Multifactorial assessment of predictors for prevention of periodontal disease progression

Antibiotics/antimicrobials: systemic and local administration in the therapy of mild to moderately advanced periodontitis

This review gives an update of the current scientific evidence on the efficacy of the adjunctive use of systemic and local antibiotics/antimicrobials in the treatment of periodontitis. In particular, it addresses whether their use can improve the results of nonsurgical mechanical therapy in mild-to-moderate forms of the disease. Large numbers of randomized clinical trials and systematic reviews with meta-analyses have clearly established that adjunctive systemic antibiotics, combined with mechanical debridement, offer clinical improvements additional to those obtained with scaling and root planing alone. These effects are more pronounced in aggressive periodontitis and in initially deep pockets, whereas more limited additional improvements, of 0.3 mm for additional pocket reduction and 0.2 mm for additional clinical attachment gain, have been documented for moderately deep sites (4-6 mm) in patients with chronic periodontitis. The marginal clinical benefit in patients with moderate disease has to be balanced against possible side effects. Notably, it has to be realized that an increasing number of warnings have been articulated against the unrestricted use of antibiotics in treating periodontal diseases because of the emerging global public health issue of bacterial resistance. The effects of the adjunctive local administration of antimicrobials have also been very well documented in several systematic reviews. Overall, in persistent or recurrent localized deep sites, the application of antimicrobials by sustained-delivery devices may offer a benefit of an additional 0.4 mm in pocket depth reduction and 0.3 mm in clinical attachment level gain. In conclusion, the slight additional benefits of adjunctive antimicrobials, which were shown for moderate forms of periodontitis, have to be balanced against their side effects and therefore their prescription should be limited as much as possible.

Influence of different post-interventional maintenance concepts on periodontal outcomes: an evaluation of three systematic reviews

BACKGROUND

To selectively review the existing literature on post-interventional maintenance protocols in patients with periodontal disease receiving either non-surgical or surgical periodontal treatment.

METHODS

Three systematic reviews with different periodontal interventions, i.e. scaling and root planing (SRP), SRP with adjunctive antibiotics or regenerative periodontal surgery were evaluated focusing on their post-interventional maintenance care. Due to the early publication of one review an additional literature search update was undertaken. The search was executed for studies published from January 2001 till March 2015 through an electronic database to ensure the inclusion of resent studies on SRP. Two reviewers guided the study selection and assessed the validity of the three reviews found.

RESULTS

Within the group of scaling and root planing alone there have been nine studies with more than three appointments for maintenance care and five studies with more than two appointments in the first 2 months after the intervention. Chlorhexidine was the most frequently used antiseptic agent used for 2 weeks after non-surgical intervention. Scaling and root planing with adjunctive antibiotics showed a similar number of visits with professional biofilm debridement, whereas regenerative studies displayed more studies with more than three visits in the intervention group. In addition, the use of antiseptics was longer and lasted 4 to 8 weeks after the regenerative intervention. The latter studies also showed more stringent maintenance protocols.

CONCLUSIONS

With increased interventional effort there was a greater tendency to increase frequency and duration of the maintenance care program and antiseptic agents.

The concomitant administration of systemic amoxicillin and metronidazole compared to scaling and root planing alone in treating periodontitis: =a systematic review=

Background

The treatment of periodontitis begins with a non-surgical phase that includes scaling and root planing(SRP) and on occasion the use of systemic antibiotics. The goal was to systematically evaluate in systemic healthy adults the effect of the concomitant administration of amoxicillin (amx) and metronidazole (met) adjunctive to SRP compared to SRP alone.

Methods

The PubMed-MEDLINE, Cochrane-CENTRAL and EMBASE databases were searched up to November 2014 to identify appropriate studies. Probing Pocket Depth (PD), Clinical Attachment Level (CAL), Bleeding on Pocket Probing(BOP) and Plaque Indices(PI) were selected as outcome variables. Based on the extracted data a meta-analysis was conducted.

Results

A total of 526 unique articles were found, 20 studies met the eligibility criteria. A meta-analysis showed that SRP + amx + met provided significantly better effects overall and more pronounced PD reduction in periodontal pockets initially measuring ≥6 mm (DiffM:-0.86 mm, p < 0.00001) and gain in CAL(DiffM:+0.75 mm, p = 0.0001). The meta-analysis for the secondary inflammatory parameter BOP showed that SRP + amx + met provided full mouth significantly greater reduction in BOP than SRP alone (DiffM:-6.98 %, p = 0.0001).

Conclusion

Adjunctive systemic amoxicillin and metronidazole medication to SRP significantly improved the clinical outcomes with respect to mean PD, CAL and BOP compared to SRP alone. There is moderate to strong evidence in support of the recommendation that adjunctive amx + met therapy to SRP significantly improves the clinical outcomes, with respect to mean PD and CAL compared to SRP alone especially in initially deep (≥6 mm) pockets. No major side effects associated with the intake of amx + met were reported. This treatment regimen is an efficacious, minimally invasive, practical and inexpensive approach for periodontitis therapy. The key components are mechanical tooth and pocket debridement, supportive treatment of the disease with systemic antibiotics and attention to proper self-care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12903-015-0123-6) contains supplementary material, which is available to authorized users.

An estimate of pocket closure and avoided needs of surgery after scaling and root planing with systemic antibiotics: a systematic review

BACKGROUND

Relevant benefits of adjunctive medication of antibiotica after conventional root surface debridement in terms of enhanced pocket depth (PD) reduction have been shown. However, means and standard deviations of enhanced reductions are difficult to translate into clinical relevant treatment outcomes such as pocket resolution or avoidance of additional surgical interventions. Accordingly, the aim of this systematic review was to calculate odds ratios for relevant cut-off values of PD after mechanical periodontal treatment with and without antibiotics, specifically the combination of amoxicilline and metronidazol, from published studies. As clinical relevant cut-off values "pocket closure" for PD ≤ 3mm and "avoidance of surgical intervention" for PD ≤ 5 mm were determined.

METHODS

The databases PubMed, Embase and Central were searched for randomized clinical studies assessing the beneficial effect of the combination of amoxicillin and metronidazole after non-surgical mechanical debridement. Titles, abstracts and finally full texts were scrutinized for possible inclusion by two independent investigators. Quality and heterogeneity of the studies were assessed and the study designs were examined. From published means and standard deviations for PD after therapy, odds ratios for the clinically relevant cut-off values were calculated using a specific statistical approach.

RESULTS

Meta-analyses were performed for the time points 3 and 6 month after mechanical therapy. Generally, a pronounced chance for pocket closure from 3 to 6 months of healing was shown. The administration of antibiotics resulted in a 3.55 and 4.43 fold higher probability of pocket closure after 3 and 6 months as compared to mechanical therapy alone. However, as the estimated risk for residual pockets > 5 mm was 0 for both groups, no odds ratio could be calculated for persistent needs for surgery. Generally, studies showed a moderate to high quality and large heterogeneity regarding treatment protocol, dose of antibiotic medication and maintenance.

CONCLUSION

With the performed statistical approach, a clear benefit in terms of an enhanced chance for pocket closure by co-administration of the combination of amoxicillin and metronidazole as an adjunct to non-surgical mechanical periodontal therapy has been shown. However, data calculation failed to show a benefit regarding the possible avoidance of surgical interventions.

The clinical effect of scaling and root planing and the concomitant administration of systemic amoxicillin and metronidazole: a systematic review

BACKGROUND

The treatment of periodontitis frequently begins with a non-surgical phase that includes scaling and root planing (SRP) and, on occasion, the use of systemic antibiotics. The goal of this review is to systematically evaluate the data concerning the effect of the concomitant administration of amoxicillin and metronidazole adjunctive to SRP in adults who are otherwise healthy.

METHODS

The PubMed-MEDLINE, Cochrane-Central, and EMBASE databases were searched to April 1, 2012, to identify appropriate studies. Probing depth (PD), clinical attachment level (CAL), bleeding on probing, and plaque index were selected as outcome variables. Based on the extracted mean values and number of individuals, changes in weighted means were calculated and a meta-analysis conducted.

RESULTS

The search yielded 526 unique titles and abstracts. Ultimately, 35 studies were selected, describing 28 clinical trials meeting the eligibility criteria. The full-mouth weighted mean change for PD showed an improvement of 1.41 mm. The full-mouth weighted mean change for CAL showed a gain of 0.94 mm.

CONCLUSION

Systemic antimicrobial therapy using a combination of amoxicillin and metronidazole as an adjunct to SRP can enhance the clinical benefits of non-surgical periodontal therapy in adults who are otherwise healthy.

Interleukin-1 gene polymorphisms and chronic periodontitis in adult whites: a systematic review and meta-analysis

BACKGROUND

Interleukin-1 (IL-1) gene polymorphisms have been associated with increased levels of inflammatory mediators and several inflammatory diseases. Periodontitis is a bacterially induced chronic inflammatory disease that destroys the connective tissues and bone that support the teeth, affects substantial numbers of adults, and has been implicated as a contributing factor in systemic diseases. IL-1 gene polymorphisms, most prominently IL1A (-889), IL1A (+4845), and IL1B (+3954), have been associated with chronic periodontitis (CP) in whites. Since the first report, ≥125 studies have examined IL-1 gene variation in relation to periodontal disease. These studies have produced mixed findings in diverse periodontal phenotypes and in different ethnic groups. One previous meta-analysis has been published on this topic and supported an association between IL-1 genes and periodontitis, but considerable doubt remains about the patient populations in which the association may be of clinical relevance.

METHODS

A systematic review and meta-analysis was conducted in an attempt to clarify whether IL-1 gene variants were associated with well-defined clinical phenotypes of CP in white patients. Study inclusion criteria focused on the analytic framework originally proposed for the IL-1 genetic effect in which overexpression of inflammatory mediators is hypothesized to result in more severe periodontitis in response to a bacterial challenge.

RESULTS

Twenty-seven studies were included in the qualitative analysis. Nineteen studies yielded significant associations between carriage of the minor IL-1 alleles and periodontitis. The meta-analysis, based on 13 qualifying studies, found significant effects for the two individual gene variations (IL1A odds ratio [OR] = 1.48; IL1B OR = 1.54) and for a composite genotype that combines minor alleles at each locus (OR = 1.51). Statistically significant heterogeneity was found that could not be explained, but there was no indication of publication bias.

CONCLUSION

This review and meta-analysis show that IL1A and IL1B genetic variations are significant contributors to CP in whites.

Tracking of plasma antibodies against Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis during 15 years

BACKGROUND

Plasma antibody measurements of antibody levels to periodontal pathogens may be used to support diagnosis, disease activity, classification, and prognosis of periodontitis.

OBJECTIVE

The aim of this study was to investigate the long-term stability of plasma antibody levels against Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis.

DESIGN

Plasma immunoglobulin G (IgG) antibody levels against the pathogens were analyzed annually during 15 years from 21 voluntary subjects, whose periodontal status was not known at the point of selection. The total number of plasma samples was 315. In connection of the last sampling, the clinical and radiographic periodontal status was examined. Pooled bacterial samples from periodontal pockets, as well as salivary samples were collected for A. actinomycetemcomitans and P. gingivalis detection, and antibody determinations, respectively. According to the clinical status, six subjects had periodontitis, whereas 15 did not.

RESULTS

Plasma IgG-class antibody levels to periodontal pathogens remained extremely stable during the 15-year period and no significant (p>0.05) intra-individual variations were observed. Retrospectively, the average plasma IgG antibody levels against A. actinomycetemcomitans and P. gingivalis were 1.6-2.3 (p<0.05) and 1.4-1.7 (p<0.05) fold higher in the subjects with periodontitis than those without, respectively, during the whole 15-year tracking. As expected, at the time of the periodontal examination the plasma and salivary IgG antibody levels were associated both with periodontitis and bacterium-positivity.

CONCLUSIONS

Plasma IgG levels against A. actinomycetemcomitans and P. gingivalis are extremely stable during 15 years both in subjects with and without periodontitis.

Prevalence of OPG and IL-1 gene polymorphisms in chronic periodontitis

AIM

To investigate the association of polymorphisms in the osteoprotegerin (OPG) and interleukin 1 (IL-1) genes with chronic periodontitis (CP).

MATERIAL AND METHODS

One hundred and ninety-four individuals (97 CP patients, 97 controls) were genotyped for the OPG polymorphisms Lys3Asn and Met256Val and for the IL-1 polymorphisms IL-1A (-889C/T) and IL-1B (+3953C/T).

RESULTS

The homozygous variants coding for Lys3 were present at a higher frequency, whereas Asn3 and Met256 were present at a lower frequency in CP patients/controls (Lys3: 31%/25%, Asn3: 23%/32% and Met256: 66%/73%). Heterozygosity for Lys3Asn was observed at a higher frequency in CP patients/controls (46%/43%). Homozygosity for the Val256 genotype was observed in two CP patients (one in controls). Met256Val heterozygosity was more prevalent in CP patients/controls (32%/20%). All differences were statistically not significant between CP patients and controls. In contrast, both IL-1 polymorphisms were statistically significant. The heterozygous variant for IL-1A was present in 32% of the CP patients and in 20% of the controls (homozygosity (patients/controls) CC: 10%/21% and TT: 55%/33%). Heterozygosity for IL-1B was observed in 37% of the CP patients versus 34% in the controls (homozygosity (patients/controls) CC: 26%/57% and TT: 37%/9%).

CONCLUSION

While the association between the IL-1 polymorphisms and CP was confirmed, no association between the OPG polymorphisms and CP could be found.

Risk ofPorphyromonas gingivalisRecolonization During the Early Period of Periodontal Maintenance in Initially Severe Periodontitis Sites

BACKGROUND

Porphyromonas gingivalis is considered a critical pathogen of periodontal diseases including recurrent periodontitis. The profound effects of active periodontal treatment (APT) on P. gingivalis elimination were previously demonstrated and revealed that the subsequent P. gingivalis-free or -suppressed status seems to be maintained during early periodontal maintenance (PMT). The aim of the present study was to show the occurrence of microbial recolonization during this early PMT period.

METHODS

In total, 128 sites from 11 generalized chronic periodontitis patients and one generalized aggressive periodontitis patient underwent clinical and microbiologic examination at baseline (Exam-I), after APT (Exam-II), and in PMT (Exam-III). Exam-III was carried out an average of 4.5 +/- 3.5 months after Exam-II. Detection and quantification of putative pathogens were performed using a polymerase chain reaction-based method.

RESULTS

The PMT used was effective in maintaining the clinical conditions improved by APT. However, in microbiological examinations, Exam-III showed higher detection frequency and levels of P. gingivalis than Exam-II. This suggests that a P. gingivalis recolonization started in the early PMT period. P. gingivalis-increased sites then showed significantly more severe signs of periodontitis in Exam-I than P. gingivalis-stable sites (bleeding on probing frequency: 76.7% versus 56.5%; suppuration frequency: 41.9% versus 12.9%). On the other hand, in Exam-II, no significant differences of clinical parameters were noted between P. gingivalis-increased and -stable sites.

CONCLUSION

Severe periodontitis sites before APT seemed to place them at risk of P. gingivalis recolonization in the early PMT period, and this microbial restoration could be a cause of recurrent periodontitis.

Intraoral dissemination of treponemes after periodontal therapy

Oral treponemes are related to chronic periodontitis, but the effect of periodontal therapy on the majority of treponemal species is unknown. The aim of this prospective study was to evaluate the dynamics in prevalence profiles of treponemes in different habitats of the oral cavity. Thirty-five patients with chronic periodontitis were randomly assigned to mechanical debridement alone (control group) or systemic amoxicillin/metronidazole plus chlorhexidine (test group). Subgingival and mucous membrane plaque samples were taken at baseline, after 10 days, and during supportive periodontal therapy at 3, 6, 9, 12, 18, and 24 months. T. denticola, T. lecithinolyticum, T. maltophilum, T. socranskii, T. vincentii, and treponemal phylotypes I-VII were detected using polymerase chain reaction (PCR) and dot blot analysis. For the majority of the assessed treponemes, a significant intragroup increase in prevalence in the different habitats ( P<0.05) occurred over the study course but, compared to debridement alone, adjunctive antimicrobial therapy resulted in a nonsignificant trend toward lower prevalence in the subgingival habitat. In no case were treponemes eradicated from the oral cavity. After both therapies, possibly new infection with and/or dissemination of Treponema ssp. occurred, which led to treponemes recovering in different habitats and to increased intraoral prevalence. The prescribed adjunctive antimicrobial therapy may limit this increase in the subgingival region.