The use of PVP-iodine as an adjunct to non-surgical treatment of chronic periodontitis

Antimicrobial Chemotherapy for Recalcitrant Severe Human Periodontitis

This study evaluated a combined systemic and topical anti-infective periodontal treatment of 35 adults who had experienced ongoing periodontal breakdown following conventional surgical periodontics. The prescribed anti-infective therapy, based on microbiological testing, consisted of a single course of metronidazole plus ciprofloxacin (23 patients), metronidazole plus amoxicillin/clavulanic acid (10 patients), and metronidazole plus ciprofloxacin followed by metronidazole plus amoxicillin/clavulanic acid (2 patients). In addition, the study patients received 0.1% povidone-iodine subgingival disinfection during non-surgical root debridement and daily patient administered oral irrigation with 0.1% sodium hypochlorite. At 1 and 5 years post-treatment, all study patients showed gains in clinical periodontal attachment with no further attachment loss, and significant decreases in pocket probing depth, bleeding on probing, and subgingival temperature. The greatest disease resolution occurred in patients who at baseline harbored predominantly major periodontal pathogens which post-antibiotics became non-detectable and substituted by non-periodontopathic viridans streptococci. The personalized and minimally invasive anti-infective treatment regimen described here controlled periodontitis disease activity and markedly improved the clinical and microbiological status of the refractory periodontitis patients.

Role of antiseptics in the prevention and treatment of infections in nursing homes

Inadequate infection control, wound care, and oral hygiene protocols in nursing homes pose challenges to residents' quality of life. Based on the outcomes from a focus group meeting and a literature search, this narrative review evaluates the current and potential roles of antiseptics within nursing home infection management procedures. We examine contemporary strategies and concerns within the management of meticillin-resistant Staphylococcus aureus (MRSA; including decolonization regimes), chronic wound care, and oral hygiene, and review the available data for the use of antiseptics, with a focus on povidone-iodine. Compared with chlorhexidine, polyhexanide, and silver, povidone-iodine has a broader spectrum of antimicrobial activity, with rapid and potent activity against MRSA and other microbes found in chronic wounds, including biofilms. As no reports of bacterial resistance or cross-resistance following exposure to povidone-iodine exist, it may be preferable for MRSA decolonization compared with mupirocin and chlorhexidine, which can lead to resistant MRSA strains. Povidone-iodine oral products have greater efficacy against oral pathogens compared with other antiseptics such as chlorhexidine mouthwash, highlighting the clinical benefit of povidone-iodine in oral care. Additionally, povidone-iodine-based products, including mouthwash, have demonstrated rapid in-vitro virucidal activity against SARS-CoV-2 and may help reduce its transmission if incorporated into nursing home coronavirus 2019 control protocols. Importantly, povidone-iodine activity is not adversely affected by organic material, such as that found in chronic wounds and the oral cavity. Povidone-iodine is a promising antiseptic agent for the management of infections in the nursing home setting, including MRSA decolonization procedures, chronic wound management, and oral care.

Efficacy of the Adjunct Use of Povidone-Iodine or Sodium Hypochlorite with Non-Surgical Management of Periodontitis: A Systematic Review and Meta-Analysis

This systematic review sought to assess the efficacy of combining either sodium hypochlorite or povidone-iodine as disinfection solutions with non-surgical treatment of periodontitis. An electronic search was conducted through PubMed, Scopus, Web of Science, CENTRAL, and Google Scholar from inception until 10 September 2022. Outcomes included clinical outcomes (probing pocket depth, plaque index, clinical attachment level, relative-horizontal attachment level, bleeding on probing, gingival recession, the position of gingival margin) and biochemical (BAPNA level) properties. A subgroup analysis was conducted according to the assessment timepoint. Ten studies reporting the use of povidone-iodine and five studies reporting the use of sodium hypochlorite were included in this review. Overall, in the meta-analysis of povidone-iodine, no significant changes were noted in any of the assessed outcomes; however, minor changes were noted in probing pocket depth and clinical attachment level at a specific timepoint. Regarding sodium hypochlorite, a significant reduction in all clinical outcomes, except for bleeding on probing, was noted. In conclusion, the use of povidone-iodine does not result in an improvement in clinical outcomes, whereas sodium hypochlorite has promising properties that result in significant improvement in probing pocket depth and clinical attachment level. However, more studies are needed to confirm these observations.

Pocket closure and residual pockets after non-surgical periodontal therapy: A systematic review and meta-analysis

Aim

To analyse the efficacy of non‐surgical therapy (NST) in terms of pocket closure (PC) and changes in percentage and number of pockets.

Materials and Methods

Three databases (PubMed, EMBASE, and Scopus) were searched up to January 2020. Prospective studies with a minimum follow‐up of 12 months and presenting data in terms of PC or number or percentage of pocket depths (PDs) before and after NST on systemically healthy patients were included. Random‐effect meta‐analyses were performed.

Results

After screening 4610 titles and abstracts, 27 studies were included. Of these, 63.9% of PC was reported by one study. The percentage of PDs ≤3 mm changed from 39.06% to 64.11% with a weighted mean difference (WMD) of 26.14% (p < .001). This accounted for a relative increase of healthy sites of 64.13%. The mean percentage of PD ≥5 mm was 28.23% and 11.71% before and after treatment, respectively, with a WMD of 15.50% (p < .001). The WMD in the number of PDs ≥5 mm before and after treatment was 24.42 (p = .036). The mean number of residual PPD ≥5 after NST was 14.13.

Conclusions

NST is able to eradicate the majority of the pockets. However, residual pockets after NST may remain and should be considered cautiously for further treatment planning.

Modulation of proinflammatory mediators by viruses-bacteria synergism in human osteoblasts-an in vitro study

BACKGROUND/PURPOSE

Viruses-bacteria synergistic interaction is associated with destructive periodontal diseases. However, the underlying mechanism for tissue destruction is not fully elucidated. In this study, lipopolysaccharide from Porphyromonas gingivalis (Pg-LPS) and polyinosinic-polycytidylic acid (poly I:C) were used to simulate bacteria and viruses, respectively. The possible combined effects of both molecular patterns on secretion of interleukin (IL)-6 and prostaglandin E₂ (PGE₂) from osteoblasts were determined. The effects of povidone-iodine (PVP-I) on the secretion of IL-6 and PGE₂ were also examined.

METHODS

Viability of treated osteoblastic cells (MG63) was examined by detection the mitochondrial dehydrogenase activity. Secretion of IL-6 and PGE₂ was detected using the enzyme-linked immunosorbent assay (ELISA). Mitogen-activated protein kinases (MAPKs) and cyclooxygenase-2 (COX-2) were determined using the Western blotting analysis.

RESULTS

Pg-LPS or poly I:C significantly enhanced the production of IL-6 and PGE₂ in MG63 cells. The additive/synergistic effects of Pg-LPS/poly I:C on production of IL-6 and PGE₂ were evident. The levels of phosphorylation of p38 MAPK and c-Jun N-terminal kinase (JNK) and expression of COX-2 protein were enhanced by Pg-LPS and/or poly I:C. On the other hand, the level of phosphorylation of extracellular signal-regulated kinase (ERK) was reduced by Pg-LPS and/or poly I:C. The stimulatory secretion of PGE₂ by poly I:C was significantly reduced by PVP-I.

CONCLUSION

Concomitant infection of viruses and bacteria may be potentially harmful to the tooth supporting tissues by production of proinflammatory mediators. The results suggest the potential anti-inflammatory effect of PVP-I on bacterial or viral infection.

Antiseptics as adjuncts to scaling and root planing in the treatment of periodontitis: a systematic literature review

BACKGROUND

Periodontitis is microbially-associated, host-mediated inflammatory condition that results in loss of periodontal attachment. The goals of periodontal therapy include arresting the disease progression, establishing healthy, stable, maintainable periodontal conditions. A fundamental strategy of treating periodontitis is scaling and root planning (SRP), however its efficacy may be restricted in areas inaccessible for mechanical instrumentation. As periodontitis is infectious in nature, it might be helpful to use additional antimicrobial adjuncts, in order to eliminate or inactivate pathogenic microflora. The aim of this study is to evaluate the current evidence regarding the potential clinical benefits of using additional antiseptics for SRP in nonsurgical periodontal therapy.

METHODS

An electronic literature search was conducted in the MEDLINE (Ovid) and Cohrane Central Register of Controlled Trials (CENTRAL) databases for articles published between January 1, 2000 and September 22, 2019. Randomized controlled clinical trials in English that compare the effectiveness of one or more antiseptic agents as adjuncts to SRP with a follow-up of ≥6 months were included. A meta-analysis using the random-effects model was performed on the selected qualifying articles.

RESULTS

The search resulted in 12 articles that met the inclusion criteria. Based on the vehicle employed to deliver the antiseptic agent, studies were divided into adjunctive sustained-release antiseptics (gels, chips and varnish) and adjunctive irrigation with antiseptics. The meta-analysis demonstrated significant improvements in probing depth (PD) reduction (p = 0.001), clinical attachment level (CAL) gain (p = 0.001), and bleeding on probing (BOP) values (p = 0.001) following the adjunctive subgingival application of sustained-release antiseptics. Additional subgingival irrigation with antiseptics failed to show significant improvements in PD (p = 0.321), CAL (p = 0.7568), or BOP values (p = 0.3549) over SRP alone.

CONCLUSIONS

Adjunctive subgingivally delivered antiseptics with a sustained-release delivery have significant clinical benefits compared to SRP alone.

Practical use of povidone-iodine antiseptic in the maintenance of oral health and in the prevention and treatment of common oropharyngeal infections

AIMS

To better inform medical practitioners on the role of antiseptics in oropharyngeal health and disease, this article focuses on povidone-iodine (PVP-I), an established and widely-available antiseptic agent.

METHODOLOGY

Review of the anti-infective profile, efficacy and safety of PVP-I in managing common upper respiratory tract infections such as the common cold, influenza and tonsillo-pharyngitis, as well as oral complications resulting from cancer treatment (oral mucositis), and dental conditions (periodontitis, caries).

RESULTS

Antiseptics with broad-spectrum anti-infective activity and low resistance potential offer an attractive option in both infection control and prevention. While there is some evidence of benefit of antiseptics in a variety of clinical settings that include dental and oral hygiene, dermatology, oncology, and pulmonology, there appears to be discordance between the evidence-base and practice. This is especially apparent in the management and prevention of oropharyngeal infections, for which the use of antiseptics varies considerably between clinical practices, and is in marked contrast to their dermal application, where they are extensively used as both a prophylaxis and a treatment of skin and wound infections, thus minimising the use of antibiotics.

CONCLUSION

The link between oral and oropharyngeal health status and susceptibility to infection has long been recognised. The high rates of antibiotic misuse and subsequent development of bacterial resistance (e.g. increasing vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA)) in large parts of the world, especially across Asia Pacific, highlight the need for identifying alternative antimicrobials that would minimise the use of these medications. This, together with recent large-scale outbreaks of, for example, avian and swine influenza virus, further underline the importance of an increasing armamentarium for infection prevention and control.

Effects of Antiseptic Solutions Commonly Used in Dentistry on Bone Viability, Bone Morphology, and Release of Growth Factors

PURPOSE

Antiseptic solutions are commonly used in dentistry for a number of sterilization procedures, including harvesting of bone chips, irrigation of extraction sockets, and sterilization of osteonecrotic bone. Despite its widespread use, little information is available regarding the effects of various antiseptic solutions on bone cell viability, morphology, and the release of growth factors.

MATERIALS AND METHODS

The antiseptic solutions included 1) 0.5% povidone iodine (PI), 2) 0.2% chlorhexidine diguluconate (CHX), 3) 1% hydrogen peroxide (H2O2), and 4) 0.25% sodium hypochlorite (HYP). Bone samples collected from porcine mandibular cortical bone were rinsed in the antiseptic solutions for 10 minutes and assessed for cell viability using an MTS assay and protein release of transforming growth factor (TGF-β1), bone morphogenetic protein 2 (BMP2), vascular endothelial growth factor (VEGF), interleukin (IL)-1β, and receptor activator of nuclear factor κB ligand (RANKL) using an enzyme-linked immunosorbent assay at 15 minutes and 4 hours after rinsing.

RESULTS

After antiseptic rinsing, changes to the surface protein content showed marked alterations, with an abundant protein layer remaining on CHX-rinsed bone samples. The amount of surface protein content gradually decreased in the following order: CHX, H2O2, PI, and HYP. A similar trend was also observed for the relative cell viability from within bone samples after rinsing, with up to 6 times more viable cells found in the CHX-rinsed bone samples than in the HYP- and PI-rinsed samples. An analysis of the growth factors found that both HYP and PI had significantly lower VEGF and TGF-β1 protein release from bone samples at 15 minutes and 4 hours after rinsing compared with CHX and H2O2. A similar trend was observed for RANKL and IL-1β protein release, although no change was observed for BMP2.

CONCLUSIONS

The results from the present study have demonstrated that antiseptic solutions present with very different effects on bone samples after 10 minutes of rinsing. Rinsing with CHX maintained significantly higher cell viability and protein release of growth factors potent to the bone remodeling cycle.

Antiseptic solutions modulate the paracrine-like activity of bone chips: differential impact of chlorhexidine and sodium hypochlorite

AIM

Chemical decontamination increases the availability of bone grafts; however, it remains unclear whether antiseptic processing changes the biological activity of bone.

MATERIALS AND METHODS

Bone chips were incubated with four different antiseptic solutions including (1) povidone-iodine (0.5%), (2) chlorhexidine diguluconate (0.2%), (3) hydrogen peroxide (1%) and (4) sodium hypochlorite (0.25%). After 10 min. of incubation, changes in the capacity of the bone-conditioned medium (BCM) to modulate gene expression of gingival fibroblasts was investigated.

RESULTS

Conditioned medium obtained from freshly prepared bone chips increased the expression of TGF-β target genes interleukin 11 (IL11), proteoglycan4 (PRG4), NADPH oxidase 4 (NOX4), and decreased the expression of adrenomedullin (ADM), and pentraxin 3 (PTX3) in gingival fibroblasts. Incubation of bone chips with 0.2% chlorhexidine, followed by vigorously washing resulted in a BCM with even higher expression of IL11, PRG4 and NOX4. These findings were also detected with a decrease in cell viability and an activation of apoptosis signalling. Chlorhexidine alone, at low concentrations, increased IL11, PRG4 and NOX4 expression, independent of the TGF-β receptor I kinase activity. In contrast, 0.25% sodium hypochlorite almost entirely abolished the activity of BCM, whereas the other two antiseptic solutions, 1% hydrogen peroxide and 0.5% povidone-iodine, had relatively no impact respectively.

CONCLUSION

These in vitro findings demonstrate that incubation of bone chips with chlorhexidine differentially affects the activity of the respective BCM compared to the other antiseptic solutions. The data further suggest that the main effects are caused by chlorhexidine remaining in the BCM after repeated washing of the bone chips.

Effect of application of a PVP-iodine solution before and during subgingival ultrasonic instrumentation on post-treatment bacteraemia: a randomized single-centre placebo-controlled clinical trial

BACKGROUND

To assess the effect of concomitant subgingival rinsing with 10% PVP-iodine during subgingival instrumentation on the prevalence and magnitude of bacteraemia of oral origin.

MATERIALS AND METHODS

Subgingival instrumentation was performed with water or PVP-iodine rinse in patients with periodontitis. Prior to instrumentation, subjects gargled for 1 min with the allocated liquid. Pockets were then rinsed for 1 min and subgingivally instrumented with liquid-cooled (water/PVP-iodine) ultrasonic scalers (1 min). Two minutes later, a blood sample from the arm vein was drawn using a lysis centrifugation blood culture system for quantitative microbiological analysis. Non-parametric statistical tests were performed to assess differences in the prevalence and extent of bacteraemia between groups.

RESULTS

Of the 19 samples in each group, oral-borne bacteraemia was detected in 10 of the control and 2 of the test samples. With an average of 3.0 [1; 5] colony forming units, significantly less bacteria and bacteraemia were found in the test group compared to the controls (12.2 [1; 46]) (p = 0.003). Anaerobic bacteria were not found in the test group.

CONCLUSIONS

Bacteraemia after subgingival instrumentation with concomitant PVP-iodine rinsing is reduced but not eliminated. Therefore, it might be recommended for patients at a high risk of endocarditis or infection of endoprostheses. However, preventive antibiotic treatment should not be omitted.

Microbiological effect of essential oils in combination with subgingival ultrasonic instrumentation and mouth rinsing in chronic periodontitis patients

Thirty chronic periodontitis patients were randomly assigned to 3 groups: control, saline, and essential oil-containing antiseptic (EO). Subgingival plaque was collected from a total of 90 pockets across all subjects. Subsequently, subgingival ultrasonic instrumentation (SUI) was performed by using EO or saline as the irrigation agent. After continuous mouth rinsing at home with EO or saline for 7 days, subgingival plaques were sampled again. Periodontopathic bacteria were quantified using the modified Invader PLUS assay. The total bacterial count in shallow pockets (probing pocket depth (PPD) = 4-5 mm) was significantly reduced in both saline (P < 0.05) and EO groups (P < 0.01). The total bacterial count (P < 0.05) and Porphyromonas gingivalis (P < 0.01) and Tannerella forsythia (P < 0.05) count in deep pockets (PPD ≥6 mm) were significantly reduced only in the EO group. In comparisons of the change ratio relative to baseline value of total bacteria counts across categories, both the saline and EO groups for PPD 4-5 mm and the EO group for PPD 6 mm showed a significantly low ratio (P < 0.05). The adjunctive use of EO may be effective in reducing subgingival bacterial counts in both shallow and deep pockets. This trial is registered with UMIN Clinical Trials Registry UMIN000007484.

Low-cost periodontal therapy

Periodontitis is a complex infectious disease that affects low-income individuals disproportionately. Periodontitis is associated with specific bacterial species and herpesviruses, and successful prevention and treatment of the disease is contingent upon effective control of these pathogens. This article presents an efficacious, highly safe, minimally invasive, practical and low-cost periodontal therapy that involves professional and patient-administered mechanical therapy and antimicrobial agents. The major components are scaling for calculus removal, periodontal pocket irrigation with potent antiseptics, and treatment with systemic antibiotics for advanced disease. Povidone-iodine and sodium hypochlorite have all the characteristics for becoming the first-choice antiseptics in the management of periodontal diseases. Both agents show excellent antibacterial and antiviral properties, are readily available throughout the world, have been safely used in periodontal therapy for decades, offer significant benefits for individuals with very limited financial resources, and are well accepted by most dental professionals and patients. Four per cent chlorhexidine applied with a toothbrush to the most posterior part to the tongue dorsum can markedly reduce or eliminate halitosis in most individuals. Systemic antibiotics are used to treat periodontopathic bacteria that are not readily reached by topical therapy, such as pathogens within gingival tissue, within furcation defects, at the base of periodontal pockets, and on the tongue, tonsils and buccal mucosae. Valuable antibiotic therapies are amoxicillin-metronidazole (250 mg of amoxicillin and 250 mg of metronidazole, three times daily for 8 days) for young and middle-aged patients, and ciprofloxacin-metronidazole (500 mg of each, twice daily for 8 days) for elderly patients and for patients in developing countries who frequently harbor enteric rods subgingivally. Scaling to remove dental calculus and the prudent use of inexpensive antimicrobial agents can significantly retard or arrest progressive periodontitis in the great majority of patients.

Debridamento ultrassônico de boca toda no tratamento da periodontite crônica: uma revisão sistematizada

INTRODUÇÃO: O debridamento ultrassônico de boca toda visa a uma instrumentação mais leve e conservadora da superfície radicular, evitando a recolonização da bolsa periodontal. OBJETIVO: Este trabalho verificou os efeitos do debridamento subgengival com o uso de ultrassom sobre os parâmetros clínicos periodontais no tratamento da periodontite crônica por meio de uma revisão na literatura. MATERIAL E MÉTODO: A revisão foi realizada nas bases de busca bibliográfica PubMed, Lilacs, Scielo, Medline e Centro de Registro de Ensaios Clínicos Controlados (Biblioteca Cochrane). Foram incluídas publicações na língua inglesa que abordaram estudos clínicos de intervenção em humanos, randomizados e controlados, e que utilizaram o debridamento ultrassônico para o tratamento não cirúrgico da periodontite crônica. RESULTADO: Inicialmente, foram encontradas 167 referências e, a partir da análise dos títulos e resumos, dez estudos perfizeram as características exigidas e foram considerados válidos para a realização desta revisão. Os estudos mostraram que a abordagem pelo debridamento ultrassônico pode ser terapia favorável ao tratamento da periodontite crônica. CONCLUSÃO: O tratamento da periodontite crônica por meio do debridamento ultrassônico periodontal de boca toda produz resultados clínicos semelhantes aos conseguidos na raspagem e no alisamento radicular convencionais.

A comparison of magnetostrictive and piezoelectric ultrasonic scaling devices: an in vitro study

Purpose

The effects of magnetostrictive and piezoelectric devices on tooth surfaces seem to differ with regard to the root surface roughness they produce. This study aimed to compare the results of scaling using magnetostrictive and piezoelectric devices on extracted teeth.

Methods

Forty-four human extracted teeth were assigned to four study groups (n=11). In two groups (C100 and C200), the teeth were scaled using a magnetostrictive device and two different lateral forces: 100 g and 200 g, respectively. In the other two groups (P100 and P200), the teeth were scaled with a piezoelectric device with 100 g and 200 g of lateral force, respectively. he teeth were scaled and the data on the duration of scaling and the amount of surface were collected and analyzed using the t-test.

Results

The mean time needed for instrumentation for the piezoelectric and magnetostrictive devices was 50:54 and 41:10, respectively, but their difference was not statistically significant (P=0.171). For root surface roughness, we only found a statistically significantly poorer result for the C200 group in comparison to the P200 group (P=0.033).

Conclusions

This study revealed that applying a piezoelectric scaler with 200 g of lateral force leaves smoother surfaces than a magnetostrictive device with the same lateral force.

Clearance of topically-applied PVP-iodine as a solution or gel in periodontal pockets in men

OBJECTIVES

The aim of the study was to investigate the clearance of PVP-iodine applied as a gel or solution in periodontal pockets.

METHODS

Teeth of 12 subjects with at least eight periodontal pockets of ≥5 mm probing depth were isolated with a rubber dam to allow contamination-free access to the pockets. In each subject, three pockets were filled with PVP-iodine gel (10%) and three with PVP-iodine solution (10%). One pocket of each subject without iodine application served as a negative control. The treatment allocation was assigned randomly. Any excess material was removed subsequently. After 1, 5 and 15 min, a paper point was used to collect the sulcus liquid and the concentration of PVP-iodine was chemically determined. In addition, PVP-iodine gel was administered into 12 periodontal pockets immediately after sub-gingival ultrasound debridement and the concentration of PVP-iodine was determined after 1 min.

RESULTS

Descending concentrations of PVP-iodine were determined at 1, 5 and 15 min after the application. No PVP-iodine was found in the pockets serving as negative controls. The mean concentrations of the gel and solution were 6.14 μg/ml and 4.44 μg/ml (1 min; p ≥ 0.028), 3.20 μg/ml and 1.44 μg/ml (5 min; p ≥ 0.126), 0.69 μg/ml and 0.23 μg/ml (15 min; p ≤ 0.019), respectively. In the pockets with previous debridement the mean concentration was 1.68 ± 1.97 μg/ml.

CONCLUSION

The application of PVP-iodine gel in periodontal pockets allows a prolonged remnant effect as compared to that of the solution formula.

Non-surgical instrumentation associated with povidone-iodine in the treatment of interproximal furcation involvements

Objective

The aim of this controlled clinical trial was to evaluate the effect of topically applied povidone-iodine (PVP-I) used as an adjunct to non-surgical treatment of interproximal class II furcation involvements.

Material and methods

Thirty-two patients presenting at least one interproximal class II furcation involvement that bled on probing with probing pocket depth (PPD) ≥5 mm were recruited. Patients were randomly chosen to receive either subgingival instrumentation with an ultrasonic device using PVP-I (10%) as the cooling liquid (test group) or identical treatment using distilled water as the cooling liquid (control group). The following clinical outcomes were evaluated: visible plaque index, bleeding on probing (BOP), position of the gingival margin, relative attachment level (RAL), PPD and relative horizontal attachment level (RHAL). BAPNA (N-benzoyl-Larginine-p-nitroanilide) testing was used to analyze trypsin-like activity in dental biofilm. All parameters were evaluated at baseline and 1, 3 and 6 months after non-surgical subgingival instrumentation.

Results

Six months after treatment, both groups had similar means of PPD reduction, RAL and RHAL gain (p>0.05). These variables were, respectively, 2.20±1.10 mm, 1.27±1.02 mm and 1.33±0.85 mm in the control group and 2.67±1.21 mm, 1.50±1.09 mm and 1.56±0.93 mm in the test group. No difference was observed between groups at none of the posttreatment periods, regarding the number of sites showing clinical attachment gain ≥2 mm. However, at 6 months posttreatment, the test group presented fewer sites with PPD ≥5 mm than the control group. Also at 6 months the test group had lower BAPNA values than control group.

Conclusion

The use of PVP-I as an adjunct in the non-surgical treatment of interproximal class II furcation involvements provided limited additional clinical benefits.

Systematic review on the effect of rinsing with povidone-iodine during nonsurgical periodontal therapy

BACKGROUND AND OBJECTIVE

The existing literature is inconsistent regarding whether there is any additional effect of povidone-iodine (PVP-iodine) as an adjunctive to scaling and root planing, and, if there is an effect, what its size is. Therefore, the aim of this study was to assess the additional effect of PVP-iodine as an adjunct to scaling and root planing compared with water, saline or no rinse in the treatment of chronic periodontitis.

MATERIAL AND METHODS

An electronic literature search of the databases PubMed, EMBASE and the Cochrane Central Library, and a handsearch, were performed (up to November 2008). Two reviewers independently identified and selected screened abstracts for possible inclusion, and assessed randomized, controlled clinical trials comparing the additional benefit of PVP-iodine with water, saline rinsing or no rinsing in the nonsurgical periodontal therapy of patients with chronic periodontitis. A fixed-effects meta-analysis was conducted in the absence of statistically significant heterogeneity.

RESULTS

A small, but statistically significant additional beneficial effect of the adjunctive use of PVP-iodine with enhanced probing pocket depth reductions of 0.28 mm (95% confidence interval: 0.08 to 0.48, p = 0.007) was found. There was no significant heterogeneity between studies (I(2) = 0%). However, most of the studies included in the meta-analysis were of low quality, and the treatment modalities showed various differences such as the use of PVP-iodine at different concentrations and application modalities. Nevertheless, single-rooted teeth, in particular, showed an additional benefit after scaling and root planing with PVP-iodine, particularly when the treatment was repeated during the healing stage.

CONCLUSION

The adjunctive use of PVP-iodine during scaling and root planing may increase the clinical pocket depth reduction, although the clinical significance is small to moderate.

Effect of short-time povidone-iodine application on osteoblast proliferation and differentiation

Background and Objective:

Povidone-iodine [polyvinylpyrrolidone-iodine complex (PVP-I)] is a broad-spectrum antimicrobial agent, frequently used in dentistry. In this study we investigated the short- and longterm effects on osteoblast number, viability, and function after short exposure to PVP-I with and without additional bone-morphogenetic protein-2 (BMP-2).

Material and Methods:

Confluent osteoblast-like cell line (MC3T3-E1, subclone 24) cultures were exposed to pure PVP-I solution (7.7 mg/ml) and dilutions of 1:10, 1:100 and 1:1000 for 10 seconds and washed with phosphate buffer solution. Cell proliferation and viability was determined by MTT and differentiation status by alkaline phosphatase (ALP) activity 6 days after initial plating. In a separate experiment, long-term cell proliferation, viability and function were assessed 4 weeks after PVP-I treatment by MTT and deposited calcium using an Alizarin-red staining test.

Results:

PVP-I decreased ALP activity substantially. Stimulation by BMP-2 recovered ALP activity to near control levels at 1:100 and 1:1000 dilutions of PVP-I. The MTT assay showed reduced proliferation of the preosteoblastic cells for all treatments, irrespective whether BMP-2 was used or not. Only at PVP-I dilutions of 1:1000 proliferation rate was back to normal levels (95.6±2.4 %). No adverse long-term effect of PVP-I on mineralization of the extracellular matrix (Alizarinred) for dilutions higher than 1:100 was observed. Interestingly, undiluted and 1:10 diluted PVP-I even showed a significant increase in mineral deposition, especially in the presence of BMP-2.

Conclusion:

Short-time application of PVP-I in concentrations of 1:10 and higher lead to decreased viability and impaired differentiation. However, surviving cells showed good recovery and mineralization potential.

The use of povidone-iodine and hydrogen peroxide mixture as an adjunct to non-surgical treatment of slight to moderate chronic periodontitis

OBJECTIVE

The aim of this study was to evaluate the clinical effects of the adjunctive use of povidone-iodine with or without hydrogen peroxide as coolant and disinfectant during ultrasonic scaling and root planing in the treatment of chronic periodontitis.

MATERIALS AND METHODS

Sixteen patients initially participated in the study. Thirteen patients (8 males and 5 females) completed the 3-month follow-up period. Their mean (±SD) age was 42.92 ± 7.55 years. In each experimental subject, the mouth was split into four quadrants. A randomly selected quadrant was chosen to receive one of the three treatment group modalities which were: Group 1 - ultrasonic scaling and root planing plus irrigation with 1% povidone-iodine and 3.0% hydrogen peroxide mixture; Group 2 - ultrasonic scaling and root planing plus irrigation with 1% povidone-iodine; Group 3 - ultrasonic scaling and root planing plus irrigation with normal saline. The fourth quadrant served as a control group.

RESULTS

At the 3-month evaluation, there was no significant difference between the three treatment groups in terms of probing depth reduction, clinical attachment gain, gingival recession increase, reduction in the bleeding upon probing or plaque score reduction (P > 0.05). However, the three treatment groups had statistically significant higher mean reduction in the probing depth, gain in the clinical attachment level and reduction in the bleeding upon probing than the control group (P < 0.05).

CONCLUSION

There were no added benefits of using a mixture of povidone-iodine and hydrogen peroxide or povidone-iodine as disinfectants during ultrasonic scaling and root planing in the treatment of chronic periodontitis.

Sonic and ultrasonic scalers in periodontal treatment: a review

Periodontal therapy aims at arresting periodontal infection and maintaining a healthy periodontium. The periodic mechanical removal of subgingival microbial biofilms is essential for controlling inflammatory periodontal disease. Mechanical periodontal therapy consists of scaling, root planing and gingival curettage. The sonic and ultrasonic scalers are valuable tools in the prevention of periodontal disease. The vibration of scaler tips is the main effect to remove the deposits from the dental surface, such as bacterial plaque, calculus and endotoxin. However, constant flushing activity of the lavage used to cool the tips and cavitational activity result in disruption of the weak and unattached subgingival plaque. The aim of the study was to review the safety, efficacy, role and deleterious side-effects of sonic and ultrasonic scalers in mechanical periodontal therapy.

In vitro comparison of chlorhexidine and povidone-iodine on the long-term proliferation and functional activity of human alveolar bone cells

This work reports the behaviour of osteoblastic human alveolar bone cells (first subculture) in the presence of chlorhexidine (CHX) and povidone-iodine (PI). Short contact (2 min) of 24-h cultures with CHX, at 0.12 and 0.2%, and PI, at 5 and 10%, caused cell death within minutes; contact with 1% PI resulted in loss of the elongated characteristic cell shape. Cell adhesion was adversely affected at concentrations higher than 5 x 10(-5)% CHX or 0.05% PI. Long-term exposure to CHX at 10(-5) and 10(-4)% or PI at 10(-4)% had little effect on cell growth and caused an induction in the synthesis of alkaline phosphatase (ALP). Concentrations of CHX and PI similar and higher than, respectively, 5 x 10(-4)% or 0.05% caused dose-dependent deleterious effects. CHX affected mainly the cell growth, whereas the effects of PI were observed mostly in ALP production and matrix mineralization. Considering the levels of CHX and PI used routinely in the oral cavity, results suggest that CHX has a higher cytotoxicity profile than PI. This observation might have some clinical relevance regarding the potential utility of PI in the prevention of alveolar osteitis.

Healing following ultrasonic debridement and PVP-iodine in individuals with severe chronic periodontal disease: a randomized, controlled clinical study

OBJECTIVE

Antiseptics and antibiotics delivered either locally or systemically have been used as an adjunct to scaling and root planing procedures in order to control the subgingival biofilm and thereby enhancing the treatment outcome. The results presented in the literature are, however, inconclusive. Povidone-iodine (PVP-iodine) has a bactericidal effect and is effective against most bacteria, including putative periodontal pathogens. The aim of the present study was to evaluate the clinical effect of PVP-iodine as an adjunct to ultrasonic scaling in the treatment of severe chronic periodontitis.

MATERIAL AND METHODS

Twenty patients were recruited to the study. Each test site and the related quadrant were randomly assigned to one of four different treatment modalities: ultrasonic scaling + subgingival irrigation with 0.5% PVP-iodine for 5 min/tooth, ultrasonic scaling + subgingival irrigation with sterile saline solution for 5 min/tooth, subgingival irrigation with sterile saline solution for 5 min/tooth, and subgingival irrigation with 0.5% PVP-iodine for 5 min/tooth. The individuals were followed longitudinally for 6 months.

RESULTS

The present study showed that non-surgical periodontal therapy by means of an ultrasonic device was effective in attaining a healthy periodontal status in patients with severe periodontal lesions. No additive effect was found when PVP-iodine was included.

CONCLUSIONS

Ultrasonic debridement using Odontogain is effective in controlling infection in patients with severe chronic periodontitis. PVP-iodine does not add any clinical benefit to the ultrasonic debridement alone under these circumstances.

Effect of different iodine formulations on the expression and activity of Streptococcus mutans glucosyltransferase and fructosyltransferase in biofilm and planktonic environments

OBJECTIVES

The glucosyltransferase (GTF) and fructosyltransferase (FTF) enzymes play a pivotal role in dental biofilm formation as they synthesize polysaccharides that act as the extracellular matrix of the biofilm. Iodine is a unique antibacterial agent that has distinct properties from other conventional antibacterial agents. In this study we have examined the effect of iodine and povidone iodine (PI) on gtf and ftf expression in biofilm and planktonic environments and on immobilized and unbound GTF and FTF activity.

METHODS

Real-time reverse transcription-PCR was used to investigate the effect of iodine and PI on ftf, gtfB and gtfC expression. The effect of iodine and PI on GTF and FTF activity was tested using radioactive assays.

RESULTS

Our results indicate that iodine and PI in a tetraglycol carrier cause enhancement of expression of gtfB in Streptococcus mutans in biofilms but not in planktonic bacteria. PI in water induced expression of gtfB and gtfC in planktonic bacteria. However, iodine and PI strongly inhibit polysaccharide production by GTF and to a lesser extent by FTF activity. The inhibitory effect on GTF activity was similar in solution compared to its activity in the immobilized environment. This unique effect may be attributed to the distinct chemical properties of iodine compared with other antibacterial agents.

CONCLUSIONS

This study indicates that iodine at sub-bactericidal concentrations demonstrates molecular and enzymatic effects that are highly associated with biofilm formation.

Periodontal Debridement With Povidone-Iodine in Periodontal Treatment: Short-Term Clinical and Biochemical Observations

BACKGROUND

The aim of the present study was to evaluate the clinical effects of one-stage periodontal debridement with an ultrasonic instrument, associated with 0.5% povidone (pvp)-iodine irrigation in patients with chronic periodontitis.

METHODS

Forty-five patients were randomly assigned into three groups: the control group (CG) received quadrant root planing at 1-week intervals over four consecutive sessions; the periodontal debridement plus pvp-iodine group (PD-PIG) received a 45-minute full-mouth debridement with an ultrasonic instrument, associated with 0.5% pvp-iodine irrigation; and the periodontal debridement group (PDG) received a 45-minute full-mouth periodontal debridement with an ultrasonic instrument, associated with NaCl irrigation.

RESULTS

At the 3-month evaluation, the mean probing depth (PD) reduction in CG was 2.51+/-0.52 mm, 2.53+/-0.50 mm in PD-PIG, and 2.58+/-0.60 mm in PDG (P<0.05). The clinical attachment level (CAL) analysis showed a statistically significant gain in all groups compared to baseline (1.87+/-0.56 mm [CG], 1.94+/-0.70 mm [PD-PIG], and 1.99+/-0.92 mm [PDG]). Intergroup analysis of PD and CAL at 1 and 3 months showed no differences (P>0.05). The N-benzoyl-L-arginine-p-nitroanilide (BAPNA) test showed a significant reduction in trypsin activity only during the first month (P<0.05); at 3 months there were no differences compared to baseline (P=0.80).

CONCLUSION

This study provides no evidence that pvp-iodine is effective as an adjunct for one-stage periodontal debridement.

Povidone-Iodine Used as an Adjunct to Non-Surgical Treatment of Furcation Involvements

BACKGROUND

The aim of this clinical trial was to evaluate the effect of topically applied povidone-iodine (polyvinylpyrrolidone and iodine [PVP-I]) used as an adjunct to non-surgical therapy of furcation involvements.

METHODS

Forty-four patients presenting at least one Class II furcation involvement that bled on probing with probing depth (PD)>or=5 mm were recruited. Patients were stratified into two treatment groups: 1) subgingival instrumentation by an ultrasonic device using PVP-I (10%) as the cooling liquid (test); and 2) identical treatment using distilled water as the cooling liquid (control). The following clinical outcomes were evaluated: plaque index, bleeding on probing (BOP), position of the gingival margin, relative attachment level (RAL), PD, and relative horizontal attachment level (RHAL). The N-benzoyl-L-arginine-p-nitroanilide (BAPNA) test was used to analyze the trypsin-like activity in dental biofilm. The clinical and biochemical parameters were evaluated at baseline and 1, 3, and 6 months after therapy.

RESULTS

Both groups had similar means of PD reduction and RAL and RHAL gain. At 6 months, these variables were, respectively, 2.31, 1.17, and 1.00 mm in the control group and 2.31, 1.23, and 1.02 mm in the test group. There was also no difference between groups regarding the number of furcation sites presenting RAL gain>or=2 mm. The results of the BAPNA test failed to demonstrate significant differences between groups.

CONCLUSION

Non-surgical therapy can effectively treat Class II furcation involvements, and the use of topically applied PVP-I as an adjunct to subgingival instrumentation does not provide additional benefits.

Position Paper: The Role of Supra- and Subgingival Irrigation in the Treatment of Periodontal Diseases

This position paper addresses the role of supra- and subgingival irrigation in the treatment of periodontal diseases. It was prepared by the Committee on Research, Science and Therapy of the American Academy of Periodontology. The document is divided into two portions, consisting of supragingival irrigation and subgingival irrigation. In their respective segments, these treatment techniques are assessed as monotherapies and as adjuncts to conventional treatment. The conclusions drawn in this paper represent the position of the American Academy of Periodontology regarding irrigation therapy in the treatment of periodontal diseases.

Impact of local adjuncts to scaling and root planing in periodontal disease therapy: a systematic review

BACKGROUND

Chronic periodontitis affects many adults in the United States, some severely enough to threaten tooth loss. Of particular clinical importance is whether scaling and root planing (SRP) accompanied by a local adjunctive therapeutic agent improves outcomes over time compared to SRP alone. The adjunctive therapeutic agents investigated include: tetracycline, minocycline, metronidazole, a group of other antibiotics, chlorhexidine, and a group of antimicrobials. Primary outcomes considered are reductions in probing depth (PD) and gains in clinical attachment level (CAL).

METHODS

RTI-UNC Evidence-Based Practice Center staff searched MEDLINE (1966 through December 2002) and EMBASE (through February 2002) to identify clinical trials published in English that 1) involved adults with chronic periodontitis but no serious comorbidities; 2) tested one or more chemical antimicrobial agents as an adjunct to SRP alone or with a placebo; 3) had a concurrent control group that received the same SRP as the treatment group; 4) reported outcomes for specified, fixed time periods; and 5) if multiple antimicrobials were tested, reported outcomes for each agent separately. We performed qualitative analyses and meta-analyses of PD and CAL effect sizes when the necessary data were available from at least three studies at 6-month follow-up.

RESULTS

Among the locally administered adjunctive antimicrobials, the most positive results occurred for tetracycline, minocycline, metronidazole, and chlorhexidine. Adjunctive local therapy generally reduced PD levels. Differences between treatment and SRP-only groups in the baseline-to-follow-up period typically favored treatment groups but usually only modestly (e.g., from about 0.1 mm to nearly 0.5 mm) even when the differences were statistically significant. Effects for CAL gains were smaller and statistical significance less common. The marginal improvements in PD and CAL were a fraction of the improvement from SRP alone.

CONCLUSIONS

Whether such improvements, even if statistically significant, are clinically meaningful remains a question. A substantial agenda of future research to address this and other issues (e.g., costs, patient-oriented outcomes) is suggested.

Effects of single-visit full-mouth ultrasonic debridement versus quadrant-wise ultrasonic debridement

BACKGROUND

The aim of this randomized controlled clinical trial was to determine the effects of single-visit full-mouth ultrasonic debridement versus quadrant-wise therapy.

MATERIAL AND METHODS

Thirty-six subjects with chronic periodontitis, were randomly allocated to three groups--quadrant-wise ultrasonic debridement, single-visit full-mouth ultrasonic debridement with povidone iodine and single-visit full-mouth ultrasonic debridement with water. Whole-mouth plaque, bleeding on probing (BOP), pocket depth and attachment level were recorded before treatment and 1, 3 and 6 months post-treatment. Plaque and saliva samples were collected for microbiological analysis.

RESULTS

After treatment, all groups showed significant improvement in clinical parameters. Full-mouth treatments resulted in similar improvements in full-mouth mean plaque percentage, probing pocket depth and probing attachment level as conventional therapy. When data were analysed based on pocket depth and tooth type, there was no difference between groups in probing depth reduction or attachment gains. The full-mouth groups demonstrated greater reduction in BOP% and number of pockets > or =5 mm and the total treatment time was significantly shorter. The detection frequencies of periodontal pathogens in plaque and saliva showed slight changes with no difference between groups.

CONCLUSION

Single-visit full-mouth mechanical debridement may have limited additional benefits over quadrant-wise therapy in the treatment of periodontitis, but can be completed in a shorter time.

Local Anti-Infective Therapy: Mechanical and Physical Approaches. A Systematic Review

BACKGROUND

Although mechanical non-surgical therapy (scaling and root planing) is the most common means of initial treatment of periodontal diseases, the relative clinical efficacy of various methods, including manual versus machine-driven, with or without adjunctive agents, has not been determined.

RATIONALE

This systematic review analyzes the literature in an effort to identify the most effective therapies, based on both clinical and patient-centered outcomes.

FOCUSED QUESTION

In patients with periodontitis, what is the effect of mechanically-driven instrumentation (e.g., power-driven) and/or subgingival irrigation with and without manual instrumentation compared to manual instrumentation alone?

SEARCH PROTOCOL

Two investigators examined MEDLINE and the Cochrane Oral Health Group specialized registry for clinical trials published in English. Hand searches were performed of the International Journal of Periodontics & Restorative Dentistry, Journal of Clinical Periodontology, Journal of Periodontology, and Journal of Periodontal Research. Searches were performed for articles published through April 2002. Editors of these journals were asked to provide information on articles currently under review. In addition, an electronic discussion group on periodontal diseases and treatment was contacted, as were manufacturers of manual and mechanical instruments and of adjunctive agents.

SELECTION CRITERIA

INCLUSION CRITERIA

Only randomized clinical trials, cohort studies, or case-control studies at least 3 months long were included. All studies had to compare manual instrumentation (MI; scaling and root planing [SRP]) alone with some other form of non-surgical therapy. These included MI versus mechanically-driven instruments (MDI) alone; MI versus MI plus MDI; MI versus MDI plus an agent (e.g., chlorhexidine); and MI versus subgingival irrigation (SGI) delivered in conjunction with MI or MDI.

EXCLUSION CRITERIA

Studies not meeting the inclusion criteria or those treating periodontal diseases as a manifestation or complication of some other disease or disorder were not included.

DATA COLLECTION AND ANALYSIS

Probing depth, clinical attachment level, bleeding on probing, and gingival recession were the primary outcomes. Because of the heterogeneity of the patient populations, treatments, and outcome measures, meta-analysis was not appropriate. Only in-study data were compared. Four of the studies required extrapolating data from figures and graphs, resulting in questionable accuracy.

MAIN RESULTS

1. Nine studies, representing a study population of 129, were included in the review. 2. Five studies compared MI with MDI alone. The other 4 compared MI alone to MI plus SGI or subgingival tissue treatment. 3. There was comparable efficacy between MI and MDI when treating single-rooted teeth. 4. The use of SGI or subgingival tissue treatment as an adjunct to MI provided no additional benefit compared to MI alone. 5. Findings reported in the review must be interpreted with considerable caution, as lack of study heterogeneity made meta-analysis unfeasible and the need to extrapolate outcomes values from graphs and figures may have resulted in some inaccuracy.

REVIEWERS' CONCLUSIONS

1. Manual and mechanically-driven instrumentation appears comparable in affecting improved clinical outcomes. 2. Instrumentation time for MI and MDI were similar, except for 1 study in which MDI was significantly shorter. 3. Adjunctive SGI plus MI and subgingival tissue treatment result in similar clinical outcomes when compared to MI alone. 4. If study data are to be effectively and analytically combined to facilitate meaningful comparisons of treatment outcomes, detailed and standardized study designs must be developed and used consistently in clinical trials.

Povidone-iodine as a periodontal pocket disinfectant

OBJECTIVES AND BACKGROUND

Povidone-iodine [polyvinylpyrrolidone-iodine complex (PVP-iodine)] might constitute a valuable adjunct to current periodontal therapy because of its broad-spectrum antimicrobial activity, low potential for developing resistance and adverse reactions, wide availability, ease of use, and low financial cost. This investigation employed a randomized, split-mouth study design to determine the microbiological and clinical effects of 10% PVP-iodine subgingival irrigation in periodontitis lesions showing radiographic evidence of subgingival calculus.

METHODS

Sixteen adults having at least one periodontal pocket of 6 mm or more in each quadrant of the dentition and harboring one or more periodontopathic bacteria participated in the study. In each subject, a study site in each quadrant was randomly chosen to receive either subgingival irrigation with 10% PVP-iodine together with scaling and root planing, scaling and root planing alone, subgingival irrigation with 10% PVP-iodine, or subgingival irrigation with sterile saline. Prior to therapy and at 5 weeks post-treatment, microbiological culture was carried out without knowledge of the clinical status or the type of treatment rendered. A blinded clinical examiner determined presence of dental plaque, probing pocket depth, and gingival bleeding on probing. Microbiological and clinical data were analyzed using a repeated measures analysis of variance and Kruskal-Wallis rank test with the Tukey and Mann-Whitney post hoc tests.

RESULTS

At 5 weeks post-treatment, subgingival irrigation with PVP-iodine together with scaling and root planing caused a 95% or greater reduction in total pathogen counts in 44% of pockets having >/= 6 mm depth whereas scaling and root planing alone, povidone-iodine irrigation alone and water irrigation alone caused 95% reduction of total pathogens only in 6-13% of similar study sites (P = 0.02). Reduction in mean pocket depth was 1.8 mm for the PVP-iodine/scaling and root planing group, 1.6 mm for the scaling and root planing group, and 0.9 mm for the PVP-iodine and the saline monotherapy groups, with statistical significance reached for the scaling and root planing group vs. the PVP-iodine group (P = 0.04) and for the scaling and root planing group vs. the saline group (P = 0.02). Reduction in visible dental plaque, which ranged from 38% to 62%, showed no significant differences among treatment groups.

CONCLUSIONS

The addition of subgingival PVP-iodine irrigation to conventional mechanical therapy may be a cost-effective means of reducing total counts of periodontal pathogens and helping control periodontal disease. However, subgingival irrigation with PVP-iodine without concomitant mechanical debridement might not improve microbiological and clinical variables in comparison with saline irrigation, at least not in sites with radiographic evidence of subgingival calculus.

Selection of antimicrobial agents in periodontal therapy

BACKGROUND

The recognition over the past 3 decades of microbial specificity in periodontitis has afforded dental practitioners the ability to prevent and treat the disease with a variety of antimicrobial drugs. These include systemic antibiotics, topical antibiotics and topical antiseptics.

RESULTS

Systemic antibiotic therapy can be essential in eliminating pathogenic bacteria that invade gingival tissue and in helping control periodontal pathogens residing in various domains of the mouth from where they may translocate to periodontal sites. Frequently used periodontal combination antibiotic therapies are metronidazole-amoxicillin (250-375 mg of each 3 x daily for 8 days) and metronidazole-ciprofloxacin (500 mg of each 2 x daily for 8 days). Microbiological analysis helps determine the optimal antibiotic therapy and effectiveness of treatment. Topical antibiotics that are commercially available as controlled release devices suffer from several potential problems, including insufficient spectrum of antimicrobial activity in some periodontal polymicrobial infections, risks of producing an antibiotic resistant microbiota, and high acquisition costs. Topical antiseptics of relevance in periodontal treatment include 10% povidone-iodine placed subgingivally by a syringe for 5 min, and 0.1% sodium hypochlorite solution applied subgingivally by patients using an irrigation device.

CLINICAL IMPLICATIONS

The present paper recommends periodontal treatment that includes a battery of professionally and patient-administered antimicrobial agents (properly prescribed systemic antibiotics, povidone-iodine and sodium hypochlorite subgingival irrigants, and chlorhexidine mouthrinse). Available chemotherapeutics can provide effective, safe, practical and affordable means of controlling subgingival colonization of periodontal pathogens and various types of periodontal disease.