Subantimicrobial dose doxycycline as an adjunct to scaling and root planing: post-treatment effects

Modulating the Immune Response in Periodontitis

Periodontitis is a chronic inflammatory condition initiated by the accumulation of bacterial biofilm. It is highly prevalent and when left untreated can lead to tooth loss. The presence of bacterial biofilm is essential for the initiation of the inflammatory response but is not the sole initiator. Currently it is unknown which mechanisms drive the dysbiosis of the bacterial biofilm leading to the dysregulation of the inflammatory response. Other players in this equation include environmental, systemic, and genetic factors which can play a role in exacerbating the inflammatory response. Treatment of periodontal disease consists of removal of the bacterial biofilm with the goal of resolving the inflammatory response; however, this does not occur in every case. Understanding the way the inflammatory response does not return to a state of homeostasis has led investigators to consider both systemic and local pharmacological interventions. Nonetheless, a better understanding of the impact that genetics and environmental factors may have on the inflammatory response could be key to helping identify how inflammation can be modulated therefore stopping the destruction of the periodontium. In this article, we will explore the current evidence associating the microbial dysbiosis and the dysregulation of the immune response, potential mechanisms or pathways that may be targeted for the modulation of the inflammatory response, and discuss the advantages and drawbacks associated with local and systemic inflammatory modulation in the management of periodontal disease. This information will be valuable for those interested in understanding potential adjunct methods for managing periodontal diseases, but not limited to, dental professionals, clinical researchers and the public at large.

Current Concepts in the Management of Periodontitis

Periodontitis is a common disorder affecting >40% of adults in the United States. Globally, the severe form of the disease has a prevalence of 11%. In advanced cases, periodontitis leads to tooth loss and reduced quality of life. The aetiology of periodontitis is multifactorial. Subgingival dental biofilm elicits a host inflammatory and immune response, ultimately leading to irreversible destruction of the periodontium (i.e. alveolar bone and periodontal ligament) in a susceptible host. In order to successfully manage periodontitis, dental professionals must understand the pathogenesis, primary aetiology, risk factors, contributing factors and treatment protocols. Careful diagnosis, elimination of the causes and reduction of modifiable risk factors are paramount for successful prevention and treatment of periodontitis. Initial non-surgical periodontal therapy primarily consists of home care review and scaling and root planing. For residual sites with active periodontitis at periodontal re-evaluation, a contemporary regenerative or traditional resective surgical therapy can be utilised. Thereafter, periodontal maintenance therapy at a regular interval and long-term follow-ups are also crucial to the success of the treatment and long-term retention of teeth. The aim of this review is to provide current concepts of diagnosis, prevention and treatment of periodontitis. Both clinical and biological rationales will be discussed.

The adjunctive use of host modulators in non-surgical periodontal therapy. A systematic review of randomized, placebo-controlled clinical studies

BACKGROUND

Considering the role of the inflammatory host response in the pathogenesis of periodontitis, different host modulators have been proposed to enhance the outcomes of non-surgical periodontal therapy (NSPT), but their efficacy has not been fully clarified.

OBJECTIVES

This systematic review investigated the efficacy of host modulators combined with NSPT in reducing probing pocket depth (PPD) in periodontitis patients.

MATERIALS AND METHODS

Placebo-controlled RCTs with ≥6 months follow-up were searched. Meta-analysis was conducted when ≥5 studies using the same host modulator were identified.

RESULTS

Fifty eight studies met the inclusion criteria. After 6 months, local administration of 1.2% statin gels as adjuncts to NSPT significantly improved PPD reduction (1.83 mm) in infrabony defects and systemic administration of sub-antimicrobial dose doxycycline (SDD) in addition to NSPT improved PPD reduction of deep pockets. Administration of probiotics conferred limited clinical benefits. Local bisphosphonate and metformin gels showed potential for clinical use in infrabony defects, which needs to be confirmed.

CONCLUSIONS

Local delivery of statins in infrabony defects and systemic SDD for deep pockets may confer additional clinical benefits to NSPT. Their long-term effectiveness and safety need to be confirmed in independent multi-centred studies. Further studies are needed to confirm the benefit of other host modulators.

BSP implementation of European S3 - level evidence-based treatment guidelines for stage I-III periodontitis in UK clinical practice

OBJECTIVES

To adapt the supranational European Federation for Periodontology (EFP) S3-Level Clinical Practice Guideline for treatment of periodontitis (stage I-III) to a UK healthcare environment, taking into account the views of a broad range of stakeholders, and patients.

SOURCES

This UK version is based on the supranational EFP guideline (Sanz et al., 2020) published in the Journal of Clinical Periodontology. The source guideline was developed using the S3-level methodology, which combined the assessment of formal evidence from 15 systematic reviews with a moderated consensus process of a representative group of stakeholders, and accounts for health equality, environmental factors and clinical effectiveness. It encompasses 62 clinical recommendations for the treatment of stage I-III periodontitis, based on a step-wise process mapped to the 2017 classification system.

METHODOLOGY

The UK version was developed from the source guideline using a formal process called the GRADE ADOLOPMENT framework. This framework allows for the adoption (unmodified acceptance), adaptation (acceptance with modifications) and the de novo development of clinical recommendations. Using this framework and following the S3-process, the underlying systematic reviews were updated and a representative guideline group of 75 delegates from 17 stakeholder organisations was assembled into three working groups. Following the formal S3-process, all clinical recommendations were formally assessed for their applicability to the UK and adoloped accordingly.

RESULTS AND CONCLUSION

Using the ADOLOPMENT protocol, a UK version of the EFP S3-level clinical practice guideline was developed. This guideline delivers evidence- and consensus-based clinical recommendations of direct relevance to the dental community in the UK.

CLINICAL SIGNIFICANCE

The aim of S3-level guidelines is to combine the evaluation of formal evidence, grading and synthesis with the clinical expertise of a broad range of stakeholders to form clinical recommendations. Herein, the first major international S3-level guideline in dentistry, the EFP guideline, was implemented for direct clinical applicability in the UK healthcare system.

Treatment of stage I-III periodontitis-The EFP S3 level clinical practice guideline

BACKGROUND

The recently introduced 2017 World Workshop on the classification of periodontitis, incorporating stages and grades of disease, aims to link disease classification with approaches to prevention and treatment, as it describes not only disease severity and extent but also the degree of complexity and an individual's risk. There is, therefore, a need for evidence-based clinical guidelines providing recommendations to treat periodontitis.

AIM

The objective of the current project was to develop a S3 Level Clinical Practice Guideline (CPG) for the treatment of Stage I-III periodontitis.

MATERIAL AND METHODS

This S3 CPG was developed under the auspices of the European Federation of Periodontology (EFP), following the methodological guidance of the Association of Scientific Medical Societies in Germany and the Grading of Recommendations Assessment, Development and Evaluation (GRADE). The rigorous and transparent process included synthesis of relevant research in 15 specifically commissioned systematic reviews, evaluation of the quality and strength of evidence, the formulation of specific recommendations and consensus, on those recommendations, by leading experts and a broad base of stakeholders.

RESULTS

The S3 CPG approaches the treatment of periodontitis (stages I, II and III) using a pre-established stepwise approach to therapy that, depending on the disease stage, should be incremental, each including different interventions. Consensus was achieved on recommendations covering different interventions, aimed at (a) behavioural changes, supragingival biofilm, gingival inflammation and risk factor control; (b) supra- and sub-gingival instrumentation, with and without adjunctive therapies; (c) different types of periodontal surgical interventions; and (d) the necessary supportive periodontal care to extend benefits over time.

CONCLUSION

This S3 guideline informs clinical practice, health systems, policymakers and, indirectly, the public on the available and most effective modalities to treat periodontitis and to maintain a healthy dentition for a lifetime, according to the available evidence at the time of publication.

Older adults and the disparity in oral health status; the problem and innovative ways to address it

The impact of oral health inequalities on one's ability to maintain good oral health is cumulative throughout life and accentuated in older age groups. While studies on factors influencing the decisions made by elders to seek dental care have been conducted in Israel and worldwide, the issue of access to and provision of dental care is complex. However, the need to address oral health issues is being voiced in high-level international meetings and there was never a better momentum to rethink the current oral health care delivery model beyond issues related solely to accessibility. Here we outline unique opportunities to ensure sustainable models of preventive services and oral health the effects of which would be amplified in concert with increases in the availability universal dental healthcare.

Macrophage immunomodulation in chronic osteolytic diseases-the case of periodontitis

Periodontitis (PD) is a chronic osteolytic disease that shares pathogenic inflammatory features with other conditions associated with nonresolving inflammation. A hallmark of PD is inflammation-mediated alveolar bone loss. Myeloid cells, in particular polymorphonuclear neutrophils (PMN) and macrophages (Mac), are essential players in PD by control of gingival biofilm pathogenicity, activation of adaptive immunity, as well as nonresolving inflammation and collateral tissue damage. Despite mounting evidence of significant innate immune implications to PD progression and healing after therapy, myeloid cell markers and targets for immune modulation have not been validated for clinical use. The remarkable plasticity of monocytes/Mac in response to local activation factors enables these cells to play central roles in inflammation and restoration of tissue homeostasis and provides opportunities for biomarker and therapeutic target discovery for management of chronic inflammatory conditions, including osteolytic diseases such as PD and arthritis. Along a wide spectrum of activation states ranging from proinflammatory to pro-resolving, Macs respond to environmental changes in a site-specific manner in virtually all tissues. This review summarizes the existing evidence on Mac immunomodulation therapies for osteolytic diseases in the broader context of conditions associated with nonresolving inflammation, and discusses osteoimmune implications of Macs in PD.

[Doxycycline or how to create new with the old?]

Tetracyclines are broad-spectrum antibiotics that interfere with protein synthesis. They were first widely prescribed by dermatologists in the early 1950s in the treatment of acne. More recently, their biological actions on inflammation, proteolysis, angiogenesis, apoptosis, metal chelation, ionophoresis, and bone metabolism were studied. Matrix metalloproteinases (MMPs) are a family of proteolytic enzymes that degrade components of the extracellular matrix (ECM). MMPs have direct or indirect effects on the vascular endothelium and the vascular relaxation/contraction system. The therapeutic effects of tetracyclines and analogues were studied in rosacea, bullous dermatoses, neutrophilic diseases, pyoderma gangrenosum, sarcoidosis, aortic aneurysms, cancer metastasis, periodontitis and autoimmune diseases autoimmune diseases such as rheumatoid arthritis and scleroderma. In addition, downregulation of MMP using doxycycline could be beneficial in reducing vascular dysfunction mediated by MMPs and progressive damage of the vascular wall. We review the nonantibiotic properties of doxycycline and its potential clinical applications.

Diagnosis and anti-infective therapy of periodontitis

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

Non-antibacterial tetracycline formulations: clinical applications in dentistry and medicine

In 1983, it was first reported that tetracyclines (TCs) can modulate the host response, including (but not limited to) inhibition of pathologic matrix metalloproteinase (MMP) activity, and by mechanisms unrelated to the antibacterial properties of these drugs. Soon thereafter, strategies were developed to generate non-antibacterial formulations (subantimicrobial-dose doxycycline; SDD) and compositions (chemically modified tetracyclines; CMTs) of TCs as host-modulating drugs to treat periodontal and other inflammatory diseases. This review focuses on the history and rationale for the development of: (a) SDD which led to two government-approved medications, one for periodontitis and the other for acne/rosacea and (b) CMTs, which led to the identification of the active site of the drugs responsible for MMP inhibition and to studies demonstrating evidence of efficacy of the most potent of these, CMT-3, as an anti-angiogenesis agent in patients with the cancer, Kaposi's sarcoma, and as a potential treatment for a fatal lung disease (acute respiratory distress syndrome; ARDS). In addition, this review discusses a number of clinical studies, some up to 2 years' duration, demonstrating evidence of safety and efficacy of SDD formulations in humans with oral inflammatory diseases (periodontitis, pemphigoid) as well as medical diseases, including rheumatoid arthritis, post-menopausal osteopenia, type II diabetes, cardiovascular diseases, and a rare and fatal lung disease, lymphangioleiomyomatosis.

Myricetin suppresses LPS-induced MMP expression in human gingival fibroblasts and inhibits osteoclastogenesis by downregulating NFATc1 in RANKL-induced RAW 264.7 cells

OBJECTIVE

Periodontitis is an inflammatory disease that affects connective tissue attachments and the supporting bone that surrounds the teeth. Gingival fibroblasts induce the overexpression of matrix metalloproteinase (MMP), which is involved in inflammatory progression in periodontitis. Osteoclasts are responsible for skeletal modeling and remodeling but may also destroy bone in several bone diseases, including osteoporosis and periodontitis. This study examined the anti-destructive effects of myricetin on human gingival fibroblasts (HGF) under lipopolysaccharide- (LPS-) induced inflammatory conditions, and the anti-osteoclastogenetic effect of myricetin on the receptor activator of NF-κB ligand (RANKL) induced RAW264.7 cells was also investigated.

DESIGN

The effects of myricetin on HGF were determined by measuring the cell viability and mRNA expression and enzyme activity of tissue-destructive proteins, including MMP-1, MMP-2 and MMP-8. The effects of myricetin on osteoclasts were examined by measuring the following: (1) the cell viability, (2) the formation of tartrate-resistant acid phosphatase (TRAP)(+) multinucleated cells, (3) MAPK signalling pathways (4) mRNA expression of osteoclast-associated genes and (5) tumor necrosis factor-α (TNF-α) and interleukin-1β (IL-1β) secretion.

RESULTS

The myricetin had no effects on the cell viability of the HGF and decreased the mRNA expression and enzyme activity of MMP-1, MMP-2 and MMP-8 in the HGF. Myricetin inhibited the formation of RANKL-stimulated TRAP(+) multinucleated cells. Myricetin also inhibited the RANKL-stimulated activation of p-38, ERK and cSrc signaling, and inhibited the RANKL-stimulated degradation of I(k)B in the RAW264.7 cells. In addition, the RANKL-stimulated induction of NFATc1 transcription factors was abrogated by myricetin. Myricetin decreased the mRNA expression of osteoclast-associated genes, including cFOS, TRAP and cathepsin K in the RAW264.7 cells. Myricetin inhibited the secretion of LPS-induced TNF-α and IL-1β in the RAW264.7 cells.

CONCLUSIONS

These findings suggest that myricetin has therapeutic effects on bone-destructive processes, such as those that occur in periodontal diseases.

Multilevel analysis of clinical parameters in chronic periodontitis after root planing/scaling, surgery, and systemic and local antibiotics: 2-year results

AIM

Find the periodontal treatment that best maintained clinical results over time evaluated by changes in pocket depth (PD) and clinical attachment level (CAL).

METHODS

229 patients with chronic periodontitis from USA (n=134) and Sweden (n=95) were randomly assigned to eight groups receiving (1) scaling+root planing (SRP) alone or combined with (2) surgery (SURG)+systemic amoxicillin (AMOX)+systemic metronidazole (MET); (3) SURG+local tetracycline (TET); (4) SURG; (5) AMOX+MET+TET; (6) AMOX+MET; (7) TET; and (8) SURG+AMOX+MET+TET. Antibiotics were given immediately after SRP. Plaque, gingival redness, bleeding on probing, suppuration, PD, and CAL were recorded at baseline and after 3, 6, 12, 18, and 24 months. Treatment effects were evaluated by linear multilevel regression and logistic multilevel regression models. We considered only data from sites with a baseline PD of at least 5 mm of 187 patients completing the study.

RESULTS

Surgically treated patients experienced most CAL loss. Adjunctive therapy including SURG was most effective in reducing PD. Combining SURG with AMOX, MET, and TET gave significant clinical benefits. Past and current smoking habits were significant predictors of deeper PD. Only current smoking was a significant predictor of CAL loss. Bleeding, accumulation of plaque, gingival redness, and suppuration were significant predictors of further CAL loss and deeper PD.

CONCLUSIONS

Both surgical and non-surgical therapies can be used to arrest chronic periodontitis. SURG+AMOX+MET+TET gave best maintenance of clinical results.

Use of minocycline as systemic antimicrobial therapy in refractory periodontitis with chronic gingival enlargement

Periodontal disease is a multifactorial disease having various risk factors, but a dynamic interaction between bacterial products and host response in association with genetic and environmental factors is considered as the primary cause for periodontal tissue destruction in periodontitis. This bacterial-host interaction which is ever-so-present in periodontitis directs us toward utilizing antimicrobial agents along with the routine mechanical debridement. This case report present a case of a female patient with recurrent periodontal infections with gingival enlargement treated with systemic Minocycline in conjunction with the conventional non-surgical approach.

Periodontal pharmacotherapy - an updated review

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

Long-term efficacy of subantimicrobial-dose doxycycline as an adjunctive treatment to scaling and root planing: a systematic review and meta-analysis

BACKGROUND

Subantimicrobial-dose doxycycline (SDD) is widely used as an adjunctive treatment to scaling and root planing (SRP), but its long-term effectiveness remains controversial. The purpose of this systematic review was to assess the actual evidence of the effectiveness of SRP + SDD compared to SRP + placebo in the treatment of chronic periodontitis.

METHODS

A literature search of electronic databases was performed for articles published through November 1, 2010. Several dental journals were screened during the manual search, and authors were contacted for missing information. The systematic review and meta-analysis were conducted according to the Quality of Reporting of Meta-Analyses statement and recommendations of the Cochrane Collaboration. The methodologic quality of the studies was determined via a Consolidated Standards of Reporting Trials-based assessment. Clinical attachment levels, probing depths, plaque and gingival indices, and gingival crevicular fluid levels were compared between baseline and the end of follow-up. Data were extracted and pooled using a random-effect model. The weighted mean difference was reported with the 95% confidence interval. Heterogeneity was assessed using the χ(2)-based Q-statistic method and I(2) measurement. P <0.05 was considered statistically significant.

RESULTS

After applying inclusion and exclusion criteria, three randomized placebo-controlled clinical trials were entered into the meta-analysis. These studies had similar treatment designs, SDD dosage regimens (20 mg twice daily for 3 months), and post-treatment follow-up lengths (9 months). Significant differences were observed for all investigated clinical parameters in favor of the SRP + SDD group.

CONCLUSION

The meta-analysis results seemed to support the long-term effectiveness of adjunctive SDD therapy; however, future studies are needed to confirm these findings.

Clinical studies on the management of periodontal diseases utilizing subantimicrobial dose doxycycline (SDD)

Periodontitis, the most common chronic inflammatory condition known to mankind, is a disease that results in the destruction of tooth supporting tissues. Periodontitis is initiated by a bacterial biofilm on the tooth surface below the gingival margin. Until fairly recently it was assumed that the bacteria were the primary cause of tissue destruction, however, a large body of research has revealed that it is the patient's immune response that is actually responsible for the majority of the breakdown of tooth supporting tissues. Contemporary thinking suggests that successful, long term management of chronic periodontitis may combine both local mechanical and antimicrobial strategies to reduce the microbial bio-burden along with modulation of the host, patient's excessive, immuno-inflammatory response to the bacterial exposure known as host modulatory therapy (HMT). Based on extensive literature documenting the enzymatic inhibition and related anti-inflammatory properties of the tetracyclines, a new drug was developed as a host modulatory agent and approved by the United States Food and Drug Administration (FDA) for use as an adjunct to conventional scaling and root planing for the treatment of chronic periodontitis. A subantimicrobial dose of doxycycline (SDD) at 20 mg (Periostat(®)) has been found to be a safe and effective adjunct when taken twice daily for at least 3 months and up to 24 months in randomized placebo controlled clinical trials. Periostat(®) is currently the only FDA approved inhibitor of the matrix metalloproteinases implicated in the plaque-induced pathologic degradation of connective tissue collagen of the periodontal supporting structures. This review paper begins with a brief description of the disease process known as periodontitis followed by an extensive review of the Phase I-IV clinical trial data that established the safety and efficacy of sub-antimicrobial dose doxycycline (SDD) as an adjunct to scaling and root planing for the treatment of periodontitis.

Clinical and biochemical efficacy of minocycline in nonsurgical periodontal therapy: a randomized controlled pilot study

The present study evaluated the effects of systemic minocycline on clinical and biochemical parameters of chronic periodontitis, which is a common inflammatory disorder of the periodontium initiated by the presence of bacteria in the gingival sulcus. Besides nonsurgical periodontal therapy, 20 individuals received minocycline systemically while another 20 subjects received placebo capsules for 2 weeks. Plaque index (PI), sulcus bleeding index (SBI), probing depth (PD), and relative attachment level (RAL) were measured and gingival crevicular fluid (GCF) samples were obtained at baseline and first, third, and sixth months. Matrix metalloproteinase-8 (MMP-8) and prostaglandin E₂ (PGE₂) levels were analyzed by enzyme immunoassay method. Significant improvements in all parameters in both groups were recorded. In the minocycline group, changes in PI and SBI were significantly greater only at first month, whereas reductions in PD, RAL, MMP-8, and PGE₂ levels were greater at all times. MMP-8 and PGE₂ exhibited positive correlations with SBI, PD, and each other. Minocycline demonstrated clinical benefit for periodontal therapy and provided further improvements on inflammatory mediators promising a host-modulating capacity.

Levels of gingival crevicular metalloproteinases-8 and -9 in periodontitis

Matrix metalloproteinases (MMPs), the key enzymes responsible for matrix degradation, are derived from polymorphonuclear leukocytes during the early stages of periodontitis. The aim of this study was planned to determine the levels of GCF (gingival crevicular fluid) matrix metalloproteinase-8 (MMP-8) and metalloproteinase-9 (MMP-9) patients with periodontitis and in healthy controls. Levels of crevicular MMP-8 and -9 were determined by ELISA in subjects with healthy without any periodontal disease (n = 10) and periodontitis (n = 10). Significantly higher crevicular MMP-8 and -9 were observed in cases of periodontitis compared to healthy adults. Crevicular MMP-8 and -9 may serve as biomarkers of periodontal disease and aid in early detection of periodontitis.

Non-surgical chemotherapeutic treatment strategies for the management of periodontal diseases

Periodontal diseases are initiated by subgingival periodontal pathogens in susceptible periodontal sites. The host immune response toward periodontal pathogens helps to sustain periodontal disease and eventual alveolar bone loss. Numerous adjunctive therapeutic strategies have evolved to manage periodontal diseases. Systemic and local antibiotics, antiseptics, and past and future host immune modulatory agents are reviewed and discussed to facilitate the dental practitioner's appreciation of this ever-growing field in clinical periodontics.

Antimicrobial therapy in periodontitis: the use of systemic antimicrobials against the subgingival biofilm

OBJECTIVES

The aim was to answer three relevant questions: can systemic antimicrobials be efficacious if the biofilm is not disrupted? Can the type of debridement of the subgingival biofilm impact upon the clinical outcomes of the adjunctive antimicrobial therapy? Is the efficacy of the adjunctive systemic antimicrobial therapy dependent on the quality of the debridement of the subgingival biofilm and the sequence debridement-antibiotic usage?

MATERIAL AND METHODS

Relevant papers were searched, critically analysed and their data were extracted.

RESULTS

For the first question, studies assessing susceptibility of bacteria in biofilms, and clinical studies evaluating systemic antimicrobials as monotherapy, were reviewed. For the second question, clinical studies comparing systemic antimicrobials as adjuncts to non-surgical debridement or to periodontal surgery and clinical trials using systemic antibiotics with periodontal surgery were evaluated. For the third question, a previous systematic review was updated.

CONCLUSION

If systemic antimicrobials are indicated in periodontal therapy, they should be adjunctive to mechanical debridement. There is not enough evidence to support their use with periodontal surgery. Indirect evidence suggests that antibiotic intake should start on the day of debridement completion, debridement should be completed within a short time (preferably <1 week) and with an adequate quality, to optimize the results.

Assessment of aprotinin influence on periodontal clinical status and matrix metalloproteinases 1, 2 and their tissue inhibitors saliva concentrations in patients with chronic periodontitis

PURPOSE

Assessment of the effect of treatment with aprotinin-containing drug on the clinical status of the periodontal tissue and on the concentrations of metalloproteinases released in the course of periodontitis (MMP-1, MMP-2) as well as their tissue inhibitors (TIMP-1 and TIMP-2) in the saliva of patients with chronic periodontitis (CP).

MATERIAL/METHODS

The study involved 25 subjects with CP (39-68 years), including 16 women and 9 men. The patients were prescribed aprotinin preparation to be taken for 2 weeks. The control group (C) involved 14 healthy subjects (41-65 years), including 10 women and 4 men. Two periodontal indices were assessed: the approximal plaque index (API) and bleeding on probing index (BOP). Periodontal pocket depth and clinical attachment level were also evaluated. The concentrations of MMP-1 and MMP-2 as well as TIMP-1 and TIMP-2 were determined by the ELISA method.

RESULTS

The mean salivary MMP-1 concentration in patients with CP was significantly higher before and after treatment, as compared to healthy subjects. The mean salivary MMP-2 concentration in CP patients at baseline was also higher as compared to the C group and increased after treatment. The mean salivary TIMP-1 and TIMP-2 concentration in CP patients was higher as compared to C group and increased after treatment.

CONCLUSIONS

Since the mean MMPs levels were found to be growing it can be assumed that aprotinin has no significant effect on the regulation of MMPs in the saliva of CP patients. It thus seems that aprotinin application after scaling has no additional therapeutic effect.

Subantimicrobial dose doxycycline effects on osteopenic bone loss: microbiologic results

BACKGROUND

Based on microbiologic concerns, the safety of a 24-month regimen of subantimicrobial dose doxycycline (SDD; 20 mg twice a day) was evaluated in postmenopausal osteopenic women with periodontitis in a double-blind, placebo-controlled, randomized clinical trial.

METHODS

Subgingival samples were collected from two sites (probing depth > or = 5 mm) in each of 128 subjects at baseline, with the same sites resampled at the conclusion of the 2-year period. The samples were enumerated on selective and non-selective media and on doxycycline (4 microg/ml) medium. Up to five different colonial morphologies were subcultured from the doxycycline medium, identified to species, and susceptibilities determined to doxycycline and five other antibiotics. Data were analyzed for microbial differences in total colony forming units (CFU), periodontal and opportunistic pathogens, and changes in species and in susceptibilities of isolates recovered on doxycycline medium.

RESULTS

There was no significant evidence that changes in total anaerobic counts over the treatment period (P = 0.96) differed between treatment groups. Likewise, periodontal pathogens, opportunistic pathogens, or normal flora did not differ descriptively between groups. Although there was a significant increase (P <0.001) in the total CFU recovered from the 4 microg/ml doxycycline plates at 24 months for SDD versus placebo, the percentage that was clinically resistant to doxycycline (minimal inhibitory concentration [MIC] > or = 16 microg/ml) decreased over the 24-month period in both groups and did not differ between the treatment groups (SDD: 79% to 76%; placebo: 83% to 70%; P = 0.2). There were no significant differences (P >0.28 for each) in the change in cross-resistance between the groups for doxycycline and the other five antibiotics.

CONCLUSIONS

No antimicrobial effect on the subgingival flora was detected following treatment with SDD for 24 months, relative to baseline or to placebo. The increase in initial resistance (at 4 microg/ml) did not translate into a significant increase in the percent resistant to doxycycline (MIC > or = 16 microg/ml) for patients in the SDD group.

The effect of adjunctive subantimicrobial dose doxycycline therapy on GCF EMMPRIN levels in chronic periodontitis

BACKGROUND

The aim of the present randomized, double-masked, placebo-controlled, parallel-arm study was to examine the effectiveness of a 3-month regimen of subantimicrobial dose doxycycline (SDD) in combination with scaling and root planing compared to scaling and root planing alone on levels of gingival crevicular fluid (GCF) extracellular matrix metalloproteinase inducer (EMMPRIN) in patients with chronic periodontitis.

METHODS

GCF samples were collected, and clinical parameters, including probing depth (PD), clinical attachment level, gingival index (GI), and plaque index, were recorded. Thirty chronic periodontitis subjects were randomized to receive SDD or placebo. The SDD group received SDD (20 mg, twice a day) for 3 months plus scaling and root planing, whereas the placebo group took placebo capsules twice a day for 3 months and received scaling and root planing. The subjects were reevaluated at 3 and 6 months. At each visit, all clinical parameters were measured and GCF was sampled. GCF EMMPRIN levels were determined by Western immunoblotting assay. Intragroup comparisons were tested by the Friedman test followed by the Wilcoxon signed-rank test to analyze the significance of changes over time. The Mann-Whitney test was used to determine differences between the SDD and placebo groups.

RESULTS

Significant improvements were observed in all clinical parameters in the SDD group over the 6-month study period (P <0.025). The SDD group showed a significantly greater reduction in mean PD scores at 6 months and in mean GI scores at 3 and 6 months than the placebo group (P <0.05). From baseline to 6 months, the GCF EMMPRIN levels were reduced significantly in the SDD group (P <0.025). The GCF EMMPRIN level in the SDD group was significantly lower than that of the placebo group at 3 and 6 months (P <0.05).

CONCLUSIONS

SDD therapy in combination with scaling and root planing reduced GCF EMMPRIN levels and improved clinical periodontal parameters in subjects with chronic periodontitis. The ability of SDD to downregulate, in vivo, the GCF levels of EMMPRIN, a unique upregulator of matrix metalloproteinase expression, is one of its beneficial host-modulatory properties. These results expand the usefulness of SDD therapy as an adjunct to scaling and root planing in the long-term management of periodontal disease.

Efficacy of sub-antimicrobial dose doxycycline in post-menopausal women: clinical outcomes

AIMS

To determine the clinical efficacy of a 2-year continuous sub-antimicrobial dose doxycycline (SDD; 20 mg bid) in post-menopausal, osteopenic, oestrogen-deficient women on periodontal maintenance.

MATERIALS AND METHODS

One-hundred and twenty-eight subjects were randomized to SDD (n=64) or placebo (n=64). Clinical measurements were performed at posterior interproximal sites at baseline and every 6 months during this 2-year randomized, double-blind, placebo-controlled clinical trial with adjunctive, no-cost 3-4-month periodontal maintenance. Statistical analyses of secondary outcomes from this clinical trial used Generalized Estimating Equations in primarily intent-to-treat analyses.

RESULTS

For the placebo group, 3.4% of the sites showed improvement in clinical attachment levels (CAL) and 2.7% had progressive loss in CAL; for the SDD group, 5.0% of the sites showed an improvement in CAL and 2.2% had progressive loss in CAL. This difference (2.1% of sites) was more favourable in the SDD group than in the placebo [odds ratio (OR)=0.81 [corrected] 95% confidence interval (CI): 0.67-0.97, p=0.03] in these well-maintained patients, whereas probing depths, bleeding on probing and supragingival plaque did not differ significantly between groups (p>0.2). However, in exploratory subgroup analysis of non-smokers, SDD showed reduced bleeding versus placebo (27%versus 33%; p=0.05). In protocol-adherent subjects, the odds of bleeding were 34% lower for SDD (p=0.05).

CONCLUSIONS

Analyses of secondary outcomes of this clinical trial indicated that SDD may be of benefit in reducing progressive attachment loss in post-menopausal females; additional research is needed to confirm these findings. Protocol registered at (ClinicalTrials.gov). Identifier:NCT00066027.

Subantimicrobial dose doxycycline effects on alveolar bone loss in post-menopausal women

AIM

Determine the efficacy of 2-year continuous subantimicrobial dose doxycycline (SDD; 20 mg bid) on alveolar bone in post-menopausal osteopenic, oestrogen-deficient women undergoing periodontal maintenance in a 2-year double-blind, placebo-controlled, randomized clinical trial.

MATERIAL AND METHODS

One-hundred and twenty-eight subjects randomized to SDD or placebo (n=64 each). Posterior vertical bite wings taken at baseline, 1 and 2 years for alveolar bone density (ABD), using radiographic absorptiometry (RA) and computer-assisted densitometric image analysis (CADIA), and alveolar bone height (ABH). Statistical analyses utilized generalized estimating equations; primary analyses were intent to treat (ITT). Results are presented as SDD versus placebo.

RESULTS

Under ITT, there was no statistically significant effect of SDD on ABD loss (RA: p=0.8; CADIA: p=0.2) or ABH loss (p=0.2). Most sites (81-95%) were inactive. For subgroup analyses, mean CADIA was higher with SDD for non-smokers (p=0.05) and baseline probing depths > or =5 mm (p=0.003). SDD was associated with 29% lower odds of more progressive ABH loss in women >5 years post-menopausal (p=0.05) and 36% lower among protocol-adherent subjects (p=0.03).

CONCLUSIONS

In post-menopausal osteopenic women with periodontitis, SDD did not differ overall from placebo. Based on exploratory subgroup analyses, additional research is needed to determine the usefulness of SDD in non-smokers, subjects >5 years post-menopausal and in deeper pockets. Protocol registered at (ClinicalTrials.gov). Identifier: NCT00066027.

Clinical changes following four different periodontal therapies for the treatment of chronic periodontitis: 1-year results

OBJECTIVE

To compare clinical changes occurring in chronic periodontitis subjects receiving SRP alone or with systemically administered azithromycin, metronidazole or a sub-antimicrobial dose of doxycycline.

MATERIAL AND METHODS

92 chronic periodontitis subjects were randomly assigned to receive SRP alone (N=23) or combined with 500 mg azithromycin per day for 3 days (N=25), 250 mg metronidazole tid for 14 days (N=24) or 20 mg doxycycline bid for 3 months (N=20). Gingival redness, bleeding on probing, suppuration, pocket depth and attachment level were measured at baseline and 3, 6 and 12 months post therapy. The significance of changes in clinical parameters within groups over time was sought using the Friedman test and among groups using ANCOVA or the Kruskal Wallis test.

RESULTS

All groups showed clinical improvements at 12 months, with subjects receiving adjunctive agents showing a somewhat better response. Sites with initial pocket depth > 6 mm showed significantly greater pocket depth reduction and greater attachment gain in subjects receiving metronidazole or azithromycin than subjects in the other groups. Some subjects showed attachment loss at 12 months in each group ranging from 15% to 39% of subjects in the SDD and SRP only groups respectively.

CONCLUSION

This study, demonstrated that periodontal therapy provides clinical benefits and that antibiotics provide a clinical benefit over SRP alone, particularly at initially deeper periodontal pockets.

A comparative study of systemic subantimicrobial and topical treatment of minocycline in experimental periodontitis of rats

OBJECTIVE

The purpose of this study was to compare the effectiveness of minocycline on treating experimentally induced periodontitis in rats when administered either as a systemic subantimicrobial dose or as a topical ointment.

DESIGN

Thirty-two adult male Sprague-Dawley rats in four experimental groups-(1) model group; (2) systemic subantimicrobial dose of minocycline (5mg/kg/day) treatment group; (3) topical subgingival dose of minocycline (2mg/animal/week) treatment group; (4) control group. Experimentally induced periodontitis-silk ligatures were placed around the crevices of the second molar teeth and the animals fed a 10% sucrose drink. Assessment was carried out at days 28 and 56 using a number of different visual, histological and ultrastructure approaches. (1) Visual assessment-tooth mobility, gingival index and alveolar bone loss. (2) Histological examination-monocyte infiltration and resorption lacunae with osteoclasts. (3) Transmission electron microscopy (TEM)-morphological transformation of fibroblasts and osteoclasts. The collected data were analysed for statistical significance using the analysis of variance statistical test.

RESULTS

Minocycline significantly reduced tooth mobility, gingival index and alveolar bone loss when administered either systemically or as a topical ointment compared to the model group (P<0.01). However, the alveolar bone loss was significantly less (P<0.01 in the systemic treatment group compared to the local treatment group. Monocyte infiltration and resorption lacunae with osteoclasts were significantly less in the both treatment groups compared to the model group (P<0.01). The osteoclasts failed to form a ruffled border in the systemic treatment group.

CONCLUSION

Topical treatment significantly reduces gingivitis while systemic treatment is beneficial in terms of inhibiting alveolar bone loss.

Salivary biomarkers of existing periodontal disease: a cross-sectional study

BACKGROUND

The authors conducted a study to determine if salivary biomarkers specific for three aspects of periodontitis--inflammation, collagen degradation and bone turnover--correlate with clinica features of periodontal disease.

METHODS

The relationship between periodontal disease and the levels of interleukin-1 beta (IL-1beta), matrix metalloproteinase (MMP)-8, and osteoprotegerin (OPG) in whole saliva of 57 adults (28 "case" subjects with moderate-to-severe periodontal disease and 29 healthy control subjects) was examined in a case-control trial.

RESULTS

Mean levels of IL-1beta and MMP-8 in saliva were significantly higher in case subjects than in controls. Both analytes correlated with periodontal indexes, whereas, after adjustment for confounders, OPG did not. Elevated salivary levels of MMP-8 or IL-1beta (more than two standard deviations above the mean of the controls) significantly increased the risk of periodontal disease (odds ratios in the 11.3-15.4 range). Combined elevated salivary levels of MMP-8 and IL-1beta increased the risk of experiencing periodontal disease 45-fold, and elevations in all three biomarkers correlated with individual clinical parameters indicative of periodontal disease.

CONCLUSION

Salivary levels of MMP-8 and IL-1beta appear to serve as biomarkers of periodontitis.

CLINICAL IMPLICATIONS

Qualitative changes in the composition of salivary biomarkers could have significance in the diagnosis and treatment of periodontal disease.

Adjunctive subantimicrobial dose doxycycline in smokers and non-smokers with chronic periodontitis

OBJECTIVES

Previous studies have demonstrated the clinical benefits of sub-antimicrobial dose doxycycline (SDD) in the treatment of chronic periodontitis (CP). The aim of this study was to retrospectively evaluate the role of SDD as an adjunct to scaling and root planing (SRP) in the treatment of smokers and non-smokers with CP.

MATERIAL AND METHODS

A meta-analysis of two previously reported clinical studies was undertaken. Both were 9-month, double-blind, randomized, placebo-controlled, multi-centre clinical trials that investigated the efficacy of SDD (20 mg doxycycline twice daily) in combination with SRP in subjects with moderate-severe CP. 36.9% of the combined study population were smokers. Three hundred and ninety-two subjects were included in the meta-analysis, which evaluated per-subject mean changes in clinical attachment level (CAL) and probing depth (PD) from baseline and the total number of sites with attachment gains and PD reductions > or =2 and > or =3 mm from baseline in four subgroups: smokers/SDD; smokers/placebo; non-smokers/SDD; non-smokers/placebo.

RESULTS

A hierarchical treatment response was observed, with non-smokers who received SDD demonstrating the greatest CAL gains and PD reductions. Smokers who received placebo demonstrated the smallest clinical improvements following treatment. Smokers who received SDD demonstrated an intermediate treatment response that was broadly equivalent to that seen in non-smokers who received placebo. In sites with baseline PD 4-6 mm, month 9 CAL gains were 19-45% better in non-smokers who received SDD compared with all other subgroups (p<0.05), and were 21% greater in smokers who received SDD compared with smokers who received placebo (p<0.05). Furthermore, month 9 PD reductions were 21-53% greater in non-smokers who received SDD compared with all other subgroups (p<0.01), and were 26% greater in smokers who received SDD compared with smokers who received placebo (p<0.05).

CONCLUSION

Adjunctive SDD enhances therapeutic outcomes compared with SRP alone, resulting in clinical benefit in both smokers and non-smokers with CP.

Effect of subantimicrobial dose doxycycline as an effective adjunct to scaling and root planing

BACKGROUND

This study evaluated the efficacy and safety of a subantimicrobial dose of doxycycline (SDD) in conjunction with scaling and root planing (SRP).

METHODS

The study was a 9-month, double masked, randomized, placebo-controlled, parallel-group trial. A total of 41 patients with moderate chronic periodontitis who received SRP were randomly allocated to receive either a doxycycline hyclate or a placebo 2 weeks after SRP. Clinical attachment level (CAL), the probing depth (PD), gingival crevicular fluid (GCF) levels, and matrix metalloproteinase (MMP)-8 and -13 levels were measured throughout the study. The effect of SDD in conjunction with SRP on the dynamics of the periodontal microflora was also assessed using dark-field microscopic and culture analysis. Information on adverse events was collected throughout the study.

RESULTS

During the treatment period, per-patient reductions in PD and CAL were demonstrated for both treatment groups, with a significantly greater reduction for the SDD group. The mean value of per-patient change in the GCF was much greater for the SDD group. Microbial analysis showed there were a general tendency for cocci, non-motile rods, and aerobes to increase with increasing treatment duration and a general decreasing tendency for spirochetes, motile rods, and anaerobes and black pigmented bacteria in both treatment groups, but no significant difference between the groups. The MMP-8 and -13 levels of the SDD group gradually reduced with time, and the mean perpatient average was significantly higher than in the placebo group. The adverse events in the SDD group were similar to those in the placebo group.

CONCLUSION

This study suggests that a submicrobial dose of doxycycline as an adjunct therapy with SRP might be safe and effective in the long-term management of chronic periodontitis.

Adjunctive subantimicrobial dose doxycycline in the management of institutionalised geriatric patients with chronic periodontitis*

OBJECTIVE

To assess the efficacy of subantimicrobial dose doxycycline (SDD; 20 mg doxycycline twice daily) as an adjunct to scaling and root planing (SRP) in the treatment of moderate-severe chronic periodontitis (CP) in institutionalised elderly patients aged 65 years or older.

BACKGROUND

Previous studies have shown that SDD is of clinical benefit in the treatment of CP. However, the benefits of SDD in geriatric populations (65+ years) have not been determined.

MATERIAL AND METHODS

A 9-month, double-blind, randomised, placebo-controlled pilot study was conducted. 24 institutionalised geriatric patients (65 years or older) with evidence of CP manifested by baseline clinical attachment levels (CAL) 5-9 mm, probing depths (PD) 4-9 mm and bleeding on probing (BOP) were recruited. At baseline, patients were treated by a standardised episode of SRP, and randomised to receive either adjunctive SDD or placebo. Full mouth PD and CAL were measured using the manual UNC-15 periodontal probe at 3, 6, and 9 months post-baseline to assess the response to treatment. Periodontal sites were stratified by baseline PD value: sites with PD 4-5 mm were considered moderately diseased and sites with PD > or = 6 mm severely diseased.

RESULTS

The SRP + placebo resulted in PD reductions similar to those reported previously in the literature. At all time-points and in both moderate and deep sites, SRP + SDD resulted in significantly greater PD reductions relative to baseline than SRP + placebo. At month 9, in moderate sites, mean PD reductions of 1.57 +/- 0.11 mm were reported in the adjunctive SDD group, compared with 0.63 +/- 0.11 mm in the adjunctive placebo group (p < 0.001). In deep sites at month 9, mean PD reductions of 3.22 +/- 0.29 mm were reported in the adjunctive SDD group, compared with 0.98 +/- 0.31 mm in the adjunctive placebo group (p < 0.05). Similar improvements were observed for CAL in the SDD group compared with the placebo group. Significantly lower BOP scores were also recorded at month 9 in the SDD group (7.5%) compared with the placebo group (71.2%) (p < 0.01).

CONCLUSION

SDD used as an adjunct to SRP provides significant benefit for elderly patients with CP compared with SRP alone.

Subantimicrobial dose doxycycline as adjunctive treatment for periodontitis. A review

BACKGROUND

Subantimicrobial dose doxycycline (SDD--20 mg doxycycline twice daily) is indicated as an adjunctive treatment for periodontitis. Doxycycline downregulates the activity of matrix metalloproteinases (MMPs), key destructive enzymes in periodontal disease. Current understanding of periodontal pathogenesis suggests that MMPs play a major role in the destruction of periodontal tissues, leading to the clinical signs of periodontitis. Research supports that downregulation of MMPs by SDD confers benefit to patients with periodontitis.

METHOD

We review the clinical, microbiological and safety data relating to the use of SDD in patients with periodontitis, and consider the historical events that led to the development of adjunctive SDD as a treatment for periodontitis.

RESULTS

Studies have shown that SDD, when prescribed as an adjunct to scaling and root planing (SRP), results in statistically and clinically significant gains in clinical attachment levels and reductions in probing depths over and above those that are achieved by SRP alone. SRP must be thorough and performed to the highest standard to maximise the benefits of adjunctive SDD. SDD does not result in antibacterial effects, or lead to the development of resistant strains or the acquisition of multiantibiotic resistance. The frequency of adverse events is low, and does not differ significantly from placebo.

CONCLUSIONS

Adjunctive SDD confers clinical benefit to patients with periodontitis. A comprehensive treatment strategy is suggested, involving patient education and motivation, reduction of the bacterial burden by SRP, host response modulation with SDD, and periodontal risk factor modification.