Microbial succession in recolonizing deep periodontal pockets after a single course of supra- and subgingival debridement

New Frontiers on Adjuvants Drug Strategies and Treatments in Periodontitis

Causes of the progression of periodontitis such as an imbalance between the immune response by the host by the release of inflammatory mediators in the response of the oral pathogenic dysbiotic biofilm have been identified. New insights on specific cell signaling pathways that appear during periodontitis have attracted the attention of researchers in the study of new personalised approaches for the treatment of periodontitis. The gold standard of non-surgical therapy of periodontitis involves the removal of supra and subgingival biofilm through professional scaling and root planing (SRP) and oral hygiene instructions. In order to improve periodontal clinical outcomes and overcome the limitations of traditional SRP, additional adjuvants have been developed in recent decades, including local or systemic antibiotics, antiseptics, probiotics, anti-inflammatory and anti-resorptive drugs and host modulation therapies. This review is aimed to update the current and recent evolution of therapies of management of periodontitis based on the adjunctive and target therapies. Moreover, we discuss the advances in host modulation of periodontitis and the impact of targeting epigenetic mechanisms approaches for a personalised therapeutic success in the management of periodontitis. In conclusion, the future goal in periodontology will be to combine and personalise the periodontal treatments to the colonising microbial profile and to the specific response of the individual patient.

Interface between Periodontal Tissues and Dental Materials: Dynamic Changes and Challenges

Periodontal tissues play an important role in the correct aesthetics, function and comfort of the dentition [...]

A re-evaluation of scaling and root planing

BACKGROUND

Extensive reviews on the role of scaling and root planing (SRP) in the treatment of periodontitis have been previously published. This commentary will address the importance of subgingival calculus in the progression and treatment of periodontitis and addresses factors that make the execution of a "definitive" SRP a critical part of therapy.

METHODS

A search for articles, using keywords relevant to the subject , (e.g., periodontitis, dental scaling, root planing, dental calculus, biofilm, inflammation) was conducted using PubMed, Ovid Medline, Cochrane Reviews and the ADA Center for Evidence Based Dentistry data bases. Additionally, references cited in relevant articles were also considered.

RESULTS

Surfaces of subgingival calculus are covered with a biofilm of metabolically active bacteria. Periodontal inflammation is clearly related to the presence of calculus and biofilm. The primary goal of SRP is removal of subgingival calculus and biofilm deposits to create a biologically compatible root surface and reduce the inflammatory burden. Current evidence suggests that inflammation associated with periodontal infections affects both the immediate oral environment and the patient's systemic health.

CONCLUSION

SRP is still critical to the treatment of periodontitis. SRP involving deep probing depths (≥ 5 mm) and root surfaces with anatomical and surface irregularities, regardless of the type of instrumentation, requires time, exceptional skill and perseverance, and patient compliance with periodontal maintenance. Sites with persistent nonresponding probing depths and signs of inflammation following a definitive SRP, should be considered for surgical intervention.

Management of generalized severe periodontitis using full-mouth disinfection and systemic antibiotics in a leukemic patient before stem cell transplantation: A case report

The full-mouth disinfection protocol implemented in this case can be integrated into established protocols for treating severe periodontitis in the context of a hematological malignancy, without any interference with the cancer treatment.

Understanding the microbial components of periodontal diseases and periodontal treatment-induced microbiological shifts

In the mid-1960s the microbial aetiology of periodontal diseases was introduced based on classical experimental gingivitis studies . Since then, numerous studies have addressed the fundamental role that oral microbiota plays in the initiation and progression of periodontal diseases. Recent advances in laboratory identification techniques have contributed to a better understanding of the complexity of the oral microbiome in both health and disease. Modern culture-independent methods such as human oral microbial identification microarray and next-generation sequencing have been used to identify a wide variety of microbial taxa residing in the gingival sulcus and the periodontal pocket. The first theory of the 'non-specific plaque' hypothesis gave rise to the 'ecological plaque' hypothesis and more recently to the 'polymicrobial synergy and dysbiosis hypothesis'. Periodontitis is now considered to be a multimicrobial inflammatory disease in which the various bacterial species within the dental biofilm are in a dysbiotic state and this imbalance favours the establishment of chronic inflammatory conditions and ultimately the destruction of tooth-supporting tissues. Apart from the known putative periodontal pathogens, the whole biofilm community is now considered to play a role in the establishment of inflammation and the initiation and progression of periodontitis in a susceptible host. Treatment is unlikely to eliminate putative pathogens but, when it is thoroughly performed it has the potential to establish a healthy ecosystem by altering the microbial community in numbers and composition and also contribute to the maturation of the host immune response.

Does chlorhexidine improve outcomes in non-surgical management of peri-implant mucositis or peri-implantitis?: a systematic review and meta-analysis

BACKGROUND

With greater number of implants being placed in clinical practice, incidence of peri-implant diseases are on the rise. It is not known whether chlorhexidine (CHX) improves outcomes in the management of peri-implant diseases. The aim of this systematic review and meta-analysis was to evaluate the role of CHX in improving outcomes with non-surgical management of peri-implant mucositis and peri-implantitis.

MATERIAL AND METHODS

An electronic search of PubMed, Scopus, Embase, and CENTRAL (Cochrane Central Register of Controlled Trials) databases up to 1st August 2019 was carried out to search for studies evaluating the efficacy of CHX for non-surgical management of peri-implant diseases.

RESULTS

Seven studies were included. Four studies evaluated the role of CHX in peri-implant mucositis and three in peri-implantitis. Oral prophylaxis with mechanical cleansing of implant surface prior to CHX use was carried out in all seven studies. Meta-analysis indicated that use of CHX did not improve probing depths in peri-implant mucositis (SMD= 0.11; 95% CI: -0.16 to 0.38; p=0.42, I2= 0%). Similarly, CHX did not significantly reduce probing depths in patients with peri-implantitis (MD= 1.57; 95% CI: -0.88 to 4.0; p=0.21, I2= 98%). Results on the efficacy of CHX in reducing BOP in peri-implantitis are conflicting.

CONCLUSIONS

Results of our study indicate that adjunctive therapy with CHX may not improve outcomes with non-surgical management of peri-implant mucositis. Conclusions with regards to its role in non-surgical management of peri-implantitis cannot be drawn. There is a need for more homogenous RCTs with large sample size to define the role of CHX in non-surgical management of peri-implant mucositis and peri-implantitis.

Twenty Years of Full-Mouth Disinfection: The Past, the Present and the Future

Background:

Conventional periodontal treatment, performed quadrant by quadrant in multiple visits, was re-evaluated in the early 1990s when the full-mouth disinfection concept was introduced. Over the years, several modifications to the full-mouth disinfection approach have been suggested.

Objective:

The purpose of this article is to review the evolution of full-mouth disinfection during the past 20 years, to specify its indications and to consider the prospects for this approach.

Materials and Methods:

An electronic and manual search of the literature, ending in December 2016, was performed by two independent researchers. Only pivotal studies and randomized controlled clinical trials published in the English language that evaluated a new approach to full-mouth disinfection were selected.

Results:

According to the studies included in our analysis (21 articles), several modified full-mouth disinfection protocols have been designed including: full-mouth treatment without chlorhexidine, the extension of hygiene methods and an increase in the duration of post-treatment chlorhexidine use, the replacement of chlorhexidine with other antiseptics, supplementation with antibiotics or probiotics, full-mouth antimicrobial photodynamic therapy and one-stage full-mouth disinfection combined with a periodontal dressing.

Conclusion:

Since 1995, several modifications have been suggested to improve the effectiveness of full-mouth disinfection. The majority of the studies demonstrate that the results obtained with full-mouth disinfection and its variants are equivalent to each other and to those obtained with the conventional quadrant method. Currently, the selection of this technique remains empirical and depends on the preferences of the practitioner and the patient. In the future, a patient-centered approach should be the best indication for the use of this technique.

Nonsurgical and surgical treatment of periodontitis: how many options for one disease?

Treatment of periodontitis aims at preventing further disease progression with the intentions to reduce the risk of tooth loss, minimize symptoms and perception of the disease, possibly restore lost periodontal tissue and provide information on maintaining a healthy periodontium. Therapeutic intervention includes introduction of techniques to change behavior, such as: individually tailored oral-hygiene instructions; a smoking-cessation program; dietary adjustment; subgingival instrumentation to remove plaque and calculus; local and systemic pharmacotherapy; and various types of surgery. No single treatment option has shown superiority, and virtually all types of mechanical periodontal treatment benefit from adjunctive antimicrobial chemotherapy. Periodontal treatment, because of the chronic nature of periodontitis, is a lifelong commitment to intricate oral-hygiene techniques, which, when properly implemented, will minimize the risk of disease initiation and progression.

Comparison of full-mouth disinfection and quadrant-wise scaling in the treatment of adult chronic periodontitis: a systematic review and meta-analysis

Scaling and root planing are widely considered as effective methods for treating chronic periodontitis. A meta-analysis published in 2008 showed no statistically significant differences between full-mouth disinfection (FMD) or full-mouth scaling and root planing (FMS) and quadrant scaling and root planing (Q-SRP). The FMD approach only resulted in modest additional improvements in several indices. Whether differences exist between these two approaches requires further validation. Accordingly, a study was conducted to further validate whether FMD with antiseptics or FMS without the use of antiseptics within 24 h provides greater clinical improvement than Q-SRP in patients with chronic periodontitis. Medline (via OVID), EMBASE (via OVID), PubMed and CENTRAL databases were searched up to 27 January 2015. Randomized controlled trials comparing FMD or FMS with Q-SRP after at least 3 mo were included. Meta-analysis was performed to obtain the weighted mean difference (WMD), together with the corresponding 95% confidence intervals. Thirteen articles were included in the meta-analysis. The WMD of probing pocket depth reduction was 0.25 mm (p < 0.05) for FMD vs. Q-SRP in single-rooted teeth with moderate pockets, and clinical attachment level gain in single- and multirooted teeth with moderate pockets was 0.33 mm (p < 0.05) for FMD vs. Q-SRP. Except for those, no statistically significant differences were found in the other subanalyses of FMD vs. Q-SRP, FMS vs. Q-SRP and FMD vs. FMS. Therefore, the meta-analysis results showed that FMD was better than Q-SRP for achieving probing pocket depth reduction and clinical attachment level gain in moderate pockets. Additionally, regardless of the treatment, no serious complications were observed. FMD, FMS and Q-SRP are all effective for the treatment of adult chronic periodontitis, and they do not lead to any obvious discomfort among patients. Moreover, FMD had modest additional clinical benefits over Q-SRP, so we prefer to recommend FMD as the first choice for the treatment of adult chronic periodontitis.

Salivary carriage of periodontal pathogens in generalized aggressive periodontitis families

BACKGROUND

Generalized aggressive periodontitis (GAP) is a multifactorial disease that shows a specific microbial profile and a familial aggregation.

AIM

This study evaluated the salivary microbial profile of families with a history of GAP and compared them with healthy families.

DESIGN

Fifteen families with parents presenting periodontal health and 15 with parents with a history of GAP were selected. Each family had a child aged 6-12 years. Stimulated saliva was collected from all subjects, and Porphyromonas gingivalis (Pg), Tannerella forsythia (Tf), and Aggregatibacter actinomycetemcomitans (Aa) amounts were determined.

RESULTS

Children of GAP families showed higher detection of Aa (90%) than children of healthy families (45%) (P < 0.05). Parents with GAP showed a Pg salivary concentration statistically higher than that of healthy parents (P < 0.05).Children of GAP families, however, exhibited similar Pg concentration than healthy children (P > 0.05). Tf amounts did not differ either in parents or in children (P > 0.05) The infection risk calculation indicates that children who have one parent who is positive for Aa have 16.3 times (95% CI 3.1-87.2) more risk of being infected with Aa (P < 0.05) than children from an Aa-negative family.

CONCLUSION

It may be concluded that children of parents with aggressive periodontitis have higher levels and higher risk of Aa infection.

Do probiotics offer opportunities to manipulate the periodontal oral microbiota?

BACKGROUND

As in other fields of healthcare, probiotics have been introduced for prevention and treatment of periodontal diseases.

OBJECTIVE

This review was initiated to explore whether the use of probiotics can influence the periodontal microbiota and periodontal health.

MATERIALS AND METHODS

Literature on the mode of action of oral probiotics was reviewed and a systematic review was performed on the microbiological and clinical effects of oral probiotics on periodontal health.

RESULTS

Three animal and 11 in vivo human studies were retrieved. Six studies reported on microbiological effects whereas eight studies report on clinical effects. Seven studies were performed on healthy or gingivitis patients and four studies on periodontitis patients. Many of the retrieved studies are pilot in nature and with low quality. The high degree of heterogeneity between studies hampered analysis.

CONCLUSION

Taking into consideration all limitations, the currently available data indicate an effect of probiotics on the oral microbiota and a more limited effect on clinical periodontal outcome measures. However, there is an urgent need for properly conducted clinical trials where probiotics are used as adjuncts to standard periodontal care, similar to antibiotics, using probiotic strains with, at least at an in vitro level, proven periodontal probiotic effects.

How beneficial is bacterial prophylaxis to periodontal health?

The term "probiotics" has become common among general practitioners. There has been an explosion in the interest regarding this topic, which is reflected in the number of scientific publications. The World Health Organization defined probiotics as: "Living microorganisms which when administered in adequate amount confirms a health benefit on the host". Probiotics have been studied extensively in the gastrointestinal tract for their health-promoting effects and have shown promising results. However, in recent times, probiotics have also been used in periodontal health and have shown promising results in controlling gastrointestinal tract infections. Probiotics have potential, but as with many other clinical situations, multicenter or randomized, controlled studies on humans are still required before they can be recommended as prophylaxis for caries or periodontal disease. In the present study, we review the effects of probiotics on maintaining periodontal health. Relevant studies were identified from 1970 to February 2010 using Old Medline, Cochrane Library, and Google Scholar.

Clinical and microbiologic follow-up evaluations after non-surgical periodontal treatment with erbium:YAG laser and scaling and root planing

BACKGROUND

This study compared erbium-doped: yttrium, aluminum, and garnet (Er:YAG) laser irradiation (100 mJ/pulse; 10 Hz; 12.9 J/cm(2)) with or without conventional scaling and root planing (SRP) to SRP only for treatment of periodontal pockets.

METHODS

Nineteen patients with pockets from 5 to 9 mm were included. In a split-mouth design, each site was allocated to a treatment group: 1) SRPL, SRP and laser; 2) L, laser; 3) SRP, SRP only; and 4) C, no treatment. Clinical parameters of probing depth (PD), gingival recession, and clinical attachment level (CAL) were evaluated at baseline and 1, 3, 6, and 12 months after treatment. Visible plaque index, gingival bleeding index (GI), bleeding on probing (BOP), and subgingival plaque samples were also measured 12 days postoperatively, in addition to the above mentioned months. Intergroup and intragroup statistical analyses were performed (P <0.05).

RESULTS

GI decreased for SRPL and increased for L, SRP, and C (P <0.05) 12 days postoperatively and decreased for SRPL and SRP (P <0.05) 3, 6, and 12 months after baseline; BOP and PD decreased for all treated groups (P <0.01) 3, 6, and 12 months after treatment. CAL gain was significant for SRPL, L, and SRP (P <0.05) 3, 6, and 12 months postoperatively. SRPL and L presented a significant reduction in the percentage of sites with bacteria 6 and 12 months after treatment (P <0.05).

CONCLUSION

Non-surgical periodontal treatment with Er:YAG laser may be an alternative treatment for reduction and control of the proliferation of microorganisms in persistent periodontitis.

Doshi Y, Siddayya Kulkarni S, Kumar Purbay S. Endodontic treatment in submerged roots: a case report

Alveolar ridge resorption has long been considered an unavoidable consequence of tooth extraction. While the extent and pattern of resorption is variable among individuals, there is a progressive loss of ridge contour as a result of physiologic bone remodeling. Even today, with best modalities of tooth preservation, there is a group of elderly individuals who do not benefit from modern preventive practices and who now present a dilemma in terms of maintaining the masticatory apparatus necessary for nutrition. Even with excellent dental care, such patients experience abrasion of the natural tooth crowns with age, and embedded roots are left within the alveolar bone. According to old concepts of dental care, extraction of these roots would have been recommended, but today's goal of excellence in endodontics dictates otherwise. We report a case in which vital and non-vital root submergence was carried out to prevent alveolar ridge reduction.

Microbiological effect of the use of an ultrasonic device and iodine irrigation in patients with severe chronic periodontal disease: a randomized controlled clinical study

OBJECTIVE

Instrumentation of the subgingival area is aimed at removing as much as possible of the bacterial biofilm and subgingival calculus. Since mechanical root debridement is a technically demanding procedure, antiseptics and antibiotics delivered either locally or systemically have been used as adjunct to scaling and root-planning procedures in order to control the subgingival biofilm and thereby enhance the treatment outcome. Our aim was to study the microbiological effect of ultrasonic debridement with or without povidone-iodine (PVP-iodine) 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 with the use of an ultrasonic device was effective in reducing the analyzed putative periodontal bacteria. No statistically significant difference between ultrasonic+saline and ultrasonic+PVP-iodine was found.

CONCLUSIONS

Ultrasonic debridement reduced the periodontal markers in patients with severe chronic periodontitis. The reduction was selective. A concentration of 0.5% PVP-iodine did not add any anti-microbiological effect compared to ultrasonic debridement alone.

Tooth loss in treated periodontitis patients responsible for their supportive care arrangements

AIM

To identify risk indicators associated with tooth loss and periodontitis in treated patients responsible for arranging supportive periodontal care (SPC).

MATERIALS AND METHODS

Ninety-seven Chinese subjects (34-77 years) who showed favourable responses to periodontal therapy provided in a teaching hospital 5-12 years previously were recalled. They were advised to seek regular SPC on discharge. Background information, general health status, smoking, oral hygiene habits, follow-up dental care, tooth loss, and periodontal parameters were investigated. Multiple regression analysis was performed.

RESULTS

Two hundred and fifty-six teeth had been lost, 195 because of self-reported periodontal reasons. Up to 26.8% sites were with pockets > or =6 mm. Positive correlations were found between total/periodontal tooth loss and (i) smoking pack-years, (ii) time spent on oral hygiene, (iii) years since therapy's conclusion, (iv) age, and negative correlations with (v) inter-dental brush use, and (vi) education levels. Tooth loss by arch was correlated with wearing of removable partial denture in that arch. Percentage sites with pockets > or =6 mm were significantly negatively correlated with percentage sites without bleeding on probing.

CONCLUSIONS

Smokers, more elderly patients, removable partial denture wearers, and patients with lower education levels or not using inter-dental brushes ought to be targeted for clinic-based SPC.

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.

Immediate effect of instrumentation on the subgingival microflora in deep inflamed pockets under strict plaque control

OBJECTIVE

To investigate (1) reduction in the number of microorganisms obtained directly after subgingival instrumentation, (2) rate of bacterial re-colonization during 2 weeks, under supragingival plaque-free conditions.

MATERIALS AND METHODS

Effects of subgingival instrumentation were measured at one deep pocket in 22 patients (11 smokers and 11 non-smokers). Immediately after initial therapy, experimental sites, under strict plaque control, were instrumented subgingivally. Microbiological evaluation was performed at pre-instrumentation, immediate post-instrumentation and 1 and 2 weeks post-instrumentation.

RESULTS

Mean total anaerobic colony forming units (CFUs) dropped from 3.9 x 10(6) before to 0.09 x 10(6) immediately following instrumentation. Significant reductions were found for Tannerella forsythia, Micromonas micros, Fusobacterium nucleatum and spirochetes. Significant reductions were not observed for Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia and Campylobacter rectus. Except for spirochetes, no reduction in prevalence of specific periodontal bacteria was found immediately after instrumentation. During follow-up, mean total CFU tended to increase. Prevalence of periodontal bacteria further reduced. No effect of smoking was found.

CONCLUSION

Results indicate that subgingival mechanical cleaning in itself, has a limited effect, in actually removing bacteria. The subsequent reduction in prevalence of specific periodontal bacteria shows that it is apparently difficult for these species to survive in treated pockets.

Detection of periodontopathic bacteria and an oxidative stress marker in saliva from periodontitis patients

We assessed the salivary levels of periodontopathic bacteria and 8-hydroxydeoxyguanosine (8-OHdG) in patients with periodontitis. The salivary levels of Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, and Tannerella forsythia (formerly Bacteroides forsythus) were assessed using real-time polymerase chain reaction. The 8-OHdG levels were determined using an enzyme-linked immunosorbent assay. The salivary levels of 8-OHdG, P. gingivalis, and T. forsythia in the periodontitis patients were significantly higher than those in healthy subjects. By contrast, the A. actinomycetemcomitans level in healthy subjects was higher than that in periodontitis patients. 8-OHdG was significantly correlated with P. gingivalis. Statistically significant decreases in the levels of P. gingivalis, probing depth, bleeding on probing, and 8-OHdG were observed after initial periodontal treatment. These results suggest that the 8-OHdG levels in saliva reflect the load of periodontal pathogens. 8-OHdG could be a useful biomarker for assessing periodontal status accurately, and for evaluating the efficacy of periodontal treatment.

Microbiological Changes With the Use of Locally Delivered Doxycycline in the Periodontal Treatment of Smokers

BACKGROUND

The aim of this study was to evaluate the effect of the association of locally delivered doxycycline 10% and scaling and root planing in the subgingival plaque of smokers.

METHODS

Sixteen smokers with chronic periodontitis and a minimum of four pockets (> or = 5 mm) on anterior teeth that bled on probing were selected. Patients were randomly assigned to one of the following groups: scaling and root planing (SRP) or scaling and root planing followed by local application of doxycycline (SRP-D). Subgingival plaque samples were collected from initially moderate (5 to 6 mm) and deep (> or = 7 mm) pockets at baseline and 3 months. Polymerase chain reaction (PCR) analysis was used to detect the frequency of Actinobacillus actinomycetemcomitans (Aa), Porphyromonas gingivalis (Pg), and Tannerella forsythensis (Tf).

RESULTS

No statistically significant difference was found in the reduction of Aa in either the SRP-D or SRP group (P > 0.05). The reduction in Tf, Pg, and Tf + Pg was statistically significant for SRP-D only (P = 0.016, 0.027, and 0.027, respectively). The proportion of sites free of Tf at 3 months was 53% for SRP-D and 9% for SRP (P = 0.02). For Pg, this proportion was 82% and 40%, respectively (P = 0.05).

CONCLUSION

The use of locally delivered doxycycline may promote the elimination of T. forsythensis and P. gingivalis in a greater proportion of sites compared to conventional scaling and root planing in smokers.

Glyceraldehyde-3-phosphate dehydrogenase of Streptococcus oralis functions as a coadhesin for Porphyromonas gingivalis major fimbriae

Cohesive interactions between Porphyromonas gingivalis and plaque-forming bacteria, such as Streptococcus oralis, are considered to play an important role in the colonization of P. gingivalis in periodontal sites. Although P. gingivalis fimbriae have been reported to mediate coaggregation with S. oralis, the S. oralis molecule involved has not been identified. We identified the coadhesin of S. oralis ATCC 9811 and purified it by affinity column chromatography. We found that the molecular mass of the purified protein was approximately 40 kDa. Dot blot and Western blot assays showed binding of the 40-kDa protein to P. gingivalis fimbriae. Further, turbidimetric assays showed that the coadhesin inhibited coaggregation between P. gingivalis and S. oralis in a dose-dependent manner. Analyses of the amino-terminal sequences of the protein and its lysyl endopeptidase-cleaved fragments revealed that the coadhesin was identical to glyceraldehyde-3-phosphate dehydrogenase (GAPDH). Next, we cloned the gene that encodes S. oralis GAPDH and found that the sequence had a high degree of homology with the sequences of GAPDHs of various bacteria, including Streptococcus gordonii and Fusobacterium nucleatum. To confirm the contribution of S. oralis GAPDH to the interaction with P. gingivalis, a recombinant GAPDH protein was generated in Escherichia coli; this protein bound to P. gingivalis fimbriae and had an inhibitory effect on coaggregation. These results suggest that S. oralis GAPDH functions as a coadhesin for P. gingivalis fimbriae. In addition, considering the high degree of homology of the GAPDHs of various bacteria, those of other plaque-forming bacteria also may contribute to the colonization of P. gingivalis.

Position PaperPeriodontal Maintenance

The purpose of this paper is to provide an overview of the role of periodontal maintenance procedures in the treatment of periodontal diseases. Reliance on this position paper in patient management will not guarantee a successful outcome, as periodontal diseases typically involve complex causes and symptoms. Ultimately, decisions regarding the diagnosis, treatment, and management of disease, as well as subsequent preventive therapy, must be made by the treating practitioner based on specific circumstances presented by the patient.

Quantification and localization of platelet-derived growth factor in gingiva of periodontitis patients

BACKGROUND

Platelet-derived growth factor (PDGF) is a mitogen and chemoattractant for cells of mesenchymal origin. Over-expression of PDGF-B can promote formation of inflammatory lesions in the lungs of transgenic mice. Moreover, continuous exposure to PDGF inhibits collagen production by osteoblastic cells. Thus, the expression of mitogenic factors in an inflammatory context may limit the differentiated function of cells, and thereby limit repair following periodontal attachment and bone loss. The goals of the present study were to test whether PDGF is present at increased levels in inflamed gingiva and to localize its expression in gingival biopsies from individuals with chronic periodontitis.

METHODS

Tissues obtained during therapeutic procedures from inflamed and control sites of 9 patients were subjected to protein extraction, descriptive histology by hematoxylin and eosin, or immunohistochemistry assays. Quantification was calculated with an enzyme-linked immunosorbent assay (ELISA) kit specific for PDGF-AB. For the immunolocalization, anti-PDGF-A and -B antibodies were employed.

RESULTS

PDGF concentration in the total protein extract was approximately 3 times higher in the inflamed sites (0.60 +/- 0.18 ng/mg versus 0.20 +/- 0.05 ng/mg; P = 0.03). Immunohistochemistry revealed prominent expression of PDGF in the pocket epithelial cells as well as the adjacent connective tissue. In contrast, little or no expression was detected in control biopsies devoid of the pocket epithelium and granulation tissue.

CONCLUSIONS

PDGF is present in increased levels in the human inflamed gingiva and is mainly localized to the pocket epithelium. It is possible that chronic expression of PDGF contributes to the inflammatory changes that occur during periodontal diseases.

Clinical significance of non-surgical periodontal therapy: an evidence-based perspective of scaling and root planing

Analysis of Egyptian hieroglyphics and medical papyri indicate that non-surgical periodontal treatment was common 3000-4000 years ago. Even today, scaling and root planing (SRP) remains an essential part of successful periodontal therapy. The collective evidence from numerous clinical trials reveals a consistency of clinical response in the treatment of chronic periodontitis by SRP using manual, sonic, or ultrasonic instrumentation. Thus, SRP remains the 'gold standard' to which more recently developed therapeutic modalities must be compared. Inherent to the clinical evaluation of SRP are such concerns as manual versus sonic and ultrasonic instrumentation, control of sub-gingival bacterial populations, removal of calculus, root smoothness and changes in various clinical parameters, e.g. probing depth, attachment levels, bleeding on probing and gingival inflammation. Lastly, an abbreviated discussion is presented on a relatively new paradigm of complete mouth 'disinfection' in a compressed time-frame that includes SRP as a significant component of the treatment regimen.

Ethyl cellulose and polyethylene glycol-based sustained-release sparfloxacin chip: an alternative therapy for advanced periodontitis

This study reports the development of a sustained-release system of sparfloxacin for use in the treatment of periodontal disease. A sustained-release sparfloxacin device was formulated, based on ethyl cellulose (EC) 10 cps, polyethylene glycol (PEG) 4000, and diethyl phthalate (DEPh). It will hereafter be called the sparfloxacin chip (SRS chip). The chip has dimensions of 10 mm length, 2 mm width, and 0.5 mm thickness. The in vitro drug release pattern and clinical evaluation of the formulations were studied. Reports of the short-term clinical study show that the use of the SRS chip may cause complete eradication of the pathogenic bacteria in the periodontal pockets of patients who have chronic generalized periodontitis. In this clinical study, the baseline and follow-up measurements of various clinical indices, such as oral hygiene index(es), plaque index, sulcular depth component of periodontal disease index, gingival crevicular fluid flow measurement, and dark field microscopic examinations of oral pathogens in plaque samples were studied. Significant improvements were observed in many parameters of the treatment group compared with the placebo group.

Antimicrobial effects of mechanical debridement

Self-performed plaque removal using manual or powered toothbrushes and interdental cleaning devices is improved in subjects that have received oral hygiene instructions. Personal oral hygiene coupled with regular professional supragingival debridement may further improve the level of plaque control but still fails to achieve a completely plaque-free dentition. Both patient-performed and professional supragingival plaque removal has an effect on subgingival microbiota that is limited to the marginal 3 mm of the periodontal pocket. At sites with 4 mm or more of probing depth, only subgingival scaling leads to a significant reduction of the bacterial load. The subgingival microflora can be further reduced by pocket elimination surgery. Due to the sequence of bacterial recolonization that occurs following mechanical debridement, the level of periodontal pathogens such as B. forsythus, P. gingivalis and T. denticola may be reduced for several months. Mechanical debridement also influences the patient's immune system response, resulting in antibody titers and avidity against periodontal pathogens. As a basis for the restoration and maintenance of periodontal health, repeated subgingival debridement, as performed in supportive periodontal therapy, can reduce the number and proportions of periodontopathogenic bacteria in subgingival plaque. However, intensive subgingival scaling and root planing should be avoided in sites that probe less than 3 mm, as this is likely to traumatize the periodontium and cause attachment loss.

The effect of postsurgical antibiotics on the healing of intrabony defects following treatment with enamel matrix proteins

BACKGROUND

Regenerative treatment with enamel matrix proteins has been shown to promote healing in intrabony defects. However, up to now various postoperative antibiotic regimens have been used in combination with enamel matrix proteins and therefore it cannot be excluded that the results may also be attributable to the effect of the antibiotic treatment. The aim of this randomized, controlled, blinded, clinical investigation was to determine the effect of postsurgical administration of antibiotics on the healing of intrabony periodontal defects treated with enamel matrix proteins.

METHODS

Thirty-four patients each of whom exhibited one deep intrabony defect were randomly treated with either enamel matrix proteins plus antibiotics (test: EMD + AB) or with enamel matrix proteins alone (control: EMD). The antibiotic regimen consisted of a combination of 3 x 375 mg amoxicillin and 3 x 250 mg metronidazole daily for 7 days. The following parameters were recorded at baseline and at 1 year by the same calibrated and blinded investigator: plaque index (PI), gingival index (GI), bleeding on probing (BOP), probing depth (PD), gingival recession (GR), and clinical attachment level (CAL). Power analysis to determine superiority of antibiotic treatment showed that the available sample size would yield 85% power to detect a 1 mm difference.

RESULTS

No statistically significant differences in any of the investigated parameters between the 2 groups were observed at baseline. No serious adverse events such as allergic reactions or abscesses after any of the treatments were observed during the entire study period. The results have shown that in the EMD + AB group the PD decreased from 9.1 +/- 1.5 mm to 4.5 +/- 1.1 mm (P<0.0001) and the CAL changed from 11.0 +/- 1.6 mm to 7.5 +/- 1.4 mm (P<0.0001). In the EMD group the PD decreased from 9.0 +/- 1.7 mm to 4.3 +/- 1.7 mm (P <0.0001) and the CAL changed from 10.6 +/- 1.6 mm to 7.3 +/- 1.5 mm (P <0.0001). There were no significant differences in any of the investigated parameters between the 2 groups.

CONCLUSIONS

It can be concluded that the systemic administration of amoxicillin and metronidazole adjacent to the use of EMD for the surgical treatment of intrabony periodontal defects does not produce statistically superior PD reduction and CAL gain when compared to treatment with EMD alone. Hence, the present results do not support the routine administration of amoxicillin and metronidazole following regenerative treatment with EMD.

The clinical and microbiological effects of systemic ornidazole in sites with and without subgingival debridement in early-onset periodontitis patients

BACKGROUND

The purpose of this study was to evaluate the clinical and microbiological effects of systemic ornidazole (ORN) in sites with or without subgingival debridement in early-onset periodontitis (EOP) patients.

METHODS

Two pooled bacterial samples consisting of 4 sites each (scaled and non-scaled sites) were obtained from 30 individuals exhibiting EOP. All patients received oral hygiene instruction (OHI), supragingival scaling and ORN. Subgingival scaling and root planing (SRP) was carried out only in scaled sites. Bacterial samples were taken at baseline (BL) and 1 week and 2, 6, and 12 months after systemic ornidazole administration (500 mg/bid for 7 days). One more sample was taken at scaled sites, one week after SRP.

RESULTS

One week following SRP (scaled sites) Gram-negative facultative and anaerobic rods were significantly reduced while Gram-positive facultative cocci were significantly increased. After ORN administration, P. gingivalis, P. denticola, P. intermedia, B. forsythus, C. rectus, and S. sputigena were no longer detectable in either scaled or non-scaled sites. A statistically significant long-term (2, 6, and 12 months) reduction of P. gingivalis, P. intermedia, P. loescheii, B. forsythus, and C. rectus and a pronounced increase of S. milleri, S. oralis, and S. sanguis counts in both scaled and non-scaled sites were detected in comparison to baseline. A sustained reduction of bleeding tendency and of probing depth was also observed in both scaled and non-scaled sites.

CONCLUSIONS

ORN combined with SRP effects beneficial shifts in the bacterial population associated with substantial clinical improvement, thereby indicating that ORN is effective adjunct in the treatment of EOP deep periodontal pockets where anaerobic bacteria are predominant.

Longitudinal effect of non-surgical treatment and systemic metronidazole for 1 week in smokers and non-smokers with refractory periodontitis: a 5-year study

BACKGROUND

Periodontitis consists of a mixture of diseases, most of which respond favorably to traditional mechanical therapy. It is now recognized that advanced periodontitis does not always respond to conventional management with scaling, periodontal surgery, and oral hygiene measures. However, various types of antibiotics given systemically or locally improve the success rate of periodontal therapy. In short-term studies, it has been shown that metronidazole, when systemically administered after debridement, resulted in treatment benefits including less need for surgical intervention.

METHODS

In this double-blind study, we evaluated periodontal treatment involving initial non-surgical treatment, systemic administration of metronidazole for 1 week, and then follow-ups for scaling and root planing every 6 months, for 5 years. The study population consisted of 64 subjects (37 smokers and 27 non-smokers), mean age 36.3 (+/-3.0 SD) years, with severe periodontal disease. After initial scaling and root planing, patients were randomly assigned to the intervention or placebo groups: 400 mg metronidazole or a placebo administered at 8-hour intervals for 1 week. The participants underwent an extensive clinical periodontal examination. Gingival crevicular fluid (GCF) was analyzed for spirochetes and granulocytes. Samples were cultured for Actinobacillus actinomycetemcomitans (A.a.), Porphyromonas gingivalis (Pg.), and Prevotella intermedia (Pi.).

RESULTS

The number of patients infected with A.a., Pg., Pi., and spirochetes decreased during the study. Most patients who harbored spirochetes at the end of the study had these microorganisms at the beginning. Smokers responded less favorably to periodontal therapy than non-smokers. Non-smoking patients who required only non-surgical therapy in the intervention group showed statistically significant improvement in the clinical parameters after 5 years. Patients with complete healing, defined as the absence of inflamed sites > or =5 mm, after 5 years were found only in the intervention group. The patients considered healthy after 5 years were the same patients found to be healthy after 6 months.

CONCLUSIONS

Decisive factors in the sustained long-term improvement of patients who respond satisfactorily to treatment are probably initial scaling and root planing; a brief course of metronidazole; and regular follow-up examinations at 6-month intervals for oral hygiene and scaling and root planing.

Effect of initial periodontal therapy on the frequency of detecting Bacteroides forsythus, Porphyromonas gingivalis, and Actinobacillus actinomycetemcomitans

BACKGROUND

Porphyromonas gingivalis, Bacteroides forsythus, and Actinobacillus actinomycetemcomitans have been described as periodontopathic bacteria, and their presence in subgingival pockets can lead to development of periodontal disease. Until now, clinical parameters have been used to evaluate the effect of conventional periodontal treatment without microbiological parameters. The present study examined the microbiological effects of initial periodontal therapy using DNA probes and the polymerase chain reaction (PCR).

METHODS

Twenty-six patients with periodontitis, 10 males and 16 females, were given instructions regarding oral hygiene, then thoroughly treated by conventional scaling and root planing. Bacterial samples were collected on paper points from 4 sites per patient at baseline and after initial therapy (total: 104 sites). Clinical parameters including probing depth, attachment level, and bleeding on probing were also recorded for each site at baseline and after therapy. A DNA probe kit was used to monitor the frequency of B. forsythus, P. gingivalis, and A. actinomycetemcomitans, the last of which was identified by PCR.

RESULTS

At baseline, B. forsythus was the bacterium most frequently detected. DNA probe analysis also showed that more than half of the sites were colonized by both B. forsythus and P. gingivalis. Initial therapy resulted in significant clinical improvement such as significant reduction in the frequency of B. forsythus and P. gingivalis detected using the DNA probe. A. actinomycetemcomitans was difficult to detect using the DNA probe, but PCR indicated that levels of A. actinomycetemcomitans did not significantly decrease.

CONCLUSIONS

These results indicate that initial conventional therapy can eliminate B. forsythus and P. gingivalis, but not A. actinomycetemcomitans. When levels of these bacteria decreased to below-detectable levels, clinical improvement was significant. These results indicate that monitoring levels of these three periodontopathic bacteria may render periodontal therapy more effective and accurate.

Oral ecology and person-to-person transmission of Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis

The ecological characteristics of the oral cavity are dissimilar for A. actinomycetemcomitans and for P. gingivalis, as judged by differences in their colonization preferences and patterns, associations with periodontal disease parameters, relationships with the subgingival microbiota and the type of periodontitis and their clonal persistence in the oral cavity. These features also suggest that as a periodontal pathogen, A. actinomycetemcomitans is different from P. gingivalis. Probably in most infected individuals, low levels of A. actinomycetemcomitans can persist for years in equilibrium with the host and the resident oral microbiota. However, it is well established that A. actinomycetemcomitans can cause disease in some individuals or in some circumstances when the regulatory mechanisms are unable to maintain homeostasis in the ecosystem. Elevated A. actinomycetemcomitans proportions of the biota can be regarded as a sign of ecological imbalance, leading to increased risk of periodontal destruction. There is also evidence showing elevated pathogenic potential of certain A. actinomycetemcomitans clones. Although A. actinomycetemcomitans seems to be relatively rarely transmitted between cohabiting adults, transmission can occur to periodontally healthy children of A. actinomycetemcomitans-positive parents. Parents and children may share factors that promote successful oral colonization of A. actinomycetemcomitans, or the window of opportunity is in childhood. Therefore, to prevent parent-child transmission of A. actinomycetemcomitans, bacterium-positive parents of young children are optimal targets for enhanced information and treatment. In selected populations, screening for specific clones of A. actinomycetemcomitans has been employed in prevention of peridontitis. Future research aiming at finding the reasons which cause the changes in the oral homeostasis to allow the growth of A. actinomycetemcomitans may give insight into novel prevention strategies for A. actinomycetemcomitans-associated periodontitis. Compared with A. actinomycetemcomitans, P. gingivalis shows a different pattern of coexistence with the host. In periodontal health or in children, P. gingivalis is absent or only rarely detected. When present, P. gingivalis is commonly recovered in high numbers from dentitions exhibiting inflamed periodontitis and poor oral hygiene. Contrary to A. actinomycetemcomitans, the data on the vertical transmission of P. gingivalis are limited. The major infection route of P. gingivalis seems to be between adults, indicating that P. gingivalis commonly colonizes in an established oral microbiota. These characteristics suggest that the degree of tolerance between P. gingivalis and the host is inferior to that between A. actinomycetemcomitans and the host. It appears that the association of P. gingivalis with disease is a rule rather than an accidental incident. On these grounds, it seems that the host-P. gingivalis relationship approaches antibiosis. Since P. gingivalis infection is related to a typical periodontal eco-pathology, the susceptibility to person-to-person transmission of this pathogen may be controlled by periodontal treatment and emphasizing the significance of high standard oral hygiene.

One stage full- versus partial-mouth disinfection in the treatment of chronic adult or generalized early-onset periodontitis. I. Long-term clinical observations

BACKGROUND

A standard treatment strategy for periodontal infections often consists of 4 consecutive sessions of scaling and root planing (per quadrant, at 1- to 2-week intervals), without proper disinfection of the remaining intra-oral niches for periodontopathogens. This could theoretically lead to a reinfection of previously disinfected pockets by bacteria from an untreated region/niche. This study aimed to investigate, over an 8-month period, the clinical benefits of a one stage full-mouth disinfection in the control of severe periodontitis.

METHODS

Sixteen patients with early-onset periodontitis and 24 patients with severe adult periodontitis were randomly assigned to test and control groups. The control group was scaled and root planed, per quadrant, at 2-week intervals and given standard oral hygiene instructions. A one stage full-mouth disinfection (test group) was sought by scaling and root planing the 4 quadrants within 24 hours in combination with the application of chlorhexidine to all intra-oral niches for periodontopathogens. Besides oral hygiene, the test group also rinsed twice daily with a 0.2% chlorhexidine solution and sprayed the tonsils with a 0.2% chlorhexidine spray, for 2 months. The plaque index, gingival index, probing depth, bleeding on probing, gingival recession, and clinical attachment level were recorded at baseline and at 1, 2, 4, and 8 months afterwards.

RESULTS

The one stage full-mouth disinfection resulted, in comparison to the standard therapy, in a significant (P <0.001) additional probing depth reduction and gain in attachment up to 8 months. For initial pockets > or =7 mm, the "additional" probing depth reduction at the 8 month follow-up was 1.2 mm for single-rooted and 0.9 mm for multi-rooted teeth, with corresponding additional gains in attachment of 1.0 mm and 0.8 mm, respectively. The additional improvements were observed for all subgroups (adult periodontitis, generalized early-onset cases, smokers), with the largest differences in the non-smoking adult periodontitis patients.

CONCLUSIONS

These findings suggest that a one stage full-mouth disinfection results in an improved clinical outcome for the treatment of chronic adult or early-onset periodontitis as compared to scaling and root planing per quadrant at 2-week intervals.

Diagnostic utility of specific microbiological markers for periodontal diseases

Specific detection of marker organisms Porphyromonas gingivalis, Prevotella intermedia, and Actinobacillus actinomycetemcomitans with an immunoassay provided 2 types of useful information directly into private clinical practice: 1) persistence of P. gingivalis in patients undergoing regular treatment allowed rapid identification of pockets requiring further treatment without waiting for measurable progression of lesions and 2) presence of A. actinomycetemcomitans in adults at any stage of diagnosis or treatment identified patients who may prove to have difficult-to-manage periodontitis. We made these findings in 253 patients (234 in specialist periodontal practices [F-ME 55; MHM 179] and 19 in general dental practice [EWM]). The search for useful diagnostic markers overlaps only partly with the search for periodontal pathogens. The P. gingivalis marker and the A. actinomycetemcomitans marker identify 2 different patterns of infection that appear to reflect 2 different underlying problems. Demonstration of pocket-dependent infection with P. gingivalis in treated patients provides an outcome marker for sites not converting to marker-negative sites at detection levels of the immunoassay. This information facilitates selection of sites and patients requiring adjustment of treatment regimens. Detection of A. actinomycetemcomitans in adult patients is significantly associated with periodontitis characterized as refractory. Positive identification of A. actinomycetemcomitans with the immunoassay supports clinical decision-making by drawing attention to adult patients who require closer monitoring and intensive persistent treatment. Successful application of immunoassay detection of microbiological markers is based on continuous patient monitoring to support clinical decisions; it does not replace careful clinical judgment.

Periodontitis-associated marker bacteria in an urban North American patient population: application of a commercial immunoassay

We used an immunoassay to demonstrate marker organisms (Porphyromonas gingivalis, Prevotella intermedia, and Actinobacillus actinomycetemcomitans) in 3 private practice populations (F-ME periodontist, 55 patients; MHM periodontist, 179 patients; and EWM general dentist, 19 patients). Occurrence of the marker organisms involves the whole oral environment, not just individual sites, as shown by close correlation between presence of the marker organisms in 2 independent sites/samples within a single mouth. Presence of the marker P. gingivalis (and P. intermedia) relates closely to periodontal pocketing while presence of A. actinomycetemcomitans does not have this pocket-associated characteristic. There was no significant relationship between presence of the marker organisms and the number of teeth in a mouth, and in the periodontal practice patients there was no significant effect of gender on occurrence of the marker organisms. A. actinomycetemcomitans and the other 2 markers were found over the entire age range (12 to 75) of our patients. Regular periodontal treatment reduced occurrence of all marker organisms and increased the frequency of marker-negative patients and sites. Occurrence of the marker organisms above immunoassay threshold levels appears to represent how receptive a patient is to each individual organism. Most patients appear receptive to the presence of P. intermedia whether treated or not. Significantly fewer patients who underwent regular treatment show the presence of P. gingivalis or A. actinomycetemcomitans when compared to untreated patients. Diagnostic application of microbial markers requires ongoing clinical assessment of patients and careful clinical judgment. 1391.