Local and systemic chemotherapy in the management of periodontal disease: an opinion and review of the concept

Review on PLGA Polymer Based Nanoparticles with Antimicrobial Properties and Their Application in Various Medical Conditions or Infections

The rise in the resistance to antibiotics is due to their inappropriate use and the use of a broad spectrum of antibiotics. This has also contributed to the development of multidrug-resistant microorganisms, and due to the unavailability of suitable new drugs for treatments, it is difficult to control. Hence, there is a need for the development of new novel, target-specific antimicrobials. Nanotechnology, involving the synthesis of nanoparticles, may be one of the best options, as it can be manipulated by using physicochemical properties to develop intelligent NPs with desired properties. NPs, because of their unique properties, can deliver drugs to specific targets and release them in a sustained fashion. The chance of developing resistance is very low. Polymeric nanoparticles are solid colloids synthesized using either natural or synthetic polymers. These polymers are used as carriers of drugs to deliver them to the targets. NPs, synthesized using poly-lactic acid (PLA) or the copolymer of lactic and glycolic acid (PLGA), are used in the delivery of controlled drug release, as they are biodegradable, biocompatible and have been approved by the USFDA. In this article, we will be reviewing the synthesis of PLGA-based nanoparticles encapsulated or loaded with antibiotics, natural products, or metal ions and their antibacterial potential in various medical applications.

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

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

Influence of Tooth-Brushing on Early Healing after Access Flap Surgery: A Randomized Controlled Preliminary Study

In the present study, the clinical outcomes obtained using three different protocols of post-operative plaque control for the 4 weeks after surgery were compared. Thirty healthy subjects, presenting at least one periodontal pocket requiring resective surgery, were selected and randomly distributed to three different groups corresponding to respective post-surgical protocols: (A) toothbrushes + chlorhexidine + anti-discoloration system (ADS + CHX); (B) toothbrushes + chlorhexidine (CHX); (C) only toothbrushes. The full-mouth plaque score (FMPS), full-mouth bleeding score (FMBS), probing pocket depth (PPD), recession depth (REC), clinical attachment level (CAL), and bleeding on probing (BoP) were measured in six aspects per tooth (mesio-buccal (MB), buccal (B), disto-buccal (DB), disto-lingual (DL), lingual (L), and mesio-lingual (ML)) at baseline, 3 months, and 6 months after surgery. FMPS and FMBS did not significantly change (p > 0.05), whereas PPD and CAL significantly decreased, and REC significantly increased in all groups during the study (p < 0.05). Clinical results were satisfactory in all cases, with no significant differences between groups 3 months after surgery. Six months after surgery, only PPD-MB was significantly different in the three groups (p < 0.05). Nevertheless, this value was not clinically relevant because the value of PPD-B (about 2 mm) in group C was physiologic. The mechanical plaque control was proven to be fundamental and sufficient in all the six aspects per tooth to guarantee an excellent clinical outcome without the need of chemical plaque control.

The Effect of Locally Delivered Statins on Treating Periodontal Intrabony Defects: A Systematic Review and Meta-Analysis

BACKGROUND

Use of statins on adult patients with chronic periodontitis shows a positive effect on their periodontal status. However, effect of locally delivered statins on periodontal treatment has not yet been systematically analyzed. Hence, the present systematic review and meta-analysis aims to evaluate efficacy of statins on treating localized periodontal intrabony defects (IBDs).

METHODS

An electronic search of three databases (PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature) between January 1, 1965 and March 1, 2016, and a hand search of peer-reviewed journals for relevant articles were performed. Controlled randomized clinical trials (RCTs) and prospective studies with data on comparison between adjunctive locally delivered statin use to mechanical scaling and root planing (SRP) and placebo in each group, with minimum 10 participants and follow-up period of at least 6 months, were included.

RESULTS

Ten studies, eight RCTs and two prospective studies, were included. Each study included 15 to 105 patients between 25 and 55 years of age. Statistical results were recorded; weighted mean difference (WMD) and confidence interval (CI) were calculated; and meta-analyses were performed for defect fill, probing depth (PD) reduction, and clinical attachment level (CAL) gain in both statin and placebo/no treatment groups. Overall analysis of defect fill presented WMD of 1.37 mm (95% CI = 0.96 to 1.77; P <0.0001), PD reduction presented WMD of 1.76 mm (95% CI = 1.04 to 2.47; P <0.0001), and CAL gain presented WMD of 1.58 mm (95% CI = 0.89 to 2.28; P <0.0001). However, comparison presented considerable heterogeneity among studies.

CONCLUSIONS

This systematic review and meta-analysis find that adjunctive use of locally delivered statins to mechanical SRP is beneficial to increasing bone fill percentage. Improved inflammatory and bleeding control as well as PD reduction and CAL gain are possible advantages to using these drugs in treating patients with periodontal IBDs.

Periodontal conditions, oral Candida albicans and salivary proteins in type 2 diabetic subjects with emphasis on gender

Background

The association between periodontal conditions, oral yeast colonisation and salivary proteins in subjects with type 2 diabetes (T2D) is not yet documented. The present study aimed to assess the relationship between these variables in type 2 diabetic subjects with reference to gender.

Methods

Fifty-eight type 2 diabetic subjects (23 males and 35 females) with random blood glucose level ≥ 11.1 mmol/L were investigated. Periodontal conditions (plaque index [PI], bleeding on probing [BOP], probing pocket depth [PD] (4 to 6 mm and ≥ 6 mm), oral yeasts, salivary immunoglobulin (Ig) A, IgG and total protein concentrations, and number of present teeth were determined.

Results

Periodontal conditions (PI [p < 0.00001], BOP [p < 0.01] and PD of 4 to 6 mm [p < 0.001], salivary IgG (μg)/mg protein (p < 0.001) and salivary total protein concentrations (p < 0.05) were higher in type 2 diabetic females with Candida albicans (C. albicans) colonisation compared to males in the same group. Type 2 diabetic females with C. albicans colonisation had more teeth compared to males in the same group (p < 0.0001).

Conclusion

Clinical and salivary parameters of periodontal inflammation (BOP and IgG (μg)/mg protein) were higher in type 2 diabetic females with oral C. albicans colonisation compared to males in the same group. Further studies are warranted to evaluate the association of gender with these variables in subjects with T2D.

Chlorhexidine with an anti discoloration system after periodontal flap surgery: a cross-over, randomized, triple-blind clinical trial

The use of chlorhexidine (CHX) has been recommended for a number of clinical applications including plaque control in the post-operative period. However, the use of CHX is burdened by some side effects that could affect the compliance of the patient. The aim of this clinical trial was to evaluate the side effects, the staining in particular, the patient acceptance, and the efficacy of a 0.2% CHX mouthwash containing an anti discoloration system (ADS) compared with a 0.2% CHX alone, after periodontal flap surgery.

MATERIAL AND METHODS

This single-centre, cross-over, triple-blind randomized clinical trial was carried out on 48 consecutive patients. After periodontal flap surgery, the patients were prescribed to rinse two times per day for 1 min for 1 week with 10 ml of test or control CHX, contained in anonymous bottles coded K or M and assigned randomly. No brushing and interdental cleaning of the surgical area was allowed. At week 1, after suture removal, patients received full-mouth prophylaxis and were given a second anonymous bottle, reversing the products, with the same instructions as at baseline. Patients resumed tooth-brushing but not interdental cleaning. At the end of week 2, prophylaxis was repeated, mouth rinsing was discontinued and patients resumed normal oral hygiene. At weeks 1 and 2, the following variables were recorded: presence of pigmentation, gingival parameters at the surgically treated sites (gingival inflammation, tissue inflammation around the sutures, gingival swelling and presence of granulation tissue), patient perception and acceptance of the 2 mouthwashes.

RESULTS

Forty-seven patients completed the study. The difference between treatments related to gingival variables was not statistically significant. The test CHX caused consistently less pigmentations than the control CHX in all the evaluated areas of the dental surfaces (odds ratio (OR)=0.083 p<0.0001 in the incisal area, OR=0.036 p<0.0001 in the approximal area and OR=0.065 p<0.0001 in the gingival area). The CHX ADS was found to be more tolerated by patients than the control mouthwash and to cause less food alteration, less alterations to the perception of salt and to be less irritant for the oral tissues.

CONCLUSIONS

(1) CHX ADS caused less pigmentation, was burdened by less side effects and was more agreeable than the control CHX; (2) CHX ADS was as effective as CHX without ADS in reducing gingival signs of inflammation in the post-surgical early healing phase; (3) the use of CHX ADS could be of value in treatment protocols in which the patient compliance with a CHX mouthwash prescription is relevant.

A study into the plaque-inhibitory activity of experimental toothpaste formulations containing antimicrobial agents

BACKGROUND/AIMS

The use of specific antimicrobial agents in toothpastes may help reduce plaque and gingivitis. There would also appear to be some value in formulating products that contain combinations of such agents that may potentiate any activity present. The aims of this exploratory and pragmatic study were twofold: (1) Exploratory: to compare the effects on plaque re-growth of two zinc citrate/triclosan formulations, one of which contained bromochlorophene and hence demonstrate any additional beneficial effects produced by the addition of the phenol. (2) Pragmatic: to assess whether both pastes were significantly better than a benchmark control, proprietary fluoride toothpaste at inhibiting plaque formation.

METHODS

Following an initial prophylaxis to remove all plaque and calculus, toothpaste slurry rinses were used over a 96 h period by 24 volunteers, while omitting all other oral hygiene procedures. After 24, 48 and 96 h, plaque was measured by plaque area and by plaque index. For comparative purposes, a conventional commercial fluoride toothpaste rinse was also used as a benchmark control in this triple cross-over double-blind study.

RESULTS

With one exception, comparisons between the three pastes failed to show any significant differences in plaque accumulation at 96 h whether assessed by plaque index or area. At this time period, significantly more plaque was seen with the zinc citrate paste without bromochlorophene, compared with that of the control paste.

CONCLUSIONS

The findings from this study failed to demonstrate a plaque-inhibitory action from the two novel formulations beyond that of a conventional benchmark toothpaste, although overall levels of plaque formed by the volunteers, especially on the control paste were generally lower than in previous studies. Nevertheless, it remains to be determined whether the test formulations could exert a direct anti-inflammatory action against gingivitis by way of the triclosan delivery system. Neither test formulation was subsequently marketed.

Chlorhexidine with an Anti Discoloration System. A comparative study

Correct oral hygiene is believed to be the basis of primary and secondary prevention. Sometimes, using a toothbrush or other mechanical instruments for oral hygiene may be difficult and it may become necessary to use an antiseptic. Chlorhexidine is an essential component in many available preparations on sale, because of its marked antiseptic qualities. One of the most frequent side-effects is the appearance of stains on the teeth and mucous membranes, which particularly disturbs the patient. A new mouthwash containing chlorhexidine has recently become available, besides maintaining its antiseptic qualities, also avoids the side-effect of staining.

OBJECTIVES

The aim of this study was to check the capacity of the new mouthwash, which contains chlorhexidine and Anti Discoloration System (ADS), not only to prevent plaque formation like the other mouthwashes containing chlorhexidine but also to avoid staining that is one of the most frequent side-effects.

STUDY DESIGN

The comparative study was carried out on a sample of 15 patients treated with two mouthwashes both containing 0.2% chlorhexidine, but different in that the first does not contain ADS, which is instead present in the second, a new product. The results obtained show that in the 15 patients treated, there is no statistically significant difference in the ability of the mouthwash to prevent bacterial plaque, however evidence of the stain was much less with the new mouthwash.

Systemic antimicrobials in the treatment of chronic periodontal diseases: a dilemma

The use of systemic antimicrobials in the treatment of acute and chronic periodontal diseases must be viewed as a dilemma. On the one hand, the approach is attractive because of the microbial nature of periodontal diseases but, on the other hand, evidence of benefit of these agents is equivocal for the majority of periodontal diseases and antimicrobials have the potential to cause harm. The disadvantages of systemic antimicrobials can be grouped under the headings of allergic reactions, superinfection, toxicity, drug interactions, patient compliance and, perhaps of most widespread importance, bacterial resistance. Mechanical debridement methods, including drainage of pus for acute periodontal abscesses, should be considered the first line treatment for most periodontal diseases. Systemic antimicrobials should be considered as adjuncts to mechanical debridement methods and, in chronic disease, never used alone as they can predispose to abscess formation. Adjunctive systemic antimicrobials may be considered in acute disease where debridement or drainage of pus is difficult, where there is local spread or systemic upset. In chronic periodontal diseases, adjunctive antimicrobials should be considered in early onset or rapidly progressive disease or in advanced chronic adult disease where mechanical therapies have failed or surgery is not a preferred option. Inadequate oral hygiene and tobacco smoking are contraindications to the use of antimicrobials. The value of systemic antimicrobials, where other systemic risk factors co-exist, has still to be established. The role of microbial diagnosis and sensitivity testing for antimicrobial selection at this time must be questioned.

Bioerodible injectable poly(ortho ester) for tetracycline controlled delivery to periodontal pockets: preliminary trial in humans

The semisolid consistency of poly(ortho esters) (POEs) containing tetracycline free base allows direct injection in the periodontal pocket and shows sustained and almost constant in vitro release in phosphate buffer, pH 7.4 at 37 degrees C, for up to 14 days. Total polymer degradation concomitant with drug release was obtained. Formulations containing 10% or 20% (wt/wt) tetracycline were evaluated in a panel of 12 patients suffering from severe and recurrent periodontitis. In the first trial including 6 patients, single-rooted teeth and molar teeth with furcations were treated immediately after scaling and root planing. Patients tolerated both formulations well, experienced no pain during application, and showed no signs of irritation or discomfort during the observation period. However, retention of the formulation was minimal in this first study. An improved clinical protocol followed in the second study (stopping bleeding after scaling and root planning) prolonged the retention of the formulations in the inflamed periodontal pockets. For up to 11 days, tetracycline concentrations in the gingival crevicular fluid were higher than the minimum inhibitory concentration of tetracycline against most periodontal pathogens.

Adjunctive effects to non-surgical periodontal therapy of systemic metronidazole and amoxycillin alone and combined. A placebo controlled study

BACKGROUND AND AIM

Several studies have reported adjunctive benefits to scaling and root planing (SRP) of systemic amoxycillin and metronidazole in the treatment of periodontal diseases. To date no comparisons have been made of these antimicrobials alone or in combination. The aim of this study was to compare the adjunctive benefits to SRP of amoxycillin and metronidazole alone and combined.

METHODS

66 subjects <46 years of age with advanced chronic periodontal disease participated in this randomised, double blind, 4 parallel treatment group designed study. All subjects received quadrant SRP and then were prescribed amoxycillin capsules (250 mg) and metronidazole tablets (200 mg) (AM) or lactate capsules and metronidazole (PM) or amoxycillin and calcium lactate tablets (AP) or lactate and calcium lactate (PP). All medication was 3 of each per day for 7 days. Subgingival plaque samples were obtained and probing depth (PD), loss of attachment (LOA), bleeding on probing (BOP), suppuration (SUPP) and plaque (DEP) were recorded pre-treatment, 1, 3 and 6 months post-treatment.

RESULTS

Final group sizes were: AM=15, PM=16, AP=16 and PP=15. PD improved in all groups. Treatment effects were highly significantly different and always greatest in the AM and least in the PP groups. Benefits of PM and AP over PP were also noted. LOA improved in all groups and showed the same highly significant treatment differences, again favouring AM. BOP improved in all groups, particularly in AM compared to the other groups. SUPP improved in all groups and was virtually eradicated in AM with differences among treatments highly significant. DEP changed little in any group and there were no significant differences among groups. Microbiological data showed significant differences in favour of AM compared to PP and PM for total aerobes and anaerobes at 1 month. P. intermedia counts were always lower in active groups compared to PP and reached significance for AM and AP at 1 month and AM and PM at 3 months.

CONCLUSION

The significant differences among treatment groups and the overall trend in the data, in line with other studies, support the considerable adjunctive benefits to SRP of amoxycillin and metronidazole combined in the treatment of advanced chronic periodontal disease.

A study to assess the plaque inhibitory action of a new zinc citrate toothpaste formulation

BACKGROUND, AIMS

Zinc-citrate-containing toothpastes have previously been suggested to be of value at inhibiting plaque and gingival inflammation. Present formulations have included triclosan which is thought to contribute major antibacterial/antiplaque effects. Alternative antimicrobial agents and other ingredients such as oils could help to produce equally effective formulations. The aim of this study was to determine whether zinc citrate toothpastes containing bromochlorophene and a triglyceride oil (1% and 8%) could inhibit de novo plaque formation.

METHODS

Toothpaste slurry rinses were used over a 96-h period by 24 volunteers, whilst omitting all other oral hygiene procedures. For comparative purposes, a conventional commercial fluoride control toothpaste was also used in this triple cross-over double blind study.

RESULTS

After 24 and 48 h, there were no statistically significant differences in plaque between the 2 test pastes and the control paste, whether assessed using a plaque index or plaque area. After 96 h, however, a significant reduction in plaque score of 10.6% and 24.2%) in plaque area (both p < 0.001) was found for the zinc citrate/1% oil toothpaste compared to the control paste. In addition, at 96 h, the 8% oil toothpaste significantly reduced plaque score compared to the control paste by 4.3% (p = 0.029).

CONCLUSIONS

These findings would appear to warrant further investigation into the potential value of the zinc citrate/bromochlorophene/triglyceride formulation at inhibiting both plaque and gingival inflammation.

A study to assess the plaque inhibitory action of a newly formulated triclosan toothpaste

BACKGROUND/AIMS

Triclosan containing toothpastes have been noted for their potential to inhibit plaque and gingival inflammation. The aim of this study was to determine whether a toothpaste containing triclosan and an enhanced fluoride system would inhibit de novo plaque formation beyond that of a non-triclosan, conventional fluoride toothpaste.

METHODS

This study used a 4-day plaque regrowth model in which 24 volunteers used toothpaste rinses as the only form of oral hygiene. Following a prophylaxis and a single brushing with the toothpastes, 2x daily rinsing with toothpaste slurries was used over the following 96 h.

RESULTS

After 24 h, there was no difference in plaque area between the triclosan paste and its control paste. After 96 h, a reduction in plaque score of 5% was noted for the test toothpaste compared to the control paste which was statistically significant (p=0.028). For plaque area this reduction was increased to 16%, which was also significant (p=0.006).

CONCLUSIONS

These findings would appear to warrant further investigation into the potential value of the paste in inhibiting both plaque and gingivitis.

Controlled and targeted drug delivery strategies towards intraperiodontal pocket diseases

Advances in the understanding of the aetiology, epidemiology, pathogenesis and microbiology of periodontal pocket flora have revolutionized the strategies for the management of intraperiodontal pocket diseases. Intra-pocket, sustained release, drug delivery devices have been shown to be clinically effective in the treatment of periodontal infections. Several degradable and non-degradable devices are under investigation for the delivery of antimicrobial agents into the periodontal pocket including non-biodegradable fibres, films (biodegradable and non-biodegradable), bio-absorbable dental materials, biodegradable gels/ointments, injectables and microcapsules. With the realization that pocket bacteria accumulate as biofilms, studies are now being directed towards eliminating/killing biofilm concentrations rather than their planktonic (fluid phase) counterparts. Intraperiodontal pocket drug delivery has emerged as a novel paradigm for the future research. Similarly, bioadhesive delivery systems are explored that could significantly improve oral therapeutics for periodontal disease and mucosal lesions. A strategy is to target a wide range of molecular mediators of tissue destruction and hence arrest periodontal disease progression. Research into regenerating periodontal structures lost as a result of disease has also shown substantial progress in the last 25 years.

Evaluation of oral hygiene products: science is true; don't be misled by the facts

Most people in industrialized countries use oral hygiene products. When an oral health benefit is expected, it is important that sufficient scientific evidence exist to support such claims. Ideally, data should be cumulative derived from studies in vitro and in vivo. The data should be available to the profession for evaluation by publication in refereed scientific journals. Terms and phrases require clarification, and claims made by implication or derived by inference must be avoided. Similarity in products is not necessarily proof per se of efficacy. Studies in vitro and in vivo should follow the basic principles of scientific research. Studies must be ethical, avoid bias and be suitably controlled. A choice of controls will vary depending on whether an agent or a whole product is evaluated and the development stage of a formulation. Where appropriate, new products should be compared with products already available and used by the general public. Conformity with the guidelines for good clinical practice appears to be a useful way of validating studies and a valuable guide to the profession. Studies should be designed with sufficient power to detect statistically significant differences if these exist. However, consideration must be given to the clinical significance of statistically significant differences between formulations since these are not necessarily the same. Studies in vitro provide supportive data but extrapolation to clinical effect is difficult and even misleading, and such data should not stand alone as proof of efficacy of a product. Short-term studies in vivo provide useful information, particularly at the development stage. Ideally, however, products should be proved effective when used in the circumstances for which they are developed. Nevertheless, a variety of variable influence the outcome of home-use studies, and the influence of the variable cannot usually be calculated. Although rarely considered, the cost-benefit ratio of some oral hygiene products needs to be considered.

Relationship of serotype, leukotoxin gene type and lysogeny in Actinobacillus actinomycetemcomitans to periodontal disease status

Actinobacillus actinomycetemcomitans has been associated with different forms of periodontitis, particularly with localized juvenile periodontitis (LJP). The bacterium possesses several virulence factors which have been shown to interact with the host immune system. Among these factors, leukotoxin, surface antigens (serotype) and bacteriophages have been suggested directly or indirectly to influence the course of infection. However, few studies have been able to show associations between these factors and periodontal disease, alone or in combination. Thus, the purpose of the present study was to investigate possible correlations between periodontal disease status and selected virulence factors (serotype, presence of bacteriophages, and the presence of a 530 bp deletion in the promoter region of the leukotoxin gene). 36 subjects took part in the study. Serotype c was the most frequently found serotype among periodontally affected subjects, although serotypes a and b were also present. 27 out of 36 strains harbored bacteriophages, and there was strong evidence that some of the bacteriophages were different from the previously characterized phi Aa phage. A. actinomycetemcomitans containing the F-fragment phage were more frequently associated with periodontal disease. Five strains, all serotype b, 3 from LJP patients and 2 from healthy subjects, showed a 530-bp deletion in the promoter region of the leukotoxin gene.