Administration of systemic antibiotics during non-surgical periodontal therapy-a consensus report

Decision-making on systemic antibiotics in the management of periodontitis: A retrospective comparison of two concepts

AIM

To retrospectively compare two approaches for the adjunctive use of systemic antibiotics in non-surgical periodontal therapy: one based on the detection of Aggregatibacter actinomycetemcomitans (Aa) and the other on age and severity of periodontitis (Age & PPD). We also assessed the additional benefit of antibiotics in reducing the need for further surgical therapy in each group.

MATERIALS AND METHODS

Patients of the Department of Periodontology, Goethe University Frankfurt, Germany, were screened for microbiological testing between 2008 and 2018. Patients were categorized by their microbiological result (Aa+/-) and demographic/clinical data (Age & PPD+/-). Agreement on antibiotic indication was tested. The clinical evaluation focussed on teeth with probing pocket depths (PPDs) ≥ 6 mm.

RESULTS

Analysis of 425 patients revealed 30% categorized as Age & PPD+ and 34% as Aa+. Sixty-three percent had consistent antibiotic recommendations (phi coefficient 0.14, p = .004). Patients in the Age & PPD+ group receiving antibiotics showed the most substantial reduction in the number of teeth with PPD ≥ 6 mm after non-surgical periodontal therapy.

CONCLUSIONS

Both strategies resulted in a significant clinical improvement compared with those without antibiotic treatment and restricted antibiotic use similarly, but targeted different patient groups. Younger individuals with severe periodontitis benefited most from antibiotics, reducing the need for additional surgeries. The study was registered in an international trial register (German Clinical Trial Register number DRKS00028768, registration date 27 April 2022, https://drks.de/search/en/trial/DRKS00028768).

Dynamic hydrogel-metal-organic framework system promotes bone regeneration in periodontitis through controlled drug delivery

Periodontitis is a prevalent chronic inflammatory disease, which leads to gradual degradation of alveolar bone. The challenges persist in achieving effective alveolar bone repair due to the unique bacterial microenvironment's impact on immune responses. This study explores a novel approach utilizing Metal-Organic Frameworks (MOFs) (comprising magnesium and gallic acid) for promoting bone regeneration in periodontitis, which focuses on the physiological roles of magnesium ions in bone repair and gallic acid's antioxidant and immunomodulatory properties. However, the dynamic oral environment and irregular periodontal pockets pose challenges for sustained drug delivery. A smart responsive hydrogel system, integrating Carboxymethyl Chitosan (CMCS), Dextran (DEX) and 4-formylphenylboronic acid (4-FPBA) was designed to address this problem. The injectable self-healing hydrogel forms a dual-crosslinked network, incorporating the MOF and rendering its on-demand release sensitive to reactive oxygen species (ROS) levels and pH levels of periodontitis. We seek to analyze the hydrogel's synergistic effects with MOFs in antibacterial functions, immunomodulation and promotion of bone regeneration in periodontitis. In vivo and in vitro experiment validated the system's efficacy in inhibiting inflammation-related genes and proteins expression to foster periodontal bone regeneration. This dynamic hydrogel system with MOFs, shows promise as a potential therapeutic avenue for addressing the challenges in bone regeneration in periodontitis.

Advances in Hydrogels for Periodontitis Treatment

Periodontitis is a common condition characterized by a bacterial infection and the disruption of the body's immune-inflammatory response, which causes damage to the teeth and supporting tissues and eventually results in tooth loss. Current therapy involves the systemic and local administration of antibiotics. However, the existing treatments cannot exert effective, sustained release and maintain an effective therapeutic concentration of the drug at the lesion site. Hydrogels are used to treat periodontitis due to their low cytotoxicity, exceptional water retention capability, and controlled drug release profile. Hydrogels can imitate the extracellular matrix of periodontal cells while offering suitable sites to load antibiotics. This article reviews the utilization of hydrogels for periodontitis therapy based on the pathogenesis and clinical manifestations of the disease. Additionally, the latest therapeutic strategies for smart hydrogels and the main techniques for hydrogel preparation have been discussed. The information will aid in designing and preparing future hydrogels for periodontitis treatment.

Comparative Study of Systemic vs. Local Antibiotics with Subgingival Instrumentation in Stage III-IV Periodontitis: A Retrospective Analysis

To improve the clinical and microbiological outcomes of non-surgical mechanical periodontal therapy, the adjunctive use of antimicrobials has been utilized in treating moderate-to-severe periodontitis. In our study, the retrospective design included previously collected health-related patient data, obtained from the printed and digital charts of patients who received systemic or local antibiotic adjuncts to SI (subgingival instrumentation). A total of 34 patients (diagnosed with generalized Stage III/IV periodontitis) met the inclusion and exclusion criteria and were evaluated. The samples were tested for the following bacterial strains: Aggregatibacter actinomycetemcomitans (A. actinomycetemcomitans), Porphyromonas gingivalis (P. gingivalis), Prevotella intermedia (P. intermedia), Tanererella forsythia (T. forsythia), and Treponema denticola (T. denticola). The inter-group comparisons of the bacterial species did not show statistically significant differences between groups. The present study aimed to evaluate the clinical effects after SI and the adjunctive use of systemically administered (SA) AMX (amoxicillin) + MET (metronidazole) (administered for 7 days), with locally delivered (LDD) piperacillin + tazobactam in step 2 of periodontal therapy. Results: Overall, all parameters were improved in the groups, with a significant difference in inter-group comparison regarding the full-mouth bleeding score (FMBS) (p < 0.05) in favor of the SA group, and the p-value < 0.05 was considered to be statistically significant. Statistically significant PPD (probing pocket depth) reductions and CAL (clinical attachment level) gains were observed in both groups at the 3-month follow-up. In conclusion, within the limitations, the outcomes of this study suggest that SI, with adjunctive local or systemic antibiotic therapy, provided comparable clinical improvements. Systemic AMX + MET protocols were more efficacious with regard to the reduction in FMBS. Follow-up studies with larger patient numbers are needed to further investigate this effect.

Mechanism of action of Coptidis Rhizome in treating periodontitis based on network pharmacology and in vitro validation

OBJECTIVE

Explore the therapeutic mechanism of Coptidis Rhizome (CR) in periodontitis using network pharmacology, and validate it through molecular docking and in vitro experiments.

METHODS

Screened potential active components and target genes of CR from TCMSP and Swiss databases. Identified periodontitis-related target genes using GeneCards. Found common target genes using Venny. Conducted GO and KEGG pathway analysis. Performed molecular docking and in vitro experiments using Berberine, the main active component of CR, on lymphocytes from healthy and periodontitis patients. Assessed effects on inflammatory factors using CCK-8, flow cytometry, and ELISA.

RESULTS

Fourteen active components and 291 targets of CR were identified. 30 intersecting target genes with periodontitis were found. GO and KEGG analysis revealed oxidative stress response and IL-17 signaling pathway as key mechanisms. Molecular docking showed strong binding of Berberine with ALOX5, AKT1, NOS2, and TNF. In vitro experiments have demonstrated the ability of berberine to inhibit the expression of Th17 + and other immune related cells in LPS stimulated lymphocytes, and reduce the secretion of IL-6, IL-8, and IL-17.

CONCLUSION

CR treats periodontitis through a multi-component, multi-target, and multi-pathway approach. Berberine, its key component, acts through the IL-17 signaling pathway to exert anti-inflammatory effects.

Supra- and sub-gingival instrumentation of periodontitis with the adjunctive treatment of a chloramine - a one-year randomized clinical trial study

Periodontitis is a bacterial-induced disease and for this reason controlling the microbiota is a necessity. Therapy includes self-performed daily oral hygiene in combination with supra- and sub-gingival instrumentation. An adjunctive antimicrobial agent may improve the outcome.

AIMS

To assess whether a chloramine (Perisolv®) has an adjunctive effect to non-surgical periodontal therapy and whether non-surgical periodontal therapy affects quality of life.

MATERIAL AND METHODS

Thirty-eight patients were randomized to a test or a control group. Clinical indices were performed at baseline and at three and twelve months. In the test group, Perisolv® was applied initially and after the sub-gingival instrumentation in pathological pockets. Oral health-related quality of life was measured with the Oral Health Impact Profile (OHIP) instrument at baseline and twelve months.

RESULTS

In both groups, an initial probing pocket depth (PPD) of > 4 mm and bleeding on probing (BOP) were statistically reduced (p < 0.002 and p < 0.002 respectively) at twelve months and after adjustment for Bonferroni. There were no significant differences between the test and the control group in terms of the number of PPD, BOP or plaque index, or in the mean OHIP score.

CONCLUSIONS

Chloramine did not have an adjunctive effect, but the overall therapy was significantly efficacious both clinically and in terms of quality of life.

TRIAL REGISTRATION

Registered at www.

CLINICALTRIALS

gov:NCT05757921.

The effect of oil pulling in comparison with chlorhexidine and other mouthwash interventions in promoting oral health: A systematic review and meta-analysis

OBJECTIVES

A meta-analytic review was performed to critically synthesize the evidence of oil pulling on improving the parameters of gingival health, plaque control and bacteria counts against chlorhexidine and other mouthwash or oral hygiene practices.

METHODS

Databases including Medline, Embase and bibliographies were searched from inception to 1 April 2023. Randomized controlled trials (RCTs) with 7 days or longer duration of oil pulling with edible oils in comparison to chlorhexidine or other mouthwashes or oral hygiene practice concerning the parameters of plaque index scores (PI), gingival index scores (GI), modified gingival index scores (MGI) and bacteria counts were included. Cochrane's Risk of Bias (ROB) tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework were employed to determine the quality of evidence. Two authors independently conducted study selection and data extraction. Meta-analyses of the effect of oil pulling on the parameters were conducted using an inverse-variance random-effects model.

RESULTS

Twenty-five trials involving 1184 participants were included. Twenty-one trials comparing oil pulling (n = 535) to chlorhexidine (n = 286) and non-chlorhexidine intervention (n = 205) were pooled for meta-analysis. More than half of the trials (n = 17) involved participants with no reported oral health issues. The duration of intervention ranged from 7 to 45 days, with half of the trials using sesame oil. When compared to non-chlorhexidine mouthwash interventions, oil pulling clinically and significantly improved MGI scores (Standardized mean difference, SMD = -1.14; 95% confidence interval [CI]: -1.31, -0.97). Chlorhexidine was more effective in reducing the PI scores compared to oil pulling, with an SMD of 0.33 (95% CI: 0.17, 0.49). The overall quality of the body of evidence was very low.

CONCLUSIONS

There was a probable benefit of oil pulling in improving gingival health. Chlorhexidine remained superior in reducing the amount of plaque, compared to oil pulling. However, there was very low certainty in the evidence albeit the clinically beneficial effect of oil pulling intervention.

Enhancing osteogenic differentiation of MC3T3-E1 cells during inflammation using UPPE/β-TCP/TTC composites via the Wnt/β-catenin pathway

Periodontitis can lead to defects in the alveolar bone, thus increasing the demand for dependable biomaterials to repair these defects. This study aims to examine the pro-osteogenic and anti-bacterial properties of UPPE/β-TCP/TTC composites (composed of unsaturated polyphosphoester [UPPE], β-tricalcium phosphate [β-TCP], and tetracycline [TTC]) under an inflammatory condition. The morphology of MC3T3-E1 cells on the composite was examined using scanning electron microscopy. The toxicity of the composite to MC3T3-E1 cells was assessed using the Alamar-blue assay. The pro-osteogenic potential of the composite was assessed through ALP staining, ARS staining, RT-PCR, and WB. The antimicrobial properties of the composite were assessed using the zone inhibition assay. The results suggest that: (1) MC3T3-E1 cells exhibited stable adhesion to the surfaces of all four composite groups; (2) the UPPE/β-TCP/TTC composite demonstrated significantly lower toxicity to MC3T3-E1 cells; and (3) the UPPE/β-TCP/TTC composite had the most pronounced pro-osteogenic effect on MC3T3-E1 cells by activating the WNT/β-catenin pathway and displaying superior antibacterial properties. UPPE/β-TCP/TTC, as a biocomposite, has been shown to possess antibacterial properties and exhibit excellent potential in facilitating osteogenic differentiation of MC3T3-E1 cells.

Emergence of Antibiotic-Resistant Porphyromonas gingivalis in United States Periodontitis Patients

Antibiotic resistance patterns of the major human periodontal pathogen Porphyromonas gingivalis were assessed over a 20-year period in the United States. Subgingival P. gingivalis was cultured pre-treatment from 2193 severe periodontitis patients during three time periods: 1999-2000 (936 patients), 2009-2010 (685 patients), and 2019-2020 (572 patients). The clinical isolates were tested for in vitro resistance to 4 mg/L for clindamycin and doxycycline, 8 mg/L for amoxicillin, and 16 mg/L for metronidazole, with a post hoc combination of data for metronidazole plus amoxicillin. Clindamycin-resistant P. gingivalis was significantly more prevalent in 2009-2010 (9.1% of patients) and 2019-2020 (9.3%; 15-fold increase) as compared to 1999-2000 (0.6%). P. gingivalis resistance to amoxicillin also significantly increased from 0.1% of patients in 1999-2000 to 1.3% in 2009-2010 and 2.8% (28-fold increase) in 2019-2020. P. gingivalis resistance to metronidazole, metronidazole plus amoxicillin, and doxycycline was low (≤0.5% prevalence), and statistically unchanged, over the 20-year period. These findings are the first to reveal marked increases over 20 years in clindamycin-resistant and amoxicillin-resistant P. gingivalis in United States periodontitis patients. Increased antibiotic resistance of P. gingivalis and other periodontitis-associated bacteria threatens the efficacy of periodontal antimicrobial chemotherapy.

Avenanthramide-C Shows Potential to Alleviate Gingival Inflammation and Alveolar Bone Loss in Experimental Periodontitis

Periodontal disease is a chronic inflammatory disease that leads to the gradual destruction of the supporting structures of the teeth including gums, periodontal ligaments, alveolar bone, and root cementum. Recently, interests in alleviating symptoms of periodontitis (PD) using natural compounds is increasing. Avenanthramide-C (Avn-C) is a polyphenol found only in oats. It is known to exhibit various biological properties. To date, the effect of Avn-C on PD pathogenesis has not been confirmed. Therefore, this study aimed to verify the protective effects of Avn-C on periodontal inflammation and subsequent alveolar bone erosion in vitro and in vivo. Upregulated expression of catabolic factors, such as matrix metalloproteinase 1 (MMP1), MMP3, interleukin (IL)-6, IL-8, and COX2 induced by lipopolysaccharide and proinflammatory cytokines, IL-1β, and tumor necrosis factor α (TNF-α), was dramatically decreased by Avn-C treatment in human gingival fibroblasts and periodontal ligament cells. Moreover, alveolar bone erosion in the ligature-induced PD mouse model was ameliorated by intra-gingival injection of Avn-C. Molecular mechanism studies revealed that the inhibitory effects of Avn-C on the upregulation of catabolic factors were mediated via ERK (extracellular signal-regulated kinase) and NF-κB pathway that was activated by IL-1β or p38 MAPK and JNK signaling that was activated by TNF-α, respectively. Based on this study, we recommend that Avn-C may be a new natural compound that can be applied to PD treatment.

Clinical benefits of systemic amoxicillin/metronidazole may depend on periodontitis stage and grade: An exploratory sub-analysis of the ABPARO trial

AIM

Assessment of treatment response after systemic amoxicillin/metronidazole adjunctive to subgingival instrumentation (SI) according to stages and grades of the 2018 classification of periodontal diseases.

MATERIALS AND METHODS

We carried out exploratory re-analysis of the placebo-controlled, multi-centre ABPARO trial (52; 45/60 years of age; 205 males, 114 active smokers). Patients were randomized to SI with systemic amoxicillin 500 mg/metronidazole 400 mg (three times a day for 7 days, n = 205; ANTI) or placebo (n = 200; PLAC) and maintenance therapy every 3 months. Patients were reclassified according to the 2018 classification (stage/extent/grade). Treatment effect was the percentage of sites per patient with new attachment loss ≥1.3 mm (PSAL ≥ 1.3 mm) at 27.5 months post-baseline/randomization.

RESULTS

All patients were assigned according to the stage (n = 49 localized stage III, n = 206 generalized stage III, n = 150 stage IV). Because of missing radiographs, only 222 patients were assigned to grades (n = 73 B, n = 149 C). Treatment (PLAC/ANTI) resulted in PSAL ≥ 1.3 mm (median; lower/upper quartile) in localized stage III (PLAC: 5.7; 3.3/8.4% vs. ANTI: 4.9; 3.0/8.3%; p = .749), generalized stage III (8.0; 4.5/14.3% vs. 4.7; 2.4/9.0%; p < .001), stage IV (8.5; 5.1/14.4% vs. 5.7; 3.3/10.6%; p = .008), grade B (4.4; 2.4/6.7% vs. 3.6; 1.9/4.7%; p = .151) and grade C (9.4; 5.3/14.3% vs. 4.8; 2.5/9.4%; p < .001).

CONCLUSIONS

In generalized periodontitis stage III/grade C, a clinically relevant lower percentage of disease progression after adjunctive systemic amoxicillin/metronidazole was observed compared to placebo (PLAC: 9.7; 5.8/14.3% vs. ANTI: 4.7; 2.4/9.0%; p < .001).

Saliva biomarkers in oral disease

Saliva is a versatile biofluid that contains a wide variety of biomarkers reflecting both physiologic and pathophysiologic states. Saliva collection is noninvasive and highly applicable for tests requiring serial sampling. Furthermore, advances in test accuracy, sensitivity and precision for saliva has improved diagnostic performance as well as the identification of novel markers especially in oral disease processes. These include dental caries, periodontitis, oral squamous cell carcinoma (OSCC) and Sjögren's syndrome (SS). Numerous growth factors, enzymes, interleukins and cytokines have been identified and are the subject of much research investigation. This review highlights current procedures for successful determination of saliva biomarkers including preanalytical factors associated with sampling, storage and pretreatment as well as subsequent analysis. Moreover, it provides an overview of the diagnostic applications of these salivary biomarkers in common oral diseases.

Efficacy of Periodontal Endoscopy during Subgingival Debridement to Treat Periodontitis: A Systematic Review of Randomized Clinical Trials

This study aims to evaluate the clinical efficacy of periodontal endoscopy (PEND) during subgingival debridement to treat periodontitis. A systematic review of randomized clinical trials (RCTs) was performed. The search strategy included four databases: PubMed, Web of Sciences, Scopus, and Scielo. The initial online exploration generated 228 reports, and 3 RCTs met the selection criteria. These RCTs described a statistically significant decrease in probing depth (PD) in the PEND group compared to controls after 6 and 12 months of follow-up. The improvement in PD was 2.5 mm for PEND and 1.8 mm for the control groups, respectively (p < 0.05). It was also described that the PEND group presented a significantly inferior proportion of PD 7 to 9 mm at 12 months (0.5%) as compared to the control group (1.84%) (p = 0.03). All RCTs noted improvements in clinical attachment level (CAL). It was described as having significant differences in bleeding on probing (BOP) in favor of PEND, with an average reduction of 43% versus 21% in the control groups. Similarly, it was also presented that they were significant differences in plaque indices in favor of PEND. PEND during subgingival debridement to treat periodontitis demonstrated efficacy in reducing PD. Improvement was also observed in CAL and BOP.

Efficacy of Proanthocyanidins in Nonsurgical Periodontal Therapy

BACKGROUND

The aim of this work was to evaluate the efficacy of proanthocyanidins (PACNs) as an adjunctive periodontal therapy in patients with periodontitis.

METHODS

Patients with periodontitis (stage III-IV) were included in this randomised clinical study. Patients with periodontitis received 2 different treatment modalities: minimally invasive nonsurgical therapy only (MINST group) or minimally invasive nonsurgical therapy and subgingival application of collagen hydrogels with PACNs (MINST + PACNs group). Clinical periodontal parameters, that is, pocket probing depth (PPD), clinical attachment level (CAL), bleeding on probing (BOP), plaque index (PI), were evaluated before treatment and after 8 weeks. Concentrations of immunologic markers, matrix metalloproteinase-3 (MMP-3), and tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) in saliva were assessed at baseline and at 8-week follow-up.

RESULTS

Forty-six patients diagnosed with periodontitis were randomised into 2 groups: 23 patients in the MINST group and 23 patients in the MINST + PACNs group received the intended treatment. PACNs combined with MINST resulted in additional statistically significant PPD reduction and CAL gain in moderate periodontal pockets by 0.5 mm (P < .05) on average compared to MINST alone. Additional use of PACNs did not result in additional statistically significant improvement of BOP or PI values. Application of PACNs showed significant reduction of MMP-3 levels in saliva after 8 weeks (P < .05).

CONCLUSIONS

Adjunctive use of PACNs in MINST resulted in better clinical outcomes for moderate pockets. Additional use of PACNs improved MMP-3 concentration in saliva more than MINST alone. Biochemical analysis revealed that MMP-3 concentration in saliva reflected the periodontal health state.

Local drug delivery in the treatment of furcation defects in periodontitis: a systematic review

OBJECTIVES

To evaluate the effect of subgingival administration of various antimicrobials and host-modulating agents in furcation defects as an adjunct to scaling and root planing (SRP) compared to SRP alone or combined with placebo.

METHODS

A systematic review was carried out using MEDLINE-PubMed, Embase, and Scopus for articles up to October 2022 in addition to hand searches. All longitudinal studies that evaluated the effect of subgingival application of antimicrobial and host-modulating agents in furcation defects as adjuncts to SRP compared to SRP alone or SRP + placebo with at least 3 months of follow-up were eligible for inclusion.

RESULTS

A total of eight studies were included. Superior clinical treatment outcomes were shown when alendronate, rosuvastatin, boric acid, simvastatin, and tetracycline (only at 3 months) were utilized in furcation defects in conjunction with SRP alone or SRP + placebo. Significant improvement was reported in radiographic bone defect depth and defect depth reduction when SRP was supplemented with alendronate, rosuvastatin, boric acid, and simvastatin.

CONCLUSIONS

Within the limitations of this review, the adjunctive subgingival administration of medications and host-modulating agents in furcation defects may confer additional clinical and radiographic benefits than non-surgical periodontal treatment alone. Future investigations are needed to confirm their long-term effectiveness.

CLINICAL RELEVANCE

Local host modulators and antimicrobials may be used supplementary to enhance the clinical and radiographic treatment outcomes of conventional periodontal therapy in furcation defects.

Synthesis, Characterization, Cytotoxicity Analysis and Evaluation of Novel Heterocyclic Derivatives of Benzamidine against Periodontal Disease Triggering Bacteria

Periodontal disease (PD) is multifactorial oral disease that damages tooth-supporting tissue. PD treatment includes proper oral hygiene, deep cleaning, antibiotics therapy, and surgery. Despite the availability of basic treatments, some of these are rendered undesirable in PD treatment due to side effects and expense. Therefore, the aim of the present study is to develop novel molecules to combat the PD triggering pathogens. The study involved the synthesis of 4-((5-(substituted-phenyl)-1,3,4-oxadiazol-2-yl)methoxy)benzamidine (5a-e), by condensation of 2-(4-carbamimidoylphenoxy)acetohydrazide (3) with different aromatic acids; and synthesis of 4-((4-(substituted benzylideneamino)-4H-1,2,4-triazol-3-yl)methoxy)benzamidine (6a-b) by treatment of compound 3 with CS₂ followed by hydrazination and a Schiff reaction with different aromatic aldehydes. Synthesized compounds were characterized based on the NMR, FTIR, and mass spectrometric data. To assess the effectiveness of the newly synthesized compound in PD, new compounds were subjected to antimicrobial evaluation against P. gingivalis and E. coli using the micro-broth dilution method. Synthesized compounds were also subjected to cytotoxicity evaluation against HEK-293 cells using an MTT assay. The present study revealed the successful synthesis of heterocyclic derivatives of benzamidine with significant inhibitory potential against P. gingivalis and E. coli. Synthesized compounds exhibited minimal to the absence of cytotoxicity. Significant antimicrobial potential and least/no cytotoxicity of new heterocyclic analogs of benzamidine against PD-triggering bacteria supports their potential application in PD treatment.

The effect of antibiotics on the periodontal treatment of diabetic patients with periodontitis: A systematic review and meta-analysis

Background: The aim of this meta-analysis was to compare the effects of periodontal treatment with or without adjunctive antibiotic on periodontal status and blood glucose level in diabetic patients with periodontitis. Methods: A search using electronic database (MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials) and a manual search were performed up to July 2022. Eligible 13 RCTs were included according to inclusion and exclusion criteria. Reviewers independently performed data screening, data selection, data extraction, and risk of bias. Quality assessment was performed according to the Cochrane Handbook for Systematic Reviews of Interventions. Weighted mean differences and 95% confidence intervals (CIs) for continuous outcomes were calculated using random or fixed-effects models. This review is registered in the PROSPERO database (CRD42022347803). Results: Of the 13 included articles, eight were on the use of systemic antibiotics and five on topical antibiotics. The results showed statistically significant improvement in periodontal status (probing depth, clinical attachment loss and bleeding on probing) at 6 months with systematic antibiotics use (PD-6M p = 0.04, BOP-6M p < 0.0001, CAL-6M p = 0.002). The improvement in PD with topical antibiotics was statistically significant at 1 month (p = 0.0006). However, there was no statistically significant improvement in periodontal status at 3 months with adjuvant systemic antibiotics. Conclusion: Antibiotics can improve the periodontal condition of diabetic patients with periodontitis to a certain extent. In clinical practice, it is necessary to comprehensively consider the balance of benefits and risks before deciding whether to use antibiotics. Systematic Review Registration: Identifier CRD42022347803, https://www.crd.york.ac.uk/PROSPERO/.

Additional benefit of systemic antibiotics in subgingival instrumentation of stage III and IV periodontitis with Aggregatibacter actinomycetemcomitans: A retrospective analysis

AIM

To evaluate subgingival instrumentation (SI) in periodontitis stage III and IV, grade B and C with systemic antibiotics (AB) only after detection of Aggregatibacter actinomycetemcomitans.

MATERIALS AND METHODS

Patients of the Department of Periodontology of Goethe University Frankfurt/Germany were screened for microbiological testing between 2008 and 2018. All patients with aggressive and generalized severe chronic periodontitis were tested. In case of positive subgingival A. actinomycetemcomitans tests, SI was combined with AB; in all other cases it was not (nAB). Clinical examinations were performed before (T0), 12.4 (9.4/15.1) weeks after SI (T1), and at the last supportive periodontal care (T2; 3.1 [1.4/5.5] years after T1). Results at T1/T2 were assessed as "treat-to-target" endpoint (≤4 sites with probing pocket depths ≥5 mm).

RESULTS

Four-hundred and twenty-five patients (280 stage III/145 stage IV, 95 grade B/330 grade C) provided complete data (AB 144/nAB 281) for T0 and T1, and 332 (AB 121/nAB 211) for T2. At T1/T2, AB resulted in 53 (37%)/76 (63%) patients with "treat-to-target" endpoint, and nAB in 76 (27%)/91 (43%) (p = .038/.001).

CONCLUSIONS

In periodontitis stage III and IV, grade B and C with subgingival A. actinomycetemcomitans infection, SI with AB resulted in higher rate of "treat-to-target" endpoint than exclusive SI in patients without the infection.

Efficacy of Systemic Amoxicillin–Metronidazole in Periodontitis Patients with Diabetes Mellitus: A Systematic Review of Randomized Clinical Trials

Systemic amoxicillin–metronidazole was proven to be effective in managing periodontitis in systemically healthy patients. It was demonstrated that systemic antibiotic therapy can effectively improve clinical periodontal parameters and reduce periodontopathogenic organisms in the subgingival biofilm. However, the evidence for prescribing this drug combination to patients with diabetes remains insufficient. This systematic review was designed to evaluate the effectiveness of a systemic amoxicillin–metronidazole combination as an adjunct to nonsurgical periodontal therapy in patients with diabetes presenting with chronic periodontitis. The PubMed, Scopus, and Web of Science databases were electronically searched for randomized clinical trials in January 2022. Randomized clinical trials evaluating systemic amoxicillin–metronidazole therapy as an adjunct to nonsurgical periodontal therapy in patients with type 2 diabetes presenting with periodontitis were selected for screening. The qualities of the studies were assessed using the Cochrane Collaboration’s Tool for Assessing Risk of Bias Version 2.0 (ROB-2), and a GRADE assessment was applied to estimate the overall certainty of the evidence. Using predefined eligibility criteria, four clinical trials examining 209 patients were selected from the 611 articles identified in the search. Two studies reported a better reduction in clinical parameters when SRP was combined with systemic amoxicillin–metronidazole. Systemic amoxicillin–metronidazole was found to be as effective as clindamycin. Surgical therapy with systemic amoxicillin–metronidazole was more effective than nonsurgical therapy with systemic amoxicillin–metronidazole, even though both resulted in reduced clinical parameters. Combined amoxicillin–metronidazole was observed to reduce periodontal probing depth (PPD), clinical attachment level (CAL), and bleeding on probing (BOP) compared to no treatment or NSPT alone. However, the effect was not greater when compared to NSPT with clindamycin or surgical therapy with amoxicillin–metronidazole. Further randomized trials are required before clinical guidelines can be established for the use of systemic amoxicillin–metronidazole. Future randomized controlled clinical trials with long-term follow-ups are required to assess the efficacy of systemic antibiotic therapy in managing periodontitis in patients with diabetes.

Implications of Porphyromonas gingivalis peptidyl arginine deiminase and gingipain R in human health and diseases

Porphyromonas gingivalis is a major pathogenic bacterium involved in the pathogenesis of periodontitis. Citrullination has been reported as the underlying mechanism of the pathogenesis, which relies on the interplay between two virulence factors of the bacterium, namely gingipain R and the bacterial peptidyl arginine deiminase. Gingipain R cleaves host proteins to expose the C-terminal arginines for peptidyl arginine deiminase to citrullinate and generate citrullinated proteins. Apart from carrying out citrullination in the periodontium, the bacterium is found capable of citrullinating proteins present in the host synovial tissues, atherosclerotic plaques and neurons. Studies have suggested that both virulence factors are the key factors that trigger distal effects mediated by citrullination, leading to the development of some non-communicable diseases, such as rheumatoid arthritis, atherosclerosis, and Alzheimer’s disease. Thus, inhibition of these virulence factors not only can mitigate periodontitis, but also can provide new therapeutic solutions for systematic diseases involving bacterial citrullination. Herein, we described both these proteins in terms of their unique structural conformations and biological relevance to different human diseases. Moreover, investigations of inhibitory actions on the enzymes are also enumerated. New approaches for identifying inhibitors for peptidyl arginine deiminase through drug repurposing and virtual screening are also discussed.

Characterization and potential oral probiotic properties of Lactobacillus plantarum FT 12 and Lactobacillus brevis FT 6 isolated from Malaysian fermented food

OBJECTIVE

This study aims to characterise the lactic acid bacteria (LAB) isolated from local Malaysian fermented foods with oral probiotics properties.

DESIGN

The LAB strains isolated from Malaysian fermented foods, Lactobacillus brevis FT 6 and Lactobacillus plantarum FT 12, were assessed for their antimicrobial properties against Porphyromonas gingivalis ATCC 33277 via disc diffusion assay. Anti-biofilm properties were determined by treating the overnight P. gingivalis ATCC 33277 biofilm with different concentrations of LAB cell-free supernatant (LAB CFS). Quantification of biofilm was carried out by measuring the optical density of stained biofilm. The ability of L. brevis FT 6 and L. plantarum FT 12 to tolerate salivary amylase was also investigated. Acid production with different sugars was carried out by pH measurement and screening for potential antimicrobial organic acid by disc diffusion assay of neutralised probiotics CFS samples. In this study, L. rhamnosus ATCC 7469, a commercial strain was used to compare the efficacy of the isolated strain with the commercial strain.

RESULTS

Lactobacillus brevis FT 6 and L. plantarum FT 12 possess antimicrobial activity against P. gingivalis with inhibition diameters of more than 10 mm, and the results were comparable with L. rhamnosus ATCC 7469. The MIC and MBC assay results for all tested strains were recorded to be 25 µl/µl concentration. All LAB CFS reduced biofilm formation proportionally to the CFS concentration and tolerated salivary amylase with more than 50% viability. Overnight cultures of all lactic acid bacteria strains showed a pH reduction and neutralised CFS of all lactic acid bacteria strains did not show any inhibition towards P. gingivalis.

CONCLUSIONS

These results indicate that the isolated probiotics have the potential as probiotics to be used as a supportive oral health treatment, especially against a periodontal pathogen, P. gingivalis.

Clinical, microbiological and immunological effects of 3- or 7-day systemic antibiotics adjunctive to subgingival instrumentation in patients with aggressive (stage III/IV grade C) periodontitis: a randomized placebo-controlled clinical trial

AIM

To evaluate the clinical non-inferiority of a 3-day-protocol of systemic antibiotics adjunctive to subgingival instrumentation (SI) compared to a 7-day-protocol in patients with stage III/IV grade C periodontitis.

METHODS

50 systemically healthy patients (32.7±4.3 years) with aggressive periodontitis (stage III/IV grade C periodontitis) were treated by SI and adjunctive amoxicillin and metronidazole randomly assigned to group A: (n=25) 500mg antibiotics 3-times-daily for 3 days, followed by placebo 3-times-daily for 4 days, or group B: (n=25) 500mg AB 3-times-daily for 7 days. Clinical, microbial and immunological parameters were assessed at baseline, 3 and 6 months, and patient-related outcomes after 2 weeks. The primary outcome variable was the number of residual sites with PD≥6mm at 6 months.

RESULTS

For the primary outcome variable (the number of residual sites with PD≥6mm at 6 months), the null hypothesis was rejected and demonstrated the non-inferiority of the 3d AB protocol compared to 7d AB (the upper limits of the 95%CI for ITT: [-2.572; 1.050] and PP: [-2.523; 1.318] were lower than the assumed margin of Δ=3.1). Comparable clinical improvements were obtained for all parameters with both antibiotic protocols (p>0.05). All investigated periodontopathogens and pro-inflammatory host-derived markers were statistically significantly reduced, without differences between the treatments (p>0.05).

CONCLUSION

These findings indicate that in patients with aggressive periodontitis (stage III/IV grade C periodontitis), a 3-day systemic administration of amoxicillin and metronidazole adjunctive to SI may lead to non-inferior clinical outcomes after 6-months with fewer adverse events compared to a 7-day-protocol.

Effect of Subgingival Instrumentation on Neutrophil Elastase and C-Reactive Protein in Grade B and C Periodontitis: Exploratory Analysis of a Prospective Cohort Study

Background: Assessment of the effect of subgingival instrumentation (SI) on systemic inflammation in periodontitis grades B (BP) and C (CP). Methods: In this prospective cohort study, eight BP and 46 CP patients received SI. Data were collected prior to and 12 weeks after SI. Blood was sampled prior to, one day, 6, and 12 weeks after SI. Neutrophil elastase (NE), C-reactive protein (CRP), leukocyte count, lipopolysaccharide binding protein, interleukin 6 (IL-6) and IL-8 were assessed. Results: Both groups showed significant clinical improvement. NE was lower in BP than CP at baseline and 1 day after SI, while CRP was lower in BP than CP at baseline (p < 0.05). NE and CRP had a peak 1 day after SI (p < 0.05). Between-subjects effects due to CP (p = 0.042) and PISA (p = 0.005) occurred. Within-subjects NE change was confirmed and modulated by grade (p = 0.017), smoking (p = 0.029), number of teeth (p = 0.033), and PISA (p = 0.002). For CRP between-subjects effects due to BMI (p = 0.008) were seen. Within-subjects PISA modulated the change of CRP over time (p = 0.017). Conclusions: In untreated CP, NE and CRP were higher than in BP. SI results in better PPD and PISA reduction in BP than CP. Trial registration: Deutsches Register Klinischer Studien DRKS00026952 28 October 2021 registered retrospectively.

Clinical and Microbiological Efficacy of Adjunctive Systemic Quinolones to Mechanical Therapy in Periodontitis: A Systematic Review of the Literature

Objectives

To assess the clinical and microbiological efficacy of systemic quinolones adjunctive to mechanical therapy in periodontitis patients. Materials and Methods. A systematic review of the scientific literature was carried out. The search scheme comprised the Scopus, PubMed/MEDLINE, SCIELO (Scientific Electronic Library Online), and LILACS (Literatura Latinoamericana y del Caribe en Ciencias de la Salud) databases, together with the gray literature. MeSH terms and keywords were utilized to explore publications in all idioms. Only randomized clinical trials (RCTs) that met the selection criteria were included.

Results

A total of 4 RCTs were selected. These RCTs found superior clinical and microbiological efficacy of adjunctive systemic moxifloxacin (MOX) and levofloxacin (LV) compared to subgingival debridement plus placebo. Improvements in PD and CAL were 2.4 ± 0.8 mm and 2.7 ± 0.9 mm for LV, and 1.5 ± 0.5 mm and 1.8 ± 0.5 mm for MOX, respectively. After six months of follow-up, adjunctive MOX reduced the presence of Aggregatibacter actinomycetemcomitans to imperceptible levels, while LV markedly reduced this microorganism. Some adverse events were reported in the LV group and none in the MOX group.

Conclusions

Adjunctive MOX and LV improve probing depth and clinical attachment level compared with subgingival debridement alone in patients with periodontitis. The efficacy of these quinolones against A. actinomycetemcomitans was also superior.

Impact of Oral Microbiome in Periodontal Health and Periodontitis: A Critical Review on Prevention and Treatment

The skin, oral cavity, digestive and reproductive tracts of the human body harbor symbiotic and commensal microorganisms living harmoniously with the host. The oral cavity houses one of the most heterogeneous microbial communities found in the human organism, ranking second in terms of species diversity and complexity only to the gastrointestinal microbiota and including bacteria, archaea, fungi, and viruses. The accumulation of microbial plaque in the oral cavity may lead, in susceptible individuals, to a complex host-mediated inflammatory and immune response representing the primary etiological factor of periodontal damage that occurs in periodontitis. Periodontal disease is a chronic inflammatory condition affecting about 20-50% of people worldwide and manifesting clinically through the detection of gingival inflammation, clinical attachment loss (CAL), radiographic assessed resorption of alveolar bone, periodontal pockets, gingival bleeding upon probing, teeth mobility and their potential loss in advanced stages. This review will evaluate the changes characterizing the oral microbiota in healthy periodontal tissues and those affected by periodontal disease through the evidence present in the literature. An important focus will be placed on the immediate and future impact of these changes on the modulation of the dysbiotic oral microbiome and clinical management of periodontal disease.

Systems Biology in Periodontitis

Systems biology is a promising scientific discipline that allows an integrated investigation of host factors, microbial composition, biomarkers, immune response and inflammatory mediators in many conditions such as chronic diseases, cancer, neurological disorders, and periodontitis. This concept utilizes genetic decoding, bioinformatic, flux-balance analysis in a comprehensive approach. The aim of this review is to better understand the current literature on systems biology and identify a clear applicability of it to periodontitis. We will mostly focus on the association between this condition and topics such as genomics, transcriptomics, proteomics, metabolomics, as well as contextualize delivery systems for periodontitis treatment, biomarker detection in oral fluids and associated systemic conditions.

The Quantification of Salivary Flow and pH and Stomatognathic System Rehabilitation Interference in Patients with Oral Diseases, Post-Radiotherapy

Xerostomia is a common complication post-radiotherapy in patients with oral cancer. The acute and long-term side effects can considerably reduce the patient’s quality of life. The aim of our study was to perform analysis of salivary flow and pH in patients after radiotherapy. Methodology: Clinical and laboratory evaluations were conducted in the 2014–2019 period; out of a total 58 subjects aged between 45 and 84, 28 individuals with oral cancer were selected from St. Spiridon Hospital, Clinic of Maxillo-facial Surgery and Oncology Hospital, Iasi post-radiotherapy. Results: Significant downsized mean values of the hydrogen ion concentration (pH) in saliva (p < 0.001) were recorded in patients after radiotherapy, pH value = 4.580 (±1.051). The mean value of resting salivary flow (MRSF) was significantly lower for the group of patients with radiotherapy (MRSF) = 0.145 mL/min. In 89.29% of cases (25 post-radiotherapy cases), in order to perform oral complex rehabilitation treatment, several endodontic and periodontal treatments were performed. A total of 78.57% of the cases received complex oral rehabilitation as mobile or hybrid prostheses or fixed solutions. Conclusion: Understanding post-radiotherapy salivary biochemic modifications in patients with oral cancer could be of critical importance, in view of related oral disorder prevention.

What Are the Potential Benefits of Using Bacteriophages in Periodontal Therapy?

Periodontitis, which may result in tooth loss, constitutes both a serious medical and social problem. This pathology, if not treated, can contribute to the development of, among others, pancreatic cancer, cardiovascular diseases or Alzheimer’s disease. The available treatment methods are expensive but not always fully effective. For this reason, the search for and isolation of bacteriophages specific to bacterial strains causing periodontitis seems to be a great opportunity to target persistent colonization by bacterial pathogens and lower the use of antibiotics consequently limiting further development of antibiotic resistance. Furthermore, antimicrobial resistance (AMR) constitutes a growing challenge in periodontal therapy as resistant pathogens may be isolated from more than 70% of patients with periodontitis. The aim of this review is to present the perspective of phage application in the prevention and/or treatment of periodontitis alongside its complicated multifactorial aetiology and emphasize the challenges connecting composition and application of effective phage preparation.

Nanocrystalline hydroxyapatite in regeneration of periodontal intrabony defects: A systematic review and meta-analysis

BACKGROUND

Alveolar bone loss and mobility of teeth is commonly observed in periodontitis patients. Regeneration of periodontal intrabony defects is indicated to restore the lost bone and periodontal tissues. The aim of the present study was to evaluate the clinical outcomes of periodontal intrabony lesions by using nanocrystalline hydroxyapatite (NHA) graft and comparing it with open flap debridement (OFD) alone.

MATERIALS AND METHODS

The eligibility criteria encompassed randomized (RCTs) and controlled clinical trials (CCTs). Weighted mean differences were calculated for clinical attachment level (CAL) gain, probing pocket depth (PPD) reduction and gingival recession (REC) change, demonstrated as forest plots. The revised Cochrane Risk of Bias tool for randomized trials (RoB2) and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool were used for quality assessment of RCTs and non-randomized trials respectively.

RESULTS

From 22 full-text articles identified, three RCTs, one CCT and one retrospective follow-up of RCT were included. All the five papers comprised the quantitative evaluation. The use of NHA graft provided additional CAL gain of 0.96 mm (p = 0.0009) and PPD reduction of 0.97 mm (p < 0.00001) when compared to OFD alone. However, in terms of REC changes, no considerable benefits of NHA graft were demonstrated than OFD alone (p = 0.48).

CONCLUSIONS

The bioactive NHA graft showed promising results clinically in regenerative periodontology and can be considered for the management of periodontal intrabony defects. The use of NHA graft considerably provided better clinical outcomes in intrabony defects compared to using the OFD alone. Future research investigating NHA graft against other regenerative materials including specific BGs, at longer follow-up periods and bigger sample sizes and in furcation defects warranted.

Comparing Nanohydroxyapatite Graft and Other Bone Grafts in the Repair of Periodontal Infrabony Lesions: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare the results of periodontal infrabony lesions treated using nanohydroxyapatite (NcHA) graft with other bone grafts (BGs).

METHODS

Four electronic databases were searched including PubMed (NLM), Embase (Ovid), Medline, and Dentistry and Oral Sciences (EBSCO). The inclusion criteria included randomised controlled clinical trials (RCTs) and controlled clinical trials (CCTs). The clinical results of NcHA were compared with other BGs. For clinical attachment level (CAL) gain, probing pocket depth (PPD) decrease, and gingival recession (REC) change, weighted averages and forest plots were computed.

RESULTS

Seven RCTs fulfilled the selection criteria that were included. When NcHA was compared to other BGs, no clinically significant differences were found in terms of each outcome assessed, except the REC change for synthetic BGs as compared to NcHA.

CONCLUSIONS

The use of an NcHA graft showed equivalent results compared to other types of BGs. To further validate these findings, future studies are required to compare the NcHA and various BGs over longer time periods and in furcation deficiencies.

Berberine as a promising natural compound for the treatment of periodontal disease: A focus on anti-inflammatory properties

Accumulating evidence during the last two decades has addressed the potential anti‐inflammatory properties of berberine (BBR), a bioactive alkaloid compound isolated from Coptidis rhizoma, in controlling or treating several inflammatory diseases. Periodontitis is one of the most common chronic and serious inflammatory diseases, in which uncontrolled and unabated host immune responses against periodontopathic pathogens play critical and crucial roles in the disease pathogenesis. Hence, regulating inflammatory responses in periodontitis has a valuable approach and holds promise in treating periodontitis. For the first time, this paper reviews the evidence from in vitro and in vivo experimental models to explore the anti‐inflammatory effects of BBR in periodontitis and exhibits that BBR has the high potency to exert anti‐inflammatory effects by reducing expression and secretion of pro‐inflammatory mediators including TNF‐α, IL‐1β, IL‐17, RANKL, MMP‐2, MMP‐9 and MCP‐1. The BBR‐mediated anti‐inflammatory actions could translate into the inhibition of the periodontal tissues and alveolar bone destruction and the control of the disease in vivo. As the second aim of this paper, we also paid attention to the therapeutic potential of BBR in treating human diseases regarding its anti‐inflammatory properties.

Clinical Efficacy of Repeated Applications of Local Drug Delivery and Adjunctive Agents in Nonsurgical Periodontal Therapy: A Systematic Review

The aim of this systematic review is to compare the clinical efficacy of repeated applications of local drug delivery and adjunctive agents (LDAs) in nonsurgical periodontal therapy (NSPT) compared to subgingival mechanical debridement (SMD) alone. The Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, EMBASE, Web of Science, hand-searched literature and grey literature databases were searched for randomized controlled clinical trials (RCTs) with a minimum of 6-month follow-up. The outcomes of interest were changes in probing pocket depth and clinical attachment level as well as patient-centred outcomes. Of 1094 studies identified, 16 RCTs were included in the qualitative analysis. Across 11 different adjuncts analysed, only two studies utilizing minocycline gel/ointment and antimicrobial photodynamic therapy (aPDT) with indocyanine green photosensitizer had statistically significant differences in primary outcomes when compared to their control groups. Only one study on aPDT methylene blue 0.005% had compared single versus multiple applications against its control group. A mean range of 0.27-3.82 mm PD reduction and -0.09-2.82 mm CAL gain were observed with repeated LDA application. Considerable clinical heterogeneity and methodological flaws in the included studies preclude any definitive conclusions regarding the clinical efficacy of repeated LDA applications. Future RCTs with a direct comparison between single and repeated applications should be conducted to confirm or refute the clinical advantages of repeated LDA application in the nonsurgical management of periodontitis.

Effect of Propolis Paste and Mouthwash Formulation on Healing after Teeth Extraction in Periodontal Disease

This study investigated the antimicrobial effects of a mouthwash containing propolis and the effect of a propolis paste formulation on dental healing after teeth extraction in patients with periodontal disease. In the mouthwash experience, the population comprised 40 patients, which were divided as follows: the control mouthwash, 0.2% chlorhexidine (v/v) mouthwash, 2% (w/v) propolis mouthwash, and propolis + chlorhexidine mouthwash. The study of the propolis paste comprised a population of 60 patients with periodontal disease, and a total of 120 symmetric tooth extractions were performed. Propolis showed antimicrobial activity by itself, and especially with the chlorhexidine association. Three days after surgery in the teeth treated with control paste, only 13.4% had completely healed; however, with propolis paste, in 90% of the periodontal sockets, healing was complete. In addition, a reduction in Streptococci mutans and Lactobacilli cfu was observed with propolis, and especially with the association of chlorhexidine + propolis. Propolis mouthwash reduced bacterial proliferation, especially in association with chlorhexidine. Propolis paste is a viable alternative for socket healing after dental extraction. The knowledge gained from these findings will provide a foundation for similar propolis therapies in order to improve the healing process after dental surgery.

A Survey of Systemic Antibiotic Prescription Patterns Amongst Iraqi Dentists

OBJECTIVES

The misuse of antibiotic prescriptions is a common behavior amongst dentists worldwide. Over-prescription of these agents is associated with multiple adverse effects and risk of developing bacterial resistance. The aim of this study was to assess systemic antibiotic prescription patterns amongst dentists in Iraq.

METHODS

A questionnaire-based survey was conducted in dental centres distributed in 12 Iraqi governates. The questionnaire was composed of two main sections: The first was dedicated to collecting demographic and work-related information, and the second section included questions seeking details about antibiotic prescriptions for different oral and dental conditions.

RESULTS

A total of 481 valid questionnaires were considered in the final analysis. The numbers of correct and incorrect patterns of prescribing antibiotics for different dental/oral conditions were almost equal (49.6% and 50.4%, respectively). Amongst independent variables investigated, qualification of the dentist and work domain were found to have significant associations with correct prescribing patterns (odds ratio, 1.166 and 1.197, respectively). The majority of dentists preferred amoxicillin as the first-choice antibiotic, followed by "Augmentin" (43.7% and 35.5%, respectively), whilst clarithromycin was the lowest on the list. Azithromycin was the most recommended antibiotic (55.9%) in cases of allergy to penicillin.

CONCLUSIONS

In general, antibiotics are prescribed for recommended conditions, but the prescription for nonrecommended conditions was also evident amongst Iraqi dentists. Correct pattern of antibiotic prescribing was significantly associated with specialists and those working in the academic field. Additionally, amoxicillin and its derivatives are the most preferred drugs.

Clindamycin as an Alternative Option in Optimizing Periodontal Therapy

Periodontal disease is an oral infectious and inflammatory disease caused by microorganisms that determine the host-mediated destruction of soft and hard periodontal tissues, which ultimately leads to tooth loss. Periodontitis affects a large part of the population, with various degrees of severity. Treatment consists of etiologic therapy: the removal of biofilm through mechanical debridement plus microbial elimination by supplementary measures. Antibiotic administration, either systemically or through local delivery, has been shown to improve clinical outcomes after mechanical periodontal treatment. Clindamycin is a lincosamide with a broad spectrum, being active against aerobic, anaerobic, and β-lactamase-producing bacteria. This antibiotic offers several advantages and some disadvantages and has been used in periodontal treatment both systemically and locally with various degrees of success. Among the properties that recommend it for periodontal treatment is the bacteriostatic effect, the inhibition of bacterial proteins synthesis, the enhancement of neutrophil chemotaxis, phagocytosis and the oxidative burst–oxidative stress storm. Furthermore, it is easily absorbed at the level of oral tissues in a considerable amount. This substantial tissue penetration, especially inside the bone, is synergistic with a stimulating effect on the host immune system. The aim of this review is to explore the applicability of this antibiotic agent and to evaluate its antimicrobial potential and limitations at the level of the oral biofilm associated with periodontal disease.

Selective Antimicrobial Therapies for Periodontitis: Win the "Battle and the War"

Traditional antimicrobial therapies for periodontitis (PD) have long focused on non-selective and direct approaches. Professional cleaning of the subgingival biofilm by instrumentation of dental root surfaces, known as scaling and root planning (SRP), is the mainstay of periodontal therapy and is indisputably effective. Non-physical approaches used as adjuncts to SRP, such as chemical and biological agents, will be the focus of this review. In this regard, traditional agents such as oral antiseptics and antibiotics, delivered either locally or systemically, were briefly reviewed as a backdrop. While generally effective in winning the “battle” against PD in the short term, by reducing its signs and symptoms, patients receiving such therapies are more susceptible to recurrence of PD. Moreover, the long-term consequences of such therapies are still in question. In particular, concern about chronic use of systemic antibiotics and their influence on the oral and gut microbiota is warranted, considering antibiotic resistance plasmids, and potential transfer between oral and non-oral microbes. In the interest of winning the “battle and the war”, new more selective and targeted antimicrobials and biologics for PD are being studied. These are principally indirect, blocking pathways involved in bacterial colonization, nutrient acquisition, inflammation or cellular invasion without directly killing the pathogens. This review will focus on current and prospective antimicrobial therapies for PD, emphasizing therapies that act indirectly on the microbiota, with clearly defined cellular and molecular targets.

Magnetic resonance imaging as a diagnostic tool for periodontal disease: A prospective study with correlation to standard clinical findings-Is there added value?

AIM

To evaluate the correlation between standard clinical findings, radiographic (OPT) and magnetic resonance imaging (MRI) as well as to assess whether MRI is capable of providing additional information related to the severity and extent of periodontal disease.

METHODS

42 patients with generalized periodontitis received pre-interventional MRI scans. These were compared to MR images of a periodontal healthy control group (n = 34). The extent of the osseous oedema, detected by MRI, was set in correlation with clinical periodontitis-associated findings.

RESULTS

A highly significant correlation between bone oedema and clinical testings such as probing depth (p < 0.0001) and bleeding on probing (p < 0.0001) was revealed. The oedema exceeded the extent of demineralized bone. Patients with a positive BOP test showed a 2.51-fold increase in risk of already having a bone oedema around the respective tooth even if probing depth was ≤3 mm (logistic binary regression analysis, OR 2.51; 95% CI: 1.54-4.11; p < 0.0001).

CONCLUSION

MRI findings correlated with standard clinical findings, and MRI was able to depict intraosseous changes before any osseous defect had occurred.

Effectiveness of a nutraceutical agent in the non-surgical periodontal therapy: a randomized, controlled clinical trial

OBJECTIVE

Nutraceutical agents have been demonstrated as adjuncts for the treatment of several inflammatory diseases. The present study analyzed and compared new nutraceutical agent as an adjunct to Scaling and root planing (SRP) versus SRP alone for the treatment of periodontitis.

MATERIALS AND METHODS

Sixty-six patients with moderate periodontitis were enrolled. Through a randomized design, the patients were randomly assigned to SRP + nutraceutical agent (test group) or SRP alone (control group). Patients were regularly examined the clinical, inflammatory mediators and visual analogue scale (VAS) changes over a 6-month period. Clinical attachment level (CAL) was the primary outcome variable chosen. Gingival crevicular fluid (GCF) inflammatory mediator change and the impact of treatment on VAS were evaluated through a linear regression model.

RESULTS

Both treatments demonstrated an improvement in periodontal parameters compared with baseline. After 6 months of treatment, compared with the control group, the test group determined a significant probing depth (PD) (p = 0.003) and bleeding on probing (BOP) reduction (p < 0.001), while CAL gain was significantly obtained at 30 and 60 days after treatment (p < 0.05). In the test group, the level of inflammatory mediators was significantly reduced compared with the control group (p < 0.05). The linear regression analysis demonstrated that the nutraceutical agent exerted, in the test group, a significant influence on VAS at 6, 12, 24, and 48 h after treatment (p < 0.05).

CONCLUSIONS

Nutraceutical agent resulted in a more significant reduction in clinical, inflammatory mediators and short-term pain compared with SRP alone.

CLINICAL RELEVANCE

Nutraceutical agent, when combined with SRP, was demonstrated to be effective in reducing periodontal parameters and controlling the levels of inflammatory mediators and pain in patients with periodontitis.

Novel indocyanine green mediated antimicrobial photodynamic therapy in the management of chronic periodontitis - A randomized controlled clinico-microbiological pilot study

BACKGROUND

The use of scaling, root planing, antimicrobials, or antibiotics in the treatment of Chronic Periodontitis have proven beneficial in the past. The reduction in inflammatory markers and significant resolve in the clinical signs and symptoms and microbial loads evinced by a number of studies are a clear corroboration of the fact, but certain restraints utilizing these methods call for more effective ways of treating the disease. Later, lasers or photodynamic dyes used with the lasers like methylene blue or toluidine blue O have also not proven much efficacy and need further research. Hence the present pilot study is a step forward in this direction as it helps analyse the microbiological and clinical effects of indocyanine green antimicrobial photodynamic therapy an as adjunct to the non-surgical periodontal therapy in treating chronic periodontitis patients.

MATERIALS AND METHODS

30 patients diagnosed with generalized chronic periodontitis were treated with scaling and root planing alone - control sites; and indocyanine green antimicrobial photodynamic therapy in addition to scaling and root planing - experimental sites. 810 ​nm low level Gallium Aluminium Arsenide diode laser was used to activate the dye in the periodontal pockets of the experimental sites. Clinical parameters i.e. gingival index, plaque index, sulcus bleeding index, probing pocket depth and relative attachment level; and microbiological parameter i.e. the total viable anaerobic count were recorded at the inception and at 3- and 6-months post therapy.

RESULTS

Experimental sites showed significantly greater amelioration in all inquired clinical parameters and microbiological parameter at the end of 3- and 6-months of therapy.

CONCLUSION

While the gold standard scaling and root planing remains, clinicians may also contemplate using the indocyanine green mediated antimicrobial photodynamic therapy as an adjunct to it. Also, it is a safer, cost effective, less arduous, and patient friendly means of treating the disease.

Utility of procalcitonin as an early diagnostic marker of bacteremia in individuals with periodontitis Stage II and III

BACKGROUND

The aim of the present study is to assess the ability of procalcitonin (PCT) to differentiate between periodontal health and Stage II and III periodontitis. We further assessed, if PCT can reflect early bacteremia induced by non-surgical periodontal treatment (NSPT).

METHODS

Sixty-four systemically healthy individuals were divided into Group I, periodontally healthy, and Group II, Stage II and III periodontitis. NSPT was done for both the groups. Standardized serum and salivary samples were obtained and analyzed for PCT levels using highly sensitive double antibody sandwich enzyme-linked immunosorbent assay at baseline and 2 weeks. In addition, the serum levels of PCT were recorded at immediate and 1-hour post-NSPT.

RESULTS

Mean PCT levels (saliva = 0.03 ng/mL and serum = 0.05 ng/mL) in periodontally healthy group were considerably lower than that in the periodontitis group (saliva = 0.22 ng/mL and serum = 1.85 ng/mL) with significant intergroup comparison at P < 0.001. Post NSPT the mean serum PCT values increased from 1.854 ng/mL to 1.871 ng/mL at the immediate interval and remained at 0.879 ng/mL after 2 weeks at P < 0.001. Spearman correlation showed highly significant positive correlation between serum and salivary PCT values to clinical attachment level (CAL) at P < 0.001 and rho = 0.78 and 0.75, respectively. Linear regression model showed serum PCT to be a significant predictor for CAL.

CONCLUSION

Screening for serum PCT levels in patients with periodontitis could act not only as a guide to assess the bacterial load and use of antibiotics but also as a predictor for CAL loss in patients with periodontitis.

In vitro anti‑bacterial activity of diosgenin on Porphyromonas gingivalis and Prevotella intermedia

Diosgenin (Dios), a natural steroidal sapogenin, is a bioactive compound extracted from dietary fenugreek seeds. It has a wide range of applications, exhibiting anti-oxidant, anti-inflammatory and anti-cancer activities. However, whether the extracts have beneficial effects on periodontal pathogens has so far remained elusive. The aim of the present study was to investigate the anti-bacterial effects of Dios on Porphyromonas gingivalis (P. gingivalis) and Prevotella intermedia (P. intermedia) in vitro. The anti-microbial effect of Dios on P. gingivalis and P. intermedia was assessed by a direct contact test (DCT) and the Cell Counting Kit (CCK)-8 assay at 60, 90 and 120 min. In addition, counting of colony-forming units (CFU) and live/dead cell staining were used to evaluate the anti-bacterial effects. The results of the DCT and CCK-8 assays indicated that Dios had beneficial dose-dependent inhibitory effects on P. gingivalis and P. intermedia. The CFU counting results also indicated that Dios had dose-dependent anti-bacterial effects on P. gingivalis and P. intermedia. Of note, Dios had significant anti-bacterial effects on the biofilms of P. gingivalis and P. intermedia in vitro as visualized by the live/dead cell staining method. In conclusion, the present results demonstrated that Dios had a marked anti-bacterial activity against P. gingivalis and P. intermedia in vitro, both in suspension and on biofilms. The present study highlighted the potential applications of Dios as a novel natural agent to prevent and treat periodontitis through its anti-bacterial effects.

Local delivery therapies as adjuvants to non-surgical periodontal treatment of periodontitis grade C: a systematic review

OBJECTIVES

The aim of this article was to perform a systematic review on the effectiveness of local adjuvant therapies in the treatment of aggressive periodontitis (AgP), now reported as periodontitis grade C.

MATERIALS AND METHODS

The authors selected randomized clinical trials of AgP patients who received local therapy as adjuvants to non-surgical periodontal with a duration of at least 90 days. Seven databases were searched up to January 2020. The gain in clinical attachment level (CAL) and reduction of probing depth (PD) were the outcomes of interest.

RESULTS

Of the 3583 studies found, only five articles were included in the qualitative analysis. Among the substances analyzed, only 1.2 mg of simvastatin gel (SMV) (1.2 mg/0.1 ml), 1% of alendronate gel (ALN) (10 mg/ml), and 25% metronidazole gel (MTZ) (Elyzol^@) showed a significant decrease in the probing depth when compared with their respective control groups. The gain CAL was shown using 1.2 mg SMV gel (1.2 mg/0.1 ml) and 1% ALN gel (10 mg/ml).

CONCLUSION

Although 1.2 mg SMV gel (1.2 mg/0.1 ml), 1% ALN gel (10 mg/ml), and 25% MTZ gel (Elyzol) have shown better results, local therapies adjuvant to SRP the data found were limited. Future clinical studies with appreciable methodological quality should be conducted.

CLINICAL RELEVANCE

Despite some benefits of local delivery therapy, up to now, it has not been possible to prove the efficacy of local therapy as an adjunct to standard treatment of AgP (periodontitis grade C).

Production and characteristics of a novel chicken egg yolk antibody (IgY) against periodontitis-associated pathogens

Periodontitis is a bacterial biofilm-induced oral disease, mostly caused by Aggregatibacter actinomycetemcomitans (A. actinomycetemcomitans) and Porphyromonas gingivalis (P. gingivalis). Oral administration of chicken egg yolk antibody (IgY) is a promising nutritional strategy to control pathogen infections. The objective of this study was to produce an A. actinomycetemcomitans- and P. gingivalis-specific IgY and evaluate its effects on bacterial agglutination and biofilm formation. Thirty laying hens were immunized with a complex of lysate containing typical molecular weights of membrane proteins of A. actinomycetemcomitans and P. gingivalis. IgY was isolated by polyethylene glycol 6000 and ammonium sulfate and purified by dialysis. The results of enzyme-linked immunosorbent assay showed that the obtained IgY were specific to both A. actinomycetemcomitans and P. gingivalis. In addition, immunoelectron microscopy scanning and crystal violet staining showed that the IgY could bind to cell wall of the pathogens and efficiently accelerate agglutination and inhibit biofilm formation. Furthermore, the activity of the IgY remained stable at different temperature, pH, and storage period. This is the first report that a novel two-in-one IgY was produced to modulate the agglutination and biofilm formation of A. actinomycetemcomitans and P. gingivalis, suggesting the potential of IgY to control periodontitis caused by oral pathogens.

Activity of five antimicrobial peptides against periodontal as well as non-periodontal pathogenic strains

Background: Due to the increasing emergence of multi-resistant bacteria the search for alternative antimicrobial substances is of high interest. Promising agents are antimicrobial peptides which are host defense molecules of the innate immune system in a wide range of different species. Objectives: The aim of this study was to assess the activity of nisin, melittin, lactoferrin, parasin-1 and LL-37 against 35 oral bacteria and Candida albicans employing the gold standard method for anaerobic susceptibility testing. Methods: The activity of the peptides was determined by an agar dilution method under anaerobic and aerobic conditions. The test media contained final peptide concentrations between 0.125 µg/ml and 8 µg/ml (melittin, lactoferrin, parasin-1, LL-37) and between 0.125 µg/ml and 128 µg/ml (nisin). Results: Nisin completely inhibited the growth of Megasphaera sp., Bifidobacterium longum, Parvimonas micra, Actinomyces israelii, Actinomyces naeslundii, Actinomyces odontolyticus, Prevotella intermedia, Streptococcus anginosus, Streptococcus constellatus and Staphylococcus aureus. Melittin and lactoferrin reduced the growth of Megasphaera sp., P. micra, B. longum (melittin) and Selenomonas flueggei (lactoferrin). Parasin-1 and LL-37 showed no activity. Conclusion: AMPs, especially nisin and to a smaller degree lactoferrin, might be promising alternatives to antibiotics because of their antimicrobial activity, high resistance to environmental conditions and partially low costs.