The effect of a systemically-administered non-steroidal anti-inflammatory drug (flurbiprofen) on experimental gingivitis in humans

The effect of systemic administration of ibuprofen in the experimental gingivitis model

BACKGROUND

Studies in humans have indicated that systemically administered flurbiprofen and ibuprofen may reduce gingivitis. De novo plaque formation is enhanced at tooth surfaces adjacent to inflamed gingivae.

OBJECTIVE

The aim of the present clinical trial was to evaluate the effect of systemic administration of ibuprofen on gingivitis and plaque build-up.

MATERIAL AND METHODS

Eleven subjects were recruited for the study and were given oral hygiene instruction, scaling and professional mechanical tooth cleaning (PTC). At the end of a preparatory period (Day 0), the participants were told to abstain from all mechanical plaque control measures during a 2-week experimental period but to rinse with an assigned mouth rinse (positive control: 0.1% chlorhexidine digluconate; negative control: saline) or administer ibuprofen (tablets of 200 mg twice daily). Mouth rinsing was performed twice a day (after breakfast and in the evening), for 60 s with 10 ml. Re-examination was performed after 14 days of experiment. After a 2-week "wash-out" period, the participants received a new PTC and a second 14-day experimental period was initiated. The experimental and "wash-out" periods were repeated until all volunteers had been involved in all three regimens. Dental plaque was scored using the Quigley & Hein Plaque Index system and gingivitis according to the Gingival Index (GI) system. Supragingival plaque was collected and prepared for dark-field microscopy. One hundred bacterial cells were counted and classified into six different groups: coccoid cells, straight rods, filaments, fusiforms, spirochetes and motile rods. Gingival crevicular fluid (GCF) was collected from the same sites that were sampled for plaque. The volume of GCF collected in each strip was measured and analysed regarding content of lactoferrin and albumin.

RESULTS

During the period when the panelists rinsed with saline they accumulated large amounts of plaque and developed marked signs of gingivitis. When they rinsed with chlorhexidine digluconate, small amounts of plaque formed and few sites received GI score > or =2. After the 2 weeks of ibuprofen administration, the panelists presented with significantly fewer sites that scored GI > or =2 but had formed similar amounts of plaque as during the negative control period.

CONCLUSION

It is suggested that ibuprofen administered via the systemic route has an effect on gingivitis but not on de novo plaque formation.

Modulation of clinical expression of plaque-induced gingivitis. III. Response of "high responders" and "low responders" to therapy

AIM

The aim of the present study was to characterize the subject-based clinical behavior of the gingiva in response to a tooth-cleaning regimen in two subpopulations, "high-responder" (HR) and "low-responder" (LR) groups, presenting a different inflammatory response to plaque accumulation.

MATERIAL AND METHODS

The study population comprised of 96 systemically and periodontally healthy subjects, 46 males and 50 females, non-smokers, enrolled in an experimental gingivitis trial. At completion of the experimental gingivitis period (day 21), all subjects were prescribed the same 21-day treatment regimen of amine/stannous fluoride (AmF/SnF(2))-containing toothpaste and mouthrinse. Plaque index (PlI), gingival index (GI), gingival crevicular fluid volume (GCF), and angulated bleeding score (AngBS) were recorded on three selected teeth. Treatment efficacy was evaluated in the overall population as well as in HR and LR groups, separately.

RESULTS

A statistically significant decrease of PlI was observed after treatment (p<0.001), with PlI reversing to baseline levels. Changes in PlI revealed the same trend in both HR and LR groups, without differences between groups. Treatment also resulted in a significant decrease of all gingivitis parameters (p<0.001 for all comparisons). After treatment, GI, AngBS, and GCF were comparable with baseline condition. However, when the two groups were compared, day 42-GCF was significantly higher in the HR group than the LR group.

CONCLUSIONS

A treatment regimen based on mechanical plaque control supplemented with AmF/SnF(2)-containing toothpaste and mouthrinse is effective in reducing plaque accumulation and re-establishing healthy gingival conditions after experimentally induced gingivitis, even in subjects with different inflammatory response to plaque accumulation.

The effect of aspirin on the periodontal parameter bleeding on probing

BACKGROUND

The absence or presence of bleeding on probing (BOP) is a sign of periodontal health or disease, but the presence of BOP is not an accurate predictor of disease progression. Aspirin is increasingly used in the prevention of cerebrovascular and cardiovascular diseases and is a non-disease factor that may modify bleeding indices given its antithrombolytic activity. The purpose of this double-blind placebo-controlled randomized clinical trial was to study the effect of short-term daily aspirin ingestion on the clinical parameter BOP.

METHODS

A total of 46 periodontally healthy subjects were included in this study: 16 received placebo, 15 low-dose aspirin (81 mg), and 15 regular dose (325 mg) aspirin. Clinical parameters assessed included plaque index, periodontal probing depth, and BOP using an automated pressure-sensitive probe. Measurements were recorded before and after 7-day exposure to placebo and aspirin regimens.

RESULTS

A statistically significant difference in BOP was found in patients with > or = 20% of bleeding sites during the visit prior to placebo or aspirin exposure (n = 11). The group treated with 325 mg aspirin exhibited a moderate yet statistically significant increase in BOP (12.4%) compared to the placebo group (there was no significant difference between the 81 mg aspirin group and placebo). The tendency to bleed was not statistically significant in the group which exhibited <20% (n = 35) of bleeding sites during the visit prior to exposure.

CONCLUSION

Aspirin intake of 325 mg daily for 7 days moderately increased the appearance of bleeding on probing in a population that had > or = 20% BOP sites.

Low-dose aspirin therapy and periodontal attachment loss in ex- and non-smokers

BACKGROUND, AIMS

This study investigated the periodontal status of non-smokers and ex-smokers in relation to their intake of low-dose aspirin.

METHODS

A self-selected sample of 392 males aged 50 years and over was recruited from the general population. Subjects were included in the study if they had a minimum of 6 or more natural teeth, took aspirin (300 mg or less per day) for at least 2 years and were either ex- or non-smokers. Controls were subjects who did not take aspirin regularly. A questionnaire was used to record demographic data, medical and dental histories. Individuals who had diabetes or other systemic diseases were excluded from the study. Periodontal attachment loss (PAL) was calculated by adding measurements of gingival recession and periodontal pocket depth made by a single examiner at 6 sites around each tooth using non-pressure sensitive periodontal probes. Plaque and gingival bleeding indices were also scored. Subjects were divided into 4 groups: aspirin non-smokers, aspirin ex-smokers, no aspirin non-smokers and no aspirin ex-smokers. Data were analysed using two-way ANOVA with age as the covariate. Severity and extent of mean PAL and the cumulative distribution of the mean of the most severe sites (MSS) of PAL were analysed.

RESULTS

Controlling for age, mean PAL in aspirin takers was significantly less 2.6+/-0.08 (se) mm than non-aspirin takers 2.9+/-0.06 (se) mm; this association was independent of smoking history. Ex-smokers had significantly more mean PAL 3.9+/-0.07 (se) mm than non-smokers 2.6+/-0.08 (se) mm, irrespective of aspirin status. When MSS-PAL was analysed, these differences became more pronounced; MSS-PAL in aspirin takers was significantly less 3.9+/-0.1 (se) mm than non-aspirin takers 4.2+/-0.08 (se) mm. Ex-smokers had significantly more MSS-PAL 4.3+/-0.08 (se) mm than non-smokers 3.8+/-0.08 (se) mm. Aspirin apparently had a protective association on PAL and it is hypothesised that low-dose aspirin may have reduced the rate of attachment loss.

CONCLUSIONS

This hypothesis needs to be confirmed by a prospective study. The results of this study suggest that individuals aged over 50 years, particularly ex-smokers, may benefit by taking low-doses of aspirin daily to reduce their risk of periodontal attachment loss.

Over-the-counter analgesics and antipyretics: a critical assessment

BACKGROUND

It is just 100 years since the introduction of aspirin to medicine. Since then, aspirin and its derivatives have been joined by acetaminophen, and the nonsteroidal anti-inflammatory drugs--ibuprofen, naproxen sodium, and ketoprofen--as the only over-the-counter (OTC) agents approved by the US Food and Drug Administration for the short-term treatment of pain, headache, dysmenorrhea, and fever. Recently the prescription use of aspirin has expanded to include a number of antiplatelet indications.

OBJECTIVE

The purpose of this paper is to review critically the history, mechanisms of action, efficacy, and tolerability of OTC analgesic and antipyretic products. Relatively new and potential future indications for these drugs are also discussed.

CONCLUSION

Although all of the OTC analgesic/antipyretic agents seem to share a common mechanism of prostaglandin inhibition, there are important differences in their pharmacology, efficacy, and side-effect profiles. Considering their often-unsupervised use, the risk-benefit ratio of this class of drugs has been extremely favorable. However, when used inappropriately, even these drugs pose significant risks to certain patient populations.

The pathogenesis of periodontal diseases

This informational paper was prepared by the Research, Science, and Therapy Committee of The American Academy of Periodontology, and is intended for the information of the dental profession. The purpose of the paper is to provide an overview of current knowledge relating to the pathogenesis of periodontal diseases. The paper will review biological processes thought to provide protection against periodontal infections. It will further discuss the mechanisms thought to be responsible for both overcoming and subverting such protective mechanisms and those that lead to destruction of periodontal tissues. Since an understanding of pathogenic mechanisms of disease is one foundation upon which new diagnostic and therapeutic modalities are based, the practitioner can use this information to help make decisions regarding the appropriate application of such new modalities in patient care settings.

Efficacy of systemically administered acetylsalicylic acid plus scaling on periodontal health and elastase-alpha 1-proteinase inhibitor in gingival crevicular fluid

The purpose of this proof of principle trial was to assess whether conventional periodontal therapy and systemically administrated acetylsalicylic acid (ASA) are functionally synergistic when combined in the treatment of periodontitis. A total of 30 patients with untreated moderate to severe adult periodontitis were enrolled into the study and were given placebo q.i.d. between the baseline and 6-week examination, and acetylsalicylic acid (ASA) 500 mg q.i.d. between the 6-week and 12-week examinations. In addition, they received supra- and subgingival scaling in 1 quadrant after baseline examination and in 2 further randomly selected quadrants after the 6-week examination. The study design resulted in the following 4 therapies: (1) scaling plus ASA 500 mg q.i.d.; (2) scaling plus placebo q.i.d.; (3) ASA 500 mg q.i.d. alone; (4) placebo q.i.d. alone. Two-way analysis of variance showed functional synergism of ASA and scaling, resulting in a therapeutic efficacy approximately equivalent to the sum of each individual therapeutic efficacy (i.e., ASA alone and scaling alone) in reducing gingival inflammation and pocket probing depth over the 6-week observation period (interaction: p > 0.05). Only the effect of ASA was significant in reducing the concentration of elastase-alpha 1-proteinase inhibitor in gingival crevicular fluid (GCF E-alpha 1-PI) (p < 0.001), reduction in GCF E-alpha 1-PI concentrations by ASA may indicate a decreased risk in periodontal disease progression. The results suggest that the combination of therapies and their different mechanisms of action, i.e., reduction of bacterial plaque and inhibition of destructive components of the immune responses, may result in functionally synergistic therapeutic efficacies in patients with untreated adult periodontitis.

Adjunctive supragingival irrigation with acetylsalicylic acid in periodontal supportive therapy

To assess the clinical efficacy of adjunctive supragingival irrigation with buffered 0.3% acetylsalicylic acid (ASA), 60 patients with periodontitis receiving supportive periodontal therapy were randomly assigned to 1 of 3 home regimens: (1) 1x daily adjunctive supragingival irrigation with 300 ml water immediately followed by 200 ml of buffered 0.3% ASA; (2) 1x daily adjunctive supragingival irrigation with 500 ml water; or (3) normal oral hygiene alone. Clinical parameters were assessed at baseline and 6 months. Irrigator use was measured by timers built into the irrigator units. Results at 6 months showed that both supragingival irrigation with buffered 0.3% ASA and supragingival irrigation with water significantly reduced gingival index scores (median 0.1 and 0.35, respectively) and pocket probing depths (both median 0.26 mm) compared to the control group. In addition, irrigation with water resulted in a significant reduction in bleeding on probing (median 0.13), whereas irrigation with buffered 0.3% ASA had no significant effect on bleeding on probing compared to the control group. The clinical efficacy of irrigation with either ASA or water was found to be positively correlated to initial disease severity and irrigator use. Thus, frequent supragingival irrigation with either 0.3% ASA or water in addition to regular oral hygiene appears to be a beneficial adjunct to periodontal supportive therapy in patients with moderate to severe signs of periodontitis. However, the use of buffered 0.3% ASA as an irrigant does not seem to enhance the clinical efficacy of supragingival irrigation on periodontal health.

A comparison of topical ketorolac, systemic flurbiprofen, and placebo for the inhibition of bone loss in adult periodontitis

Systemic non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to reduce alveolar bone loss in periodontitis. This study assesses the efficacy of a topical NSAID rinse, containing ketorolac tromethamine as the active agent. Adult periodontitis patients (n = 55) were studied in this 6-month randomized, double blind, parallel, placebo and positive-controlled study. Each patient had a least 3 sites at high risk for bone loss as assessed by low dose bone scan. Groups, balanced for gender, were assigned to one of three regimens: bid ketorolac rinse (0.1%) with placebo capsule; 50 mg bid flurbiprofen capsule (positive control) with placebo rinse; or bid placebo rinse and capsule. Prophylaxes were provided every 3 months. Monthly examinations assessed safety, gingival condition, and gingival crevicular fluid PGE2. Standardized radiographs were taken at baseline and at 3 and 6 months for digital subtraction radiography. A significant loss in bone height was observed during the study period in the placebo group (-0.63 +/- 0.11; P < 0.001), but not in the flurbiprofen (-0.10 +/- 0.12; P = 0.40) or ketorolac rinse (+0.20 +/- 0.11 mm; P = 0.07) groups. Nested ANOVA revealed that ketorolac and flurbiprofen groups had less bone loss (P < 0.01) and reduced gingival crevicular fluid PGE2 levels (P < 0.03) compared to placebo. ANOVA suggests (P = 0.06) that ketorolac rinse preserved more alveolar bone than systemic flurbiprofen at the dose regimens utilized. These data indicate that ketorolac rinse may be beneficial in the treatment of adult periodontitis.

Preventive therapy for periodontal diseases

Rational approaches to the prevention of destructive periodontitis should be based on a clear understanding of etiology and pathogenesis. However, we are dealing with a heterogeneous family of diseases in which different factors operate. It is an oversimplification to regard poor oral hygiene, and hence an accumulation of non-specific dental bacterial plaque, as the major risk factor. Epidemiological evidence indicates that host factors are likely to be of overriding importance for the most severe forms. The limitations of nonspecific plaque control are therefore discussed. Specific inhibitors of virulence factors provide a logical approach, but their clinical application awaits improved knowledge. Improvement of general health and resistance to disease by proper nutrition, the avoidance of intercurrent disease, and elimination of smoking and stress-induced risk are encouraged. The genetic basis of susceptibility to periodontitis is increasingly understood, and, while gene therapy is not likely to be a practicable approach to prevention, genetic markers of risk are emerging.

The effect of systemically-administered flurbiprofen as an adjunct to toothbrushing on the resolution of experimental gingivitis

Non-steroidal anti-inflammatory drugs (NSAIDs) have been widely researched in an attempt to control periodontal diseases. This double-blind parallel group study investigated the effect of a systemic flurbiprofen preparation (100 mg daily), when combined with toothbrushing on the resolution of experimental gingivitis in human volunteers. 47 volunteers abstained from tooth cleaning for 21 days. On day 21, 23 subjects were prescribed 100 mg of flurbiprofen daily whereas 24 subjects were prescribed placebo. In both groups, toothbrushing was re-introduced and all subjects used the Bass technique for 2 min each day. Both treatment regimens were continued for 7 days. Plaque indices, gingival indices and gingival crevicular fluid flow were assessed at baseline (day 0) and on days 21 and 27. There were no significant differences at p = 0.05 between the groups for plaque indices or gingival crevicular fluid flow. The flurbiprofen group, however, demonstrated greater resolution of gingival inflammation by day 27 when compared to the placebo controls (p = 0.04). The plasma levels of flurbiprofen in the test group showed mean concentrations of flurbiprofen of 4.7 (+/- 2.1) micrograms/ml at 1 h after dosing. After 6 h, this had fallen to 4.4 (+/- 1.6) micrograms/ml. It is concluded that these serum concentrations of flurbiprofen are sufficient to produce significant anti-inflammatory effects in the gingival tissues.

The effect of systemic ibuprofen on gingival inflammation in humans

This clinical trial investigated the influence of short-term ibuprofen therapy on the early phase of the treatment of adult chronic periodontitis. The subjects were 17 patients in good general health referred for specialist periodontal treatment, having moderate chronic adult periodontitis. A series of assessments were made every 2 weeks over an 8-week period, including evaluations of oral hygiene, gingival inflammation and probing pocket depths. All participants received oral hygiene instruction, and following baseline examinations, had half the dentition, chosen at random, treated by scaling and root planing. The patients were randomly distributed into 2 groups, a test group receiving a 14-day course of 800 mg ibuprofen daily, in 4 divided doses, and a control group who did not receive any drug regime. At the 2-week assessment following the drug regime, significantly greater reduction in gingival bleeding, colour and pocketing was detected in the test compared with the control group. The beneficial effects were less evident thereafter. Although clinical application of the regime used in this study would not be justified by these results, further research into anti-inflammatory agents as an adjunct in the treatment of periodontal diseases could be considered, in the light of the beneficial effect on gingivitis in the early phase of periodontal treatment reported.

Microcirculatory dynamics in experimental human gingivitis

The purpose of this study was to determine the changes that occur in the gingival microcirculation during the development of experimental gingivitis in humans. There have been no studies published to date combining videomicroscopy and laser Doppler flowmetry to study vascular dynamics in experimental gingivitis. Alterations occurring in the microcirculation of the marginal gingiva in 10 (18-30-year-old), healthy male humans when they suspended oral hygiene procedures in a proscribed area for 12-16 days were monitored. A partial mouth, experimental gingivitis model was employed. Gingival health was evaluated before and after the experimental period by assessing gingival and plaque indices and gingival crevicular fluid volume. Gingival vascular monitoring included measurement of red blood cell velocity in individual gingival microvessels via videomicroscopy and measurement of regional gingival blood flow using laser doppler flowmetry. The number of vessels visible in a given microscopic field in a given subject and the number of vessels exhibiting flow were also determined from the videotapes. Systemic cardiovascular and respiratory parameters were monitored to ensure that gingival vascular changes were not secondary to systemic changes. Gingivitis developed in all subjects; significant increases (Student t-test, p < 0.05) were seen in plaque index, gingival index, bleeding on probing and crevicular fluid volume. No change in superficial capillary blood velocity and a significant decrease in gingival regional blood flow were seen with gingivitis. A significant increase in the number of vessels visible in microscopic fields and a decrease in the % of vessels exhibiting flow were observed. Gingival microcirculation exhibited a dramatic, dynamic change in response to the development and progression of gingivitis.

Nonsteroidal antiinflammatory drugs as inhibitors of periodontal disease progression

Recent interest in the control and modulation of periodontal disease has focused on the potential benefits of blocking the host response mechanisms involved in the progression of the disease. In addition to recent advances in the identification and control of etiologic bacteria, investigators have indicated promising results using nonsteroidal antiinflammatory drugs (NSAIDs) as inhibitors of the inflammatory destruction in periodontal disease. This article examines research efforts over the last 20 years describing the role of prostaglandins in periodontal disease and the effect of NSAIDs on the progression of gingival inflammation and alveolar bone loss.

Report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry

The growth in the dental literature continues to escalate, as evidenced by the publication of at least 326 new books in 1988 and 1989 and more than 20 new journals in 1989. There still appears to be undue emphasis on quantity instead of quality of research. This proliferation in the literature poses ever increasing difficulties to this Committee in filtering out the articles that are of particular interest to the members of the Academy and identifying those that are most likely to have a major impact on dental practice and service. The subjects covered include periodontics, caries and preventive dentistry, craniomandibular disorders, occlusion, pulp biology, ceramics, and restorative dental materials.