actinomycetemcomitans were randomly allocated to two groups. Thirty-five individuals were allocated to full mouth SRP+AZM (500 mg oral delivery (OD) × 3 days) while 35 individuals were allocated to SRP+Placebo (OD × 3 days) group. The clinical variables evaluated were probing depth (PD), clinical attachment level (CAL), gingival index (GI), plaque index (PI), and percent bleeding on probing sites (%BOP), while microbiologic variables included percentage of subjects positive for A. actinomycetemcomitans at baseline, 3, 6, and 12 months.

RESULTS

The AZM group showed statistically significant reduction in mean PD (2.91 ± 0.88 mm) as compared to placebo (1.51 ± 0.98 mm) (P < 0.001), while CAL gain was significant in the AZM group (2.71 ± 1.15 mm) as compared to the placebo group (1.71 ± 1.29 mm) (P < 0.001). There was also a statistically significant reduction in the number of subjects positive for A. actinomycetemcomitans in the AZM group (P < 0.0001).

CONCLUSION

Azithromycin was found to significantly improve the clinical and microbiological parameters in AAAP individuals.

Evaluation of the role of antibiotics in preventing postoperative complication after routine periodontal surgery: A comparative clinical study

Background and Objectives:

Aim of this randomly controlled clinical study was to evaluate the role of antibiotics to prevent postoperative complications after routine periodontal surgery and also to determine whether their administration improved the surgical outcome.

Materials and Methods:

Forty-five systemically healthy patients with moderate to severe chronic periodontitis requiring flap surgery were enrolled in the study. They were randomly allocated to Amoxicillin, Doxycycline, and control groups. Surgical procedures were carried out with complete asepsis as per the protocol. Postoperative assessment of patient variables like swelling, pain, temperature, infection, ulceration, necrosis, and trismus was performed at intervals of 24 h, 48 h, 1 week, and 3 months. Changes in clinical parameters such as gingival index, plaque index, probing pocket depth, and clinical attachment level were also recorded.

Results:

There was no incidence of postoperative infection in any of the patients. Patient variables were comparable in all the three groups. Though there was significant improvement in the periodontal parameters in all the groups, no statistically significant result was observed for any group over the others.

Conclusion:

Results of this study showed that when periodontal surgical procedures were performed following strict asepsis, the incidence of clinical infection was not significant among all the three groups, and also that antibiotic administration did not influence the outcome of surgery. Therefore, prophylactic antibiotics for patients who are otherwise healthy administered following routine periodontal surgery to prevent postoperative infection are unnecessary and have no demonstrable additional benefits.

Lessons learned and unlearned in periodontal microbiology

Periodontal diseases are initiated by bacterial species living in polymicrobial biofilms at or below the gingival margin and progress largely as a result of the inflammation elicited by specific subgingival species. In the past few decades, efforts to understand the periodontal microbiota have led to an exponential increase in information about biofilms associated with periodontal health and disease. In fact, the oral microbiota is one of the best-characterized microbiomes that colonize the human body. Despite this increased knowledge, one has to ask if our fundamental concepts of the etiology and pathogenesis of periodontal diseases have really changed. In this article we will review how our comprehension of the structure and function of the subgingival microbiota has evolved over the years in search of lessons learned and unlearned in periodontal microbiology. More specifically, this review focuses on: (i) how the data obtained through molecular techniques have impacted our knowledge of the etiology of periodontal infections; (ii) the potential role of viruses in the etiopathogenesis of periodontal diseases; (iii) how concepts of microbial ecology have expanded our understanding of host-microbe interactions that might lead to periodontal diseases; (iv) the role of inflammation in the pathogenesis of periodontal diseases; and (v) the impact of these evolving concepts on therapeutic and preventive strategies to periodontal infections. We will conclude by reviewing how novel systems-biology approaches promise to unravel new details of the pathogenesis of periodontal diseases and hopefully lead to a better understanding of their mechanisms.

Surgical and nonsurgical periodontal therapy. Learned and unlearned concepts

This review aims to highlight concepts relating to nonsurgical and surgical periodontal therapy, which have been learned and unlearned over the past few decades. A number of treatment procedures, such as gingival curettage and aggressive removal of contaminated root cementum, have been unlearned. Advances in technology have resulted in the introduction of a range of new methods for use in nonsurgical periodontal therapy, including machine-driven instruments, lasers, antimicrobial photodynamic therapy and local antimicrobial-delivery devices. However, these methods have not been shown to offer significant benefits over and above nonsurgical debridement using hand instruments. The method of debridement is therefore largely dependent on the preferences of the operator and the patient. Recent evidence indicates that specific systemic antimicrobials may be indicated for use as adjuncts to nonsurgical debridement in patients with advanced disease. Full-mouth disinfection protocols have been proven to be a relevant treatment option. We have learned that while nonsurgical and surgical methods result in similar long-term treatment outcomes, surgical therapy results in greater probing-depth reduction and clinical attachment gain in initially deep pockets. The surgical technique chosen seems to have limited influence upon changes in clinical attachment gain. What has not changed is the importance of thorough mechanical debridement and optimal plaque control for successful nonsurgical and surgical periodontal therapy.

Periodontal debridement: still the treatment of choice

Periodontal debridement (PD) remains a gold standard for the treatment of inflammatory periodontitis.

BACKGROUND/PURPOSE

The evidence base regarding the causal relationship between oral biofilm and the host inflammatory response to the etiology of periodontal disease has substantially increased over the years. What has not changed significantly during that time is the conservative manner in which the disease can be treated with periodontal debridement (PD). Since dental hygienists, in particular, specialize in providing these procedures it is important to evaluate the evidence that supports periodontal debridement as a primary and fundamental treatment modality.

METHOD

An extensive narrative literature review that included systematic reviews, examined traditional PD, the use of adjuncts to enhance PD and newer PD procedures to determine what are the best practices for achieving optimal clinical outcomes.

CONCLUSION

Compared to surgical therapy, PD results in maintenance of attachment levels over time, but is not as effective in the initial reduction of probing depths in deep pockets. Sustained release local drug delivery agents have some modest adjunctive effects when used with PD, as do systemic antibiotics in aggressive periodontitis cases. Reported analyses of the long term effects of chemotherapeutic agents usually do not extend beyond a few months to a year. While laser therapy is still under investigation it remains as a potential PD therapy. New instruments being refined to better visualize the root surface either non-surgically or with mini papilla reflection flaps, hold promise for the future when they become more affordable and accessible. Despite the development of new technology, it still appears that periodontal debridement (PD) remains the gold standard for the treatment of inflammatory periodontitis.

Diagnosis and anti-infective therapy of periodontitis

Periodontal diseases (gingivitis and periodontitis) are chronic bacterial infections with a remarkably high prevalence and morbidity. Periodontitis, in contrast to gingivitis, is not reversible, is associated with certain bacterial species and affects all of the soft tissue and bone that support teeth. Among the periodontal pathogens, species, such as Aggregatibacter (Actinobacillus) actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Tannerella forsythensis, and several forms of uncultivable spirochetes play the major role in the pathogenesis. In severe chronic, recurrent and especially aggressive forms of periodontitis, diagnosis of the species involved and, whenever possible, an optimized evidence-based antimicrobial treatment is indicated. In order to monitor alarming bacterial changes in the periodontal pocket, several techniques, namely microscopy, culture, immunoassays, enzyme tests and DNA-based techniques, have been established and the methods are described in the first part of this review. In the second part, the selection and use of locally delivered (topical) and systemic antibiotics used adjunctively in periodontal therapy are discussed.

Prevention of inflammation-mediated bone loss in murine and canine periodontal disease via recruitment of regulatory lymphocytes

The hallmark of periodontal disease is the progressive destruction of gingival soft tissue and alveolar bone, which is initiated by inflammation in response to an invasive and persistent bacterial insult. In recent years, it has become apparent that this tissue destruction is associated with a decrease in local regulatory processes, including a decrease of forkhead box P3-expressing regulatory lymphocytes. Accordingly, we developed a controlled release system capable of generating a steady release of a known chemoattractant for regulatory lymphocytes, C-C motif chemokine ligand 22 (CCL22), composed of a degradable polymer with a proven track record of clinical translation, poly(lactic-co-glycolic) acid. We have previously shown that this sustained presentation of CCL22 from a point source effectively recruits regulatory T cells (Tregs) to the site of injection. Following administration of the Treg-recruiting formulation to the gingivae in murine experimental periodontitis, we observed increases in hallmark Treg-associated anti-inflammatory molecules, a decrease of proinflammatory cytokines, and a marked reduction in alveolar bone resorption. Furthermore, application of the Treg-recruiting formulation (fabricated with human CCL22) in ligature-induced periodontitis in beagle dogs leads to reduced clinical measures of inflammation and less alveolar bone loss under severe inflammatory conditions in the presence of a diverse periodontopathogen milieu.

Reporting adverse events in randomized controlled trials in periodontology: a systematic review

BACKGROUND/AIMS

Reporting of adverse events is of paramount importance in randomized controlled trials (RCTs) to guide the implementation of new therapeutic approaches in clinical practice. The aim of this study was to assess the quality of adverse events reporting in RCTs published in the periodontal literature.

MATERIALS AND METHODS

Two authors (CMF and NNG) searched the PubMed and LILACS electronic databases independently and in duplicate to identify RCTs published in periodontology from 2002 to 2003 and from 2011 to 2012. Reporting quality in RCTs was assessed with reference to the 2004 CONSORT Extension for Harms checklist. Differences in adverse events reporting between industry- and non-industry-funded RCTs were also determined. Cohen's kappa statistic was used to determine the extent of inter-reviewer agreement. Fischer's exact test was used to assess differences in reporting between the two samples.

RESULTS

The analysis included 246 publications. One hundred twenty-four of 990 (13%) items and 223 of 1460 (15%) items were adequately reported in publications from 2002 to 2003 and from 2011 to 2012 respectively. Three checklist topics were significantly better reported in the 2011-2012 sample; two recommendations were better reported in non-industry-funded trials in publications from both periods.

CONCLUSION

Improvement and standardization of adverse events reporting in periodontology are needed.

Periodontal disease in chronic kidney disease and end-stage renal disease patients: a review

Periodontal disease is a chronic inflammatory disorder and being so it has been associated with accelerated atherosclerosis and malnutrition. Cardiovascular diseases are the leading cause of mortality in chronic kidney disease (CKD) and end-stage renal disease (ESRD) patients [National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases: Annual Data Report, 2010]. A recent scientific statement released by the American Heart Association [Lockhart et al.: Circulation 2012;125:2520-2544] claims that, even though evidence exists to believe that periodontal interventions result in a reduction in systemic inflammation and endothelial dysfunction, there is little evidence that those interventions prevent atherosclerotic vascular disease or modify the outcomes. In this review, we discuss the periodontal findings and their association with an increased prevalence of inflammatory markers and cardiovascular mortality in ESRD patients and CKD.

LPS-induced inflammatory response after therapy of aggressive periodontitis

We have reported a lipopolysaccharide (LPS)-induced hyper-inflammatory response in localized aggressive periodontitis (LAP). It is unknown whether treatment is able to modulate this LPS responsiveness. Fifty-nine individuals with LAP were treated by mechanical debridement and systemic antibiotics. Clinical parameters and cyto/chemokine responsiveness of whole blood stimulated with Porphyromonas gingivalis or Escherichia coli LPS were monitored at baseline and 3, 6, and 12 months post-treatment. Overall, clinical parameters were improved following treatment. Additionally, P. gingivalis LPS induction of eotaxin, IFNγ, IL10, IL12p40, IL1β, IL6, IP10, MCP1, MIP1α, GM-CSF, and TNFα was significantly decreased (p < .05). Similarly, induction of eotaxin, INFγ, IL10, IL12p40, GM-CSF, and TNFα by E. coli LPS was also reduced post-treatment. These reductions correlated with decreases in clinical parameters. Importantly, these reductions in LPS responsiveness were most robust at 3 months, and some lost significance at 6 to 12 months post-treatment. In conclusion, LPS-induced hyper-inflammatory response in LAP can be partially modulated by periodontal therapy. Conversely, rebound in the hyper-responsiveness of some mediators, in the presence of improved clinical parameters, suggests that this phenotype could be partially influenced by a genetic trait and play a role in future disease recurrence (ClinicalTrials.gov, NCT01330719).

Effect of periodontal therapy on the subgingival microbiota over a 2-year monitoring period. I. Overall effect and kinetics of change

AIM

To examine the 2-year post-therapy kinetics of change in the composition of subgingival biofilms.

MATERIAL AND METHODS

In this study, 178 chronic periodontitis subjects were recruited and clinically monitored at baseline, 3, 6, 12, 18 and 24 months after therapy. All subjects received scaling and root planing and 156 one or more of periodontal surgery, systemically administered amoxicillin + metronidazole or local tetracycline at pockets ≥5 mm. Subgingival biofilm samples taken from each subject at each time point were analysed for their content of 40 bacterial species using checkerboard DNA-DNA hybridization. The significance of changes in median species counts over time was sought using the Wilcoxon or Friedman tests and adjusted for multiple comparisons.

RESULTS

Mean counts were significantly reduced from baseline to 2 years for 30 of the 40 taxa. Marked reductions were observed for periodontal pathogens including Tannerella forsythia, Treponema denticola and Eubacterium nodatum. The kinetics of change differed from species to species. When data were subset according to baseline PD, patterns of change in the microbial profiles were generally similar.

CONCLUSION

Periodontal therapy leads to a rapid reduction in periodontal pathogens, followed by a slower reduction in other taxa that can be sustained for at least 2 years.

Single or repeated antimicrobial photodynamic therapy as adjunct to ultrasonic debridement in residual periodontal pockets: clinical, microbiological, and local biological effects

This study aims to assess in residual periodontal pockets the clinical, microbiological, and local biological effects of antimicrobial photodynamic therapy (PDT), delivered after ultrasonic instrumentation either once or twice in a 1-week interval. A single center, three-arm randomized longitudinal study was carried out for 6 months. Twenty-eight systemically healthy patients on periodontal maintenance with residual pockets (pocket depth (PD) ≥5 mm, clinical attachment loss ≥2 mm, and bleeding upon probing (BOP+)) were included. Residual pockets on three teeth, separated from each other by at least two other teeth, served as study sites. After ultrasonic debridement, they were randomly assigned to either PDT delivered twice within 1 week (group A), PDT delivered only once (group B), or sham treatment without activating the laser (group C). Methylene blue was applied with a blunt irrigator tip into the pockets. Sites were irradiated with laser light at a wavelength of 670 nm using a light-diffusing tip introduced into the pocket. Initial PD was 5.9 ± 0.9, 6.3 ± 1.3, and 6.3 ± 1.5 mm in groups A, B, and C, respectively, differences being nonsignificant. PD was significantly reduced in all groups. At month 3, PD was significantly lower in groups A (2.9 ± 1.1 mm; p = 0.04) and B (2.8 ± 1.1 mm; p = 0.03) compared to group C (3.5 ± 1.2 mm). At month 6, none of the sites in group A had persisting pockets PD >4 mm and BOP+, whereas two sites in group B and four sites in group C stayed in this category. Detection frequencies of the studied microorganisms at >1,000 and >100.000 cells/ml did not change significantly from baseline to months 3 or 6 in any group. A significant overall decrease was observed from baseline to month 6 for C-reactive protein, serum amyloid A, fibrinogen, procalcitonin, and α-2 macroglobulin. When looking at the groups separately, C-reactive protein was significantly lower only if the laser had been activated twice (p < 0.05). Other differences between groups were not significant. A single or double episodes of PDT had some additional benefit over ultrasonic instrumentation alone.

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.

Azithromycin suppresses human osteoclast formation and activity in vitro

Azithromycin is an antibiotic with anti-inflammatory properties used as an adjunct to treat periodontitis, a common inflammatory mediated condition featuring pathologic alveolar bone resorption. This study aimed to determine the effect of azithromycin on human osteoclast formation and resorptive activity in vitro. Osteoclasts were generated from peripheral blood mononuclear cells stimulated with macrophage colony stimulating factor (M-CSF) and receptor activator of nuclear factor kappa B (RANK) ligand. The effects of azithromycin at concentrations ranging from 0.5 to 40 µg/ml were tested. Osteoclast formation and activity, acidification, actin ring formation and expression of mRNA, and protein encoding for key osteoclast genes were assessed. The results demonstrated that azithromycin reduced osteoclast resorptive activity at all concentrations tested with osteoclast formation being significantly reduced at the higher concentrations (20 and 40 µg/ml). mRNA and protein expression of key osteoclast transcription factor Nuclear Factor of Activated T cells (NFATc1) was significantly reduced by azithromycin at later stages of osteoclast development (day 17). Azithromycin also reduced tumor necrosis factor receptor associated factor-6 (TRAF6) mRNA expression at day 14, and cathepsin K mRNA expression at days 14 and 17. Integrin β3 and MMP-9 mRNA expression was reduced by azithromycin at day 17 in osteoclasts cultured on dentine. The osteoclast proton pump did not appear to be affected by azithromycin, however formation of the actin ring cytoskeleton was inhibited. This study demonstrates that azithromycin inhibits human osteoclast function in vitro, which may account for at least some of the beneficial clinical effects observed with azithromycin treatment in periodontitis.

Improvement of glycated hemoglobin in Japanese subjects with type 2 diabetes by resolution of periodontal inflammation using adjunct topical antibiotics: results from the Hiroshima Study

AIMS

Periodontal treatment reduces glycated hemoglobin (HbA1) in subjects with type 2 diabetes, although effective strategy for different severities of periodontitis remains unclear. We hypothesized that resolution of periodontitis-induced inflammation by the therapy combined with antibiotics may have beneficial effects on the glycemic control of diabetes.

METHODS

A total of 523 subjects with type 2 diabetes were screened for periodontal disease. Of these, 160 subjects who visited dentists were divided into two groups according to high-sensitivity c-reactive protein (hsCRP) level: >500 ng/ml and <500 ng/ml. The group with hsCRP over 500 ng/ml was further sub-divided into two groups according to treatment strategy: topical application of antibiotics combined with conventional mechanical debridement (group A), and debridement alone (B). Subjects with hsCRP below 500 ng/ml were sub-divided similarly (C: combination therapy; D: debridement alone). hsCRP was measured after 1 month and changes of HbA1c after 3 months. These parameters were also measured in control subjects (N=118) who did not visit dentists (E: initial hsCRP>500 ng/ml; F: hsCRP<500 ng/ml).

RESULTS

A multiple comparison by ANOVA revealed that only group A showed a significant reduction in HbA1c over time (P<0.001). Multivariable analyses revealed elevated hsCRP and the combination treatment with antibiotics were two independent variables influencing the decrease of HbA1c over the study (P<0.01 and P<0.001, respectively).

CONCLUSIONS

In subjects with type 2 diabetes and periodontitis-induced mild inflammation (hsCRP>500 ng/ml), treatment to reduce hsCRP using antibiotics is recommended.

Azithromycin: a new concept in adjuvant treatment of periodontitis

In most patients periodontitis is successfully treated by scaling and root planing, but some studies have shown that certain sites continue to show periodontal tissue destruction despite conventional periodontal therapy. To solve this problem, antibiotics may be administered as an adjuvant treatment. This includes azithromycin (AZM), which is effective against Gram-negative aerobic and anaerobic bacteria and has a long half-life in periodontal tissues. The purpose of the present study was to determine the efficacy of azithromycin as an adjuvant treatment for periodontitis through a review of the literature in Medline, Lilacs and Scielo, combining the keywords "azithromycin", "periodontal treatment" and "periodontitis" in both Portuguese and English languages. To be included, articles had to be clinical trials, randomized, controlled, double-blind or blind, and published between 2001 and 2011. 70 articles were found, of which 12 were selected based on title and abstract. Most studies used AZM as an adjuvant treatment for chronic periodontitis, usually in a single daily dose of 500 mg over three days, and indicated that AZM significantly reduced probing depth and increased periodontal attachment when compared to controls. Furthermore, a reduction in red and orange complex and an increase in bacteria associated with healthy periodontal conditions were observed in subjects treated with AZM. It may be concluded that the use of AZM as an adjuvant treatment for periodontitis improves clinical and microbiological parameters when compared to conventional treatment alone.