Two different antibiotic protocols as adjuncts to one‐stage full‐mouth ultrasonic debridement to treat generalized aggressive periodontitis: A pilot randomized controlled clinical trial

Smoking negatively impacts the clinical, microbiological, and immunological treatment response of young adults with Grade C periodontitis

OBJECTIVE

This study aimed to investigate the influence of smoking on clinical, microbiological and immunological parameters in young adult with stage III-IV Grade C periodontitis after full-mouth ultrasonic debridement (FMUD) associated with Amoxicillin and Metronidazole (AMX + MTZ), comparing smokers (PerioC-Y-Smk) with non-smokers (PerioC-Y-NSmk).

MATERIALS AND METHODS

Fifteen PerioC-Y-NSmk and 14 PerioC-Y-Smk patients underwent FMUD associated with AMX + MTZ for 10 days. All parameters were collected at baseline and 3 and 6 months after treatment. Plaque index (PI), bleeding on probing (BoP), probing depth (PD), clinical attachment level (CAL)- the primary variable-, and gingival recession (GR) were clinically assessed. The impact of PI on CAL change at 6-month was verified by a regression analysis. Samples of the subgingival biofilm was collected for detection of levels of Aggregatibacter actinomycetemcomitans (A. actinomycetemcomitans), Porphyromonas gingivalis (P.gingivalis), Tannerella forsythia (T. forsythia), and Fusobacterium nucleatum ssp (F. nucleatum), and were analyzed by real-time qPCR; gingival crevicular fluid was collected for detection of levels of interleukin (IL)-1β, IL-4, IL-6, IL-10, tumor necrosis factor (TNF)-α, and interferon (IFN)-γ, which were analyzed using an enzyme immunoassay.

RESULTS

PerioC-Y-Smk had significantly higher PI, BOP, and GR at baseline compared to non-smokers (p < .05). PerioC-Y-Smk presented higher PD, CAL, and GR at 3 and 6 months (p < .05) compared with PerioC-Y-NSmk in the same periods; PI negatively affected CAL gain in PerioC-Y-NSmk at 6-month follow-up (p = .052) and did not impact on clinical response in PerioC-Y-Smk (p = .882). Lower levels of IFN-γ, IL1-β, and IL-4 were observed at 3 months in the PerioC-Y-NSmk (p < .05) compared with PerioC-Y-Smk. Lower proportions of P. gingivalis were observed in PerioC-Y-NSmk at baseline and at 3 months (p < .05) and lower proportions of F. nucleatum were observed at 6 months, in the PerioC-Y-NSmk (p < .05).

CONCLUSIONS

PerioC-Y-Smk presents an unfavorable clinical, microbiological, and immunological response after 3 and 6 months after FMUD associated with AMX + MTZ.

CLINICAL RELEVANCE

Smoking worsens periodontal condition of young treated adults presenting stage III/IV Grade C periodontitis.

Open flap debridement compared to repeated applications of photodynamic therapy in the treatment of residual pockets. A randomized clinical trial

BACKGROUND

The aim of the present study was to compare repeated applications of antimicrobial photodynamic therapy (aPDT) to open flap debridement (OFD) in the treatment of residual periodontal pockets in non-furcation sites.

METHODS

Forty-six subjects with a diagnosis of Stage III or IV Grade C periodontitis, that had been previously treated, participated in the study.  Residual pockets were divided between two groups: 1) aPDT group: received ultrasonic periodontal debridement followed by immediate application of aPDT, and repeated on1st, 2nd, 7th and 14th days; and 2) OFD group: treated by modified papilla preservation technique, where granulation tissue and visible calculus were removed with hand curettes and an ultrasonic device. Clinical, immunological and microbiological parameters were evaluated before and after treatment.

RESULTS

Both treatments were effective reducing clinical parameters of disease. OFD resulted in a greater mean probing pocket depths (PPD) reduction in deep pockets (p = 0.001). However, aPDT resulted in a lower occurrence of gingival recession (GR), dentin hypersensitivity and analgesic intake. Reduction in Porphyromonas gingivalis was observed in both groups. Only the OFD group had a significant reduction in Aggregatibacter actinomycetemcomitans. aPDT group had greater increase in IL-10 levels and a greater reduction of IL-1β at 14 days when compared to the OFD group (p<0.05).

CONCLUSION

OFD was superior in reducing PPD in deep pockets compared to the aPDT. However, OFD resulted in greater GR.  Both treatments lowered P. gingivalis levels but only OFD reduced levels of A. actinomycemtemcomitans. This article is protected by copyright. All rights reserved.

Randomized clinical trials in periodontology: focus on outcomes selection

Randomized clinical trials (RCTs) are human studies carried out to compare different treatments or interventions, and their results are used to support clinical decision-making and improve patient care. Herein, the aim of this study was to review the selection process of study outcomes in periodontology. Primary outcomes should draw the main conclusions of the study, whereas secondary outcomes should only be used to help explain the main findings and generate future research hypothesis. Outcomes are classified as clinically relevant (CROs) or surrogate outcomes. CROs - the first option for primary outcome variables - should convey not only substantial health benefits, but also be deemed important by patients. In periodontology, tooth loss/retention and oral health-related quality of life (OHRQoL) are examples of CROs. While tooth loss has main limitations as a primary outcome, emerging evidence suggest that patient-reported outcome measures (PROMs) can accurately detect OHRQoL following periodontal therapy. When CROs cannot be assessed, validated surrogate outcomes can be used as proxies. Primary outcome variables should reflect a treatment endpoint at the patient level that can be easily used to inform decision-making in daily practice. These outcomes should allow the implementation of a treat-to-target concept in which the intervention can be clearly judged against a prespecified treatment target. Recently, the presence of at most 4 sites with periodontal probing depth ≥5 mm post-treatment was suggested as an effective endpoint for periodontal trials. In perspective, a combination of validated clinical parameters and PROMs will provide a more comprehensive assessment of periodontal treatments.

Adjunctive Application of Systemic Antibiotics in Non-surgical Aggressive Periodontitis Treatment: Clinical and Microbiological Findings

BACKGROUND: Aggressive periodontitis (AgP) is associated with an extensive and rapid destruction of periodontal tissues. Unpredictable treatment outcomes of the disease are consequences of various cross-linked factors. Antimicrobial adjunctive treatment is routinely used as a part of non-surgical periodontal treatment (NSPT) of AgP. AIM: Therefore, the aim of this study was to compare the effects of active periodontal treatment (APT) combined with systemic antibiotics with mechanical debridement alone, in patients with generalized AgP (GAgP). METHODS: Two groups, consisting of 10 participants each, were randomly formed. Both groups were clinically and microbiologically tested and monitored for 3 months. Test group received APT with antimicrobial supplementation (amoxicillin and metronidazole [AMX-MET]). Patients from the control group were treated by APT only. Clinical and microbiological parameters were recorded at baseline and 3 months following the NSPT. Clinical measurements involved probing depth, clinical attachment level, bleeding on probing, and plaque index. Samples of subgingival crevicular fluid were analyzed by qualitative polymerase chain reaction. RESULTS: Significant improvement of all clinical parameters was observed 3 months following the NSPT (p < 0.05), but significant difference between groups was not found (p > 0.05). Periodontal pathogens’ detection between baseline and 3 months follow-up was also not statistically significant in both examined groups (p > 0.05). CONCLUSION: Similarity of results obtained in both treatment groups underlined the key role of APT in the treatment of AgP. The AMX-MET supplementation did not improve clinical and microbiological outcomes, when compared to APT alone. Longer follow-up period, with larger sample, could provide a more comprehensive insight into this issue.

Clarithromycin as an adjunct to periodontal therapy: a systematic review and meta-analysis

OBJECTIVE

To collate the literature evaluating the efficacy of clarithromycin as an adjunct to non-surgical periodontal therapy and conduct meta-analyses for changes in probing pocket depth (PPD) and clinical attachment level (CAL).

METHODS

Five electronic databases were searched from inception to May 2020 (PubMed, Cochrane CENTRAL, EMBASE via OVID, Web of Science and OpenGrey). Clinical outcomes were extracted, pooled and meta-analyses conducted using mean difference with standard deviations.

RESULTS

Systemic delivery: 0.65 mm (95% CI: 0.02 to 1.27 mm) mean additional PPD reduction was observed at 3 months and 0.28 mm (95% CI: -0.32 to 0.87 mm) at 6 months. 0.41 mm (95% CI: -0.12 to 0.95 mm) mean additional CAL gain was observed at 3 months, and 0.16 mm (95% CI: -0.41 to 0.74 mm) at 6 months. Increased risk of adverse events was observed; RR: 5.13 (95% CI: 0.63 to 41.98). Local delivery: 1.01 mm (95% CI: 0.84 to 1.17 mm) mean additional PPD reduction was observed at 3 months, and 1.20 mm (95% CI: 0.76 to 1.64 mm) at 6 months. 0.56 mm (95% CI: 0.46 to 0.66 mm) mean additional CAL gain was observed at 3 months, and 0.83 mm (95% CI: 0.65 to 1.02 mm) at 6 months. No adverse events were observed.

CONCLUSIONS

The use of locally delivered clarithromycin significantly improves treatment outcomes.

Adjunctive systemic antimicrobials for the non-surgical treatment of periodontitis

BACKGROUND

Systemic antimicrobials can be used as an adjunct to mechanical debridement (scaling and root planing (SRP)) as a non-surgical treatment approach to manage periodontitis. A range of antibiotics with different dosage and combinations are documented in the literature. The review follows the previous classification of periodontitis as all included studies used this classification.

OBJECTIVES

To assess the effects of systemic antimicrobials as an adjunct to SRP for the non-surgical treatment of patients with periodontitis.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases to 9 March 2020: Cochrane Oral Health's Trials Register, CENTRAL, MEDLINE, and Embase. The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) which involved individuals with clinically diagnosed untreated periodontitis. Trials compared SRP with systemic antibiotics versus SRP alone/placebo, or with other systemic antibiotics.

DATA COLLECTION AND ANALYSIS

We selected trials, extracted data, and assessed risk of bias in duplicate. We estimated mean differences (MDs) for continuous data, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included 45 trials conducted worldwide involving 2664 adult participants. 14 studies were at low, 8 at high, and the remaining 23 at unclear overall risk of bias. Seven trials did not contribute data to the analysis. We assessed the certainty of the evidence for the 10 comparisons which reported long-term follow-up (≥ 1 year). None of the studies reported data on antimicrobial resistance and patient-reported quality of life changes. Amoxicillin + metronidazole + SRP versus SRP in chronic/aggressive periodontitis: the evidence for percentage of closed pockets (MD -16.20%, 95% CI -25.87 to -6.53; 1 study, 44 participants); clinical attachment level (CAL) (MD -0.47 mm, 95% CI -0.90 to -0.05; 2 studies, 389 participants); probing pocket depth (PD) (MD -0.30 mm, 95% CI -0.42 to -0.18; 2 studies, 389 participants); and percentage of bleeding on probing (BOP) (MD -8.06%, 95% CI -14.26 to -1.85; 2 studies, 389 participants) was of very low certainty. Only the results for closed pockets and BOP showed a minimally important clinical difference (MICD) favouring amoxicillin + metronidazole + SRP. Metronidazole + SRP versus SRP in chronic/aggressive periodontitis: the evidence for percentage of closed pockets (MD -12.20%, 95% CI -29.23 to 4.83; 1 study, 22 participants); CAL (MD -1.12 mm, 95% CI -2.24 to 0; 3 studies, 71 participants); PD (MD -1.11 mm, 95% CI -2.84 to 0.61; 2 studies, 47 participants); and percentage of BOP (MD -6.90%, 95% CI -22.10 to 8.30; 1 study, 22 participants) was of very low certainty. Only the results for CAL and PD showed an MICD favouring the MTZ + SRP group. Azithromycin + SRP versus SRP for chronic/aggressive periodontitis: we found no evidence of a difference in percentage of closed pockets (MD 2.50%, 95% CI -10.19 to 15.19; 1 study, 40 participants); CAL (MD -0.59 mm, 95% CI -1.27 to 0.08; 2 studies, 110 participants); PD (MD -0.77 mm, 95% CI -2.33 to 0.79; 2 studies, 110 participants); and percentage of BOP (MD -1.28%, 95% CI -4.32 to 1.76; 2 studies, 110 participants) (very low-certainty evidence for all outcomes). Amoxicillin + clavulanate + SRP versus SRP for chronic periodontitis: the evidence from 1 study, 21 participants for CAL (MD 0.10 mm, 95% CI -0.51 to 0.71); PD (MD 0.10 mm, 95% CI -0.17 to 0.37); and BOP (MD 0%, 95% CI -0.09 to 0.09) was of very low certainty and did not show a difference between the groups. Doxycycline + SRP versus SRP in aggressive periodontitis: the evidence from 1 study, 22 participants for CAL (MD -0.80 mm, 95% CI -1.49 to -0.11); and PD (MD -1.00 mm, 95% CI -1.78 to -0.22) was of very low certainty, with the doxycycline + SRP group showing an MICD in PD only. Tetracycline + SRP versus SRP for aggressive periodontitis: we found very low-certainty evidence of a difference in long-term improvement in CAL for the tetracycline group (MD -2.30 mm, 95% CI -2.50 to -2.10; 1 study, 26 participants). Clindamycin + SRP versus SRP in aggressive periodontitis: we found very low-certainty evidence from 1 study, 21 participants of a difference in long-term improvement in CAL (MD -1.70 mm, 95% CI -2.40 to -1.00); and PD (MD -1.80 mm, 95% CI -2.47 to -1.13) favouring clindamycin + SRP. Doxycycline + SRP versus metronidazole + SRP for aggressive periodontitis: there was very low-certainty evidence from 1 study, 27 participants of a difference in long-term CAL (MD 1.10 mm, 95% CI 0.36 to 1.84); and PD (MD 1.00 mm, 95% CI 0.30 to 1.70) favouring metronidazole + SRP. Clindamycin + SRP versus metronidazole + SRP for aggressive periodontitis: the evidence from 1 study, 26 participants for CAL (MD 0.20 mm, 95% CI -0.55 to 0.95); and PD (MD 0.20 mm, 95% CI -0.38 to 0.78) was of very low certainty and did not show a difference between the groups. Clindamycin + SRP versus doxycycline + SRP for aggressive periodontitis: the evidence from 1 study, 23 participants for CAL (MD -0.90 mm, 95% CI -1.62 to -0.18); and PD (MD -0.80 mm, 95% CI -1.58 to -0.02) was of very low certainty and did not show a difference between the groups. Most trials testing amoxicillin, metronidazole, and azithromycin reported adverse events such as nausea, vomiting, diarrhoea, mild gastrointestinal disturbances, and metallic taste. No serious adverse events were reported.

AUTHORS' CONCLUSIONS

There is very low-certainty evidence (for long-term follow-up) to inform clinicians and patients if adjunctive systemic antimicrobials are of any help for the non-surgical treatment of periodontitis. There is insufficient evidence to decide whether some antibiotics are better than others when used alongside SRP. None of the trials reported serious adverse events but patients should be made aware of the common adverse events related to these drugs. Well-planned RCTs need to be conducted clearly defining the minimally important clinical difference for the outcomes closed pockets, CAL, PD, and BOP.

Effects of eradication of Helicobacter pylori on oral malodor and the oral environment: a single-center observational study

Objective

Although a relationship between Helicobacter pylori and oral malodor has been suggested, it remains to be confirmed. One reason for this is that many studies assess oral malodor subjectively. Another reason for the uncertainty is that the reduction in oral malodor may be due to the effect of antibiotics on the oral microbiota. In this study, changes in oral malodor along with the eradication treatment of H. pylori were investigated by organoleptic test and gas chromatography. In addition, the salivary bacterial composition and clinical parameters were analyzed.

Results

The organoleptic test score, hydrogen sulfide and dimethyl sulfide concentrations, and all clinical parameters except for tongue-coating score were significantly decreased at 1 week compared with baseline. Although antibiotic treatment also altered the overall composition of the salivary bacterial population, it had recovered at 7 weeks. On the date that H. pylori was determined to have been eradicated from all of the subjects (7 weeks after treatment), only the organoleptic test score was significantly lower compared with baseline. The hydrogen sulfide and dimethyl sulfide concentrations were non-significantly lower than those at baseline.

Omega-3 PUFA and aspirin as adjuncts to periodontal debridement in patients with periodontitis and type 2 diabetes mellitus: Randomized clinical trial

BACKGROUND

Supplementation with omega-3 polyunsaturated fatty acids (ω-3 PUFA) and low-dose aspirin (ASA) have been proposed as a host modulation regimen to control chronic inflammatory diseases. The aim of this study was to investigate the clinical and immunological impact of orally administered ω-3 PUFA and ASA as adjuncts to periodontal debridement for the treatment of periodontitis in patients type 2 diabetes.

METHODS

Seventy-five patients (n = 25/group) were randomly assigned to receive placebo and periodontal debridement (CG), ω-3 PUFA + ASA (3 g of fish oil/d + 100 mg ASA/d for 2 months) after periodontal debridement (test group [TG]1), or ω-3 PUFA + ASA (3 g of fish oil/d + 100 mg ASA/d for 2 months) before periodontal debridement (TG2). Periodontal parameters and GCF were collected at baseline (t0), 3 months after periodontal debridement and ω-3 PUFA + ASA or placebo for TG1 and CG (t1), after ω-3 PUFA + ASA (before periodontal debridement) for TG2 (t1), and 6 months after periodontal debridement (all groups) (t2). GCF was analyzed for cytokine levels by multiplex ELISA.

RESULTS

Ten patients (40%) in TG1 and nine patients (36%) in TG2 achieved the clinical endpoint for treatment (less than or equal to four sites with probing depth ≥ 5 mm), as opposed to four (16%) in CG. There was clinical attachment gain in moderate and deep pockets for TG1. IFN-γ and interleukin (IL)-8 levels decreased over time for both test groups. IL-6 levels were lower for TG1. HbA1c levels reduced for TG1.

CONCLUSION

Adjunctive ω-3 and ASA after periodontal debridement provides clinical and immunological benefits to the treatment of periodontitis in patients with type 2 diabetes.