Supportive periodontal therapy using mechanical instrumentation or 2% minocycline gel: a 12 month randomized, controlled, single masked pilot study

Photodynamic therapy adjuvant to non-surgical periodontal therapy: Systematic review of randomized clinical trials

OBJECTIVES

To systematically evaluate randomised controlled trials (RCTs) on whether adjuvant application of antimicrobial photodynamic therapy (aPDT) through the technique of irradiation in the external region of the periodontal pocket with optic-fibre tip offers benefits to scaling and root planning (SRP).

METHODS

Five databases were searched by two independent reviewers according to pre-specified eligibility criteria up to April 2023. No restrictions regarding date of publication, language and minimum follow-up period were imposed. The Cochrane Collaboration's Risk of Bias tool (RoB 2.0) was used for quality appraisal and Grading of Recommendations, Assessment, Development and Evaluation for assessing the certainty of evidence.

RESULTS

A total of 1388 publications were identified and reviewed for eligibility. Four of them fulfilled the inclusion criteria. The sample consisted of a total of 83 patients with periodontitis. In these, 330 periodontal sites were evaluated. The clinical findings of the majority of the included studies demonstrated that patients who received the association of aPDT + RAR with the protocol evaluated here, obtained clinical results similar to patients who received only the SRP alone. In none of the evaluated RCTs, clinical advantages were observed that would categorise this aPDT protocol as superior to conventional treatment.

CONCLUSION

Applying aPDT after SRP with external irradiation of the periodontal pocket does not seem to result in any clinical benefit compared to the use of SRP alone in patients with periodontitis.

Comparing the clinical effects of local administration of minocycline ointment and doxycycline solution in the treatment of acute periodontal abscesses: a retrospective clinical study

PURPOSE

The objective of this retrospective clinical study was to provide evidence supporting the adjunctive local application of doxycycline solution or minocycline ointment, in conjunction with drainage, for the treatment of acute periodontal abscesses.

METHODS

The study included 63 patients who had received treatment for acute periodontal abscesses through drainage supplemented with 1 of 3 types of adjunctive medications during their initial visit (visit 1; baseline): 1) saline irrigation (the control group), 2) 2% minocycline ointment (the TM group), or 3) 300 mg/mL doxycycline irrigation (the TD group). The same adjunctive medication was administered at visit 2, which took place 1 week after visit 1. Probing depth (PD), bleeding on probing (BOP), plaque index, gingival recession, clinical attachment level, and tooth mobility were clinically evaluated at visits 1, 2, and a third visit (visit 3; 4 weeks after visit 1). Statistical significance was considered to be indicated by P values <0.05.

RESULTS

By visit 3, all clinical indices and tooth mobility had significantly decreased in each group. At this visit, PD and BOP on the abscess side were significantly lower in the TM and TD groups compared to the control group. The TD group showed a significantly greater improvement than the TM group, with mean PD reductions of 1.09 mm in the control group, 1.88 mm in the TM group, and 2.88 mm in the TD group. Similarly, mean BOP reductions were 45% in the control group, 73.02% in the TM group, and 95.45% in the TD group.

CONCLUSIONS

Local and adjunctive administration of doxycycline and minocycline in combination with drainage exhibited clinical advantages over drainage alone in improving PD and BOP. Notably, a doxycycline solution of 300 mg/mL was more effective than a 2% minocycline ointment.

Clinical and microbiological effects of a single application of sodium hypochlorite gel during subgingival re-instrumentation: a triple-blind randomized placebo-controlled clinical trial

OBJECTIVES

The aim of this study is to assess the clinical and microbiological effects of a single subgingival administration of sodium hypochlorite gel (NaOCl) and compare it with 1% chlorhexidine (CHX) gel and a placebo gel following mechanical re-instrumentation during supportive periodontal therapy (SPT).

MATERIALS AND METHODS

Sixty-two patients who had been treated for stage III-IV periodontitis and enrolled in SPT were included in the study based on following criteria: (1) active periodontal therapy completed at least 6 months before enrollment in the study, (2) presence of at least 4 non-adjacent sites with probing pocket depths (PPDs) ≥ 4 mm with bleeding on probing (BOP), or presence of 5-8 mm PPDs with or without BOP. All sites presenting PPD ≥ 4 mm and BOP at baseline and 3-, 6-, and 9-month follow-up timepoints were subgingivally re-instrumented with ultrasounds. Selected patients were randomly assigned into three groups and treated additionally with a single subgingival administration of NaOCl gel (group A); 1% CHX gel (group B); and placebo gel (group C). Main outcome variable was pocket closure at 12 months. Secondary outcome variables were changes in mean PPD, BOP, and clinical attachment level (CAL) along with changes in the numbers of the following five keystone bacterial pathogens: Aggregatibacter actinomycetemcomitans (A.a.), Porphyromonas gingivalis (P.g.), Prevotella intermedia (P.i.), Tannerella forsythia (T.f.), and Treponema denticola (T.d.).

RESULTS

At 12 months, pocket closure was obtained in 77.5% in the NaOCl treated sites. The reduction in PPD was higher with CHX than with NaOCl, although a statistically significant adjunctive effect for NaOCl (P = 0.028) was only observed in comparison with placebo only. Mean CAL improved in all groups and at all timepoints, compared to the baseline (P < 0.05). However, after 6 months, CAL gain was statistically significantly higher in the NaOCl treated group than following application of CHX (P = 0.0026).

CONCLUSION

In SPT patients, a single adjunctive use of a NaOCl gel may provide benefits in controlling inflammation and residual pockets.

TRIAL REGISTRATION

ISRCTN Registry of Clinical Trials (ISRCTN11387188).

CLINICAL RELEVANCE

A baseline single application of NaOCl gel in conjunction with mechanical debridement may achieve substantial pocket closure in patients enrolled in SPT; treatment time, cost, and applicability considerations should be taken into account when selecting this therapy.

Effects of Antimicrobial Photodynamic Therapy and Local Administration of Minocycline on Clinical, Microbiological, and Inflammatory Markers of Periodontal Pockets: A Pilot Study

Objective

We evaluated the efficacies of antimicrobial photodynamic therapy (aPDT) and minocycline ointment (MO) on clinical and bacteriological markers and the local host inflammatory response.

Materials and Methods

A total of 30 patients with chronic periodontitis were randomly assigned to two groups. Selected periodontal pockets (probing depth 5-7 mm with bleeding on probing) were treated with aPDT or MO. Measurements of clinical parameters and the collection of gingival crevicular fluid (GCF) and subgingival plaque were performed at baseline, and at 1 and 4 weeks after treatment. Quantification of periodontopathic bacteria in the sulcus and a multiplex bead immunoassay of ten inflammatory cytokines in the GCF were performed.

Results

Local MO administration exhibited a significant decrease in scores for clinical parameters (P < 0.01) and a significant reduction in bacterial counts (P < 0.01) and interleukin-1β and interferon-γ levels at 1 and 4 weeks after treatment (P < 0.01). No significant changes were observed in the aPDT group, except in clinical parameters.

Conclusions

Although our study had some limitations, we found that while local administration of MO may slightly help to improve clinical, microbiological, and crevicular cytokine levels in periodontal pockets, aPDT did not show any effects. This trial is registered with the UMIN Clinical Trials Registry UMIN000013376.

Supportive periodontal therapy (SPT) for maintaining the dentition in adults treated for periodontitis

BACKGROUND

Periodontitis is a bacterially-induced, chronic inflammatory disease that destroys the connective tissues and bone that support teeth. Active periodontal treatment aims to reduce the inflammatory response, primarily through eradication of bacterial deposits. Following completion of treatment and arrest of inflammation, supportive periodontal therapy (SPT) is employed to reduce the probability of re-infection and progression of the disease; to maintain teeth without pain, excessive mobility or persistent infection in the long term, and to prevent related oral diseases.According to the American Academy of Periodontology, SPT should include all components of a typical dental recall examination, and importantly should also include periodontal re-evaluation and risk assessment, supragingival and subgingival removal of bacterial plaque and calculus, and re-treatment of any sites showing recurrent or persistent disease. While the first four points might be expected to form part of the routine examination appointment for periodontally healthy patients, the inclusion of thorough periodontal evaluation, risk assessment and subsequent treatment - normally including mechanical debridement of any plaque or calculus deposits - differentiates SPT from routine care.Success of SPT has been reported in a number of long-term, retrospective studies. This review aimed to assess the evidence available from randomised controlled trials (RCTs).

OBJECTIVES

To determine the effects of supportive periodontal therapy (SPT) in the maintenance of the dentition of adults treated for periodontitis.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 8 May 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Issue 5), MEDLINE Ovid (1946 to 8 May 2017), and Embase Ovid (1980 to 8 May 2017). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating SPT versus monitoring only or alternative approaches to mechanical debridement; SPT alone versus SPT with adjunctive interventions; different approaches to or providers of SPT; and different time intervals for SPT delivery.We excluded split-mouth studies where we considered there could be a risk of contamination.Participants must have completed active periodontal therapy at least six months prior to randomisation and be enrolled in an SPT programme. Trials must have had a minimum follow-up period of 12 months.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results to identify studies for inclusion, assessed the risk of bias in included studies and extracted study data. When possible, we calculated mean differences (MDs) and 95% confidence intervals (CIs) for continuous variables. Two review authors assessed the quality of evidence for each comparison and outcome using GRADE criteria.

MAIN RESULTS

We included four trials involving 307 participants aged 31 to 85 years, who had been previously treated for moderate to severe chronic periodontitis. Three studies compared adjuncts to mechanical debridement in SPT versus debridement only. The adjuncts were local antibiotics in two studies (one at high risk of bias and one at low risk) and photodynamic therapy in one study (at unclear risk of bias). One study at high risk of bias compared provision of SPT by a specialist versus general practitioner. We did not identify any RCTs evaluating the effects of SPT versus monitoring only, or of providing SPT at different time intervals, or that compared the effects of mechanical debridement using different approaches or technologies.No included trials measured our primary outcome 'tooth loss'; however, studies evaluated signs of inflammation and potential periodontal disease progression, including bleeding on probing (BoP), clinical attachment level (CAL) and probing pocket depth (PPD).There was no evidence of a difference between SPT delivered by a specialist versus a general practitioner for BoP or PPD at 12 months (very low-quality evidence). This study did not measure CAL or adverse events.Due to heterogeneous outcome reporting, it was not possible to combine data from the two studies comparing mechanical debridement with or without the use of adjunctive local antibiotics. Both studies found no evidence of a difference between groups at 12 months (low to very low-quality evidence). There were no adverse events in either study.The use of adjunctive photodynamic therapy did not demonstrate evidence of benefit compared to mechanical debridement only (very low-quality evidence). Adverse events were not measured.The quality of the evidence is low to very low for these comparisons. Future research is likely to change the findings, therefore the results should be interpreted with caution.

AUTHORS' CONCLUSIONS

Overall, there is insufficient evidence to determine the superiority of different protocols or adjunctive strategies to improve tooth maintenance during SPT. No trials evaluated SPT versus monitoring only. The evidence available for the comparisons evaluated is of low to very low quality, and hampered by dissimilarities in outcome reporting. More trials using uniform definitions and outcomes are required to address the objectives of this review.

Microbiological outcomes from different periodontal maintenance interventions: a systematic review

This study aimed to investigate the differences in the subgingival microbiological outcomes between periodontal patients submitted to a supragingival control (SPG) regimen as compared to subgingival scaling and root planing performed combined with supragingival debridement (SPG + SBG) intervention during the periodontal maintenance period (PMP). A systematic literature search using electronic databases (MEDLINE and EMBASE) was conducted looking for articles published up to August 2016 and independent of language. Two independent reviewers performed the study selection, quality assessment and data collection. Only human randomized or non-randomized clinical trials with at least 6-months-follow-up after periodontal treatment and presenting subgingival microbiological outcomes related to SPG and/or SPG+SBG therapies were included. Search strategy found 2,250 titles. Among these, 148 (after title analysis) and 39 (after abstract analysis) papers were considered to be relevant. Finally, 19 studies were selected after full-text analysis. No article had a direct comparison between the therapies. Five SPG and 14 SPG+SBG studies presented experimental groups with these respective regimens and were descriptively analyzed while most of the results were only presented graphically. The results showed that both SPG and SPG+SBG protocols of PMP determined stability in the microbiological results along time. Nevertheless, new studies comparing these interventions in PMP are needed, especially if the limitations herein discussed could be better controlled.

Systemic antibiotics in the treatment of periodontitis

Despite the fact that several clinical studies have shown additional benefits when certain systemic antibiotics are used as adjuncts to periodontal treatment, clear guidelines for the use of these agents in the clinical practice are not yet available. Basic questions concerning the use of systemic antibiotics to treat periodontitis remain unanswered, such as: which drug(s) should be used; which patients would most benefit from treatment; which are the most effective protocols (i.e. doses and durations); and in which phase of the mechanical therapy should the drug(s) be administered? Although not all of those questions have been directly addressed by controlled randomized clinical trials, recent concepts related to the ecology of periodontal diseases, as well as the major advances in laboratory and clinical research methods that have occurred in the past decade, have significantly broadened our knowledge in this field. This article endeavored to provide a 'state of the art' overview on the use of systemic antibiotics in the treatment of periodontitis, based on the most recent literature on the topic as well as on a compilation of data from studies conducted at the Center of Clinical Trials at Guarulhos University (São Paulo, Brazil) from 2002 to 2012.

Minocycline Ointment as a Local Drug Delivery in the Treatment of Generalized Chronic Periodontitis - A Clinical Study

INTRODUCTION

The primary goal in periodontal therapy includes removal of the etiological factors by mechanical periodontal treatment, which sometimes fail to eliminate the anaerobic infection at the base of the pocket and requires adjuvant chemical therapy.

AIM

The aim of the study was to evaluate the effectiveness of 2% minocycline ointment when used as an adjunct to periodontal flap surgery and post-operative maintenance period for the treatment of generalized chronic periodontitis.

MATERIALS AND METHODS

The study included 30 subjects comprising of 60 posterior sextants in a split mouth design in which 30 sextants were treated as experimental and 30 sextants as control with a probing pocket depth≥6mm. In Group A (experimental group) 30 sextants were treated with open flap debridement followed by the application of minocycline ointment as a local drug delivery. In Group B (control group) 30 sextants were treated with open flap debridement alone. Minocycline hydrochloride ointment was applied on the 0 day and 3(rd) month. The clinical parameters such as plaque index, probing pocket depth, clinical attachment level and gingival bleeding index were recorded at 0 day, 3(rd) month and 6(th) month in both the groups. Paired and unpaired t-test were used to compare the means of the two groups.

RESULTS

When Group A and Group B were compared, Group A showed significantly greater reduction in gingival bleeding index, probing pocket depth and gain in clinical attachment level than Group B, from 0 day to 3 months and from 0 day to 6 months. Group A showed significant reduction in plaque index than Group B when they were compared at 6 months.

CONCLUSION

The results demonstrate that there was significant reduction in the clinical parameters with improvement in the periodontal status on application of minocycline ointment as an adjunct to periodontal flap surgery in generalized chronic periodontitis.

Effects of systemic ornidazole, systemic and local compound ornidazole and pefloxacin mesylate on experimental periodontitis in rats

Background

The purpose of the current study is to evaluate the effects of systemic ornidazole (SO) and systemic and local compound ornidazole and pefloxacin mesylate (SCOPM/LCOMP) on the inflammatory response associated with rat experimental chronic periodontitis (ECP) in sites with subgingival debridement.

Material/Methods

Periodontitis was induced in male Sprague-Dawley rats by placing a thin steel ligature around the upper first molars and inoculating them with Porphyromonas gingivalis 381. After the successful induction of the rat ECP, the periodontitis rats were randomly divided into 3 different combined treatment groups: (A) SO with scaling and root planing (SRP); (B) SCOMP with SRP; and (C) LCOMP with SRP. After 2 weeks the effects of the treatments were evaluated based on gingivitis, plaque index, probing pocket depth, aspartate aminotransferase, alveolar bone loss, and hematoxylin-eosin staining of the region around the first molars.

Results

After treatment, comparison with ECP was performed. The mean percentage reductions of SBI in SO, SCOPM, and LCOPM were 27.73%, 33.61%, and 58.82%, respectively. Those of PI were 33.20%, 42.80%, and 60.00%; those of PPD were 48.66%, 55.70%, and 72.48%; those of GCF-AST were 41.64%, 49.03%, and 66.42%; and those of ABL were 41.19%, 43.63%, and 54.47%, respectively. The inflammatory score of H&E showed median scores of 2.5, 1.75, 1.63, and 0.95 for ECP, SO, SCOMP, and LCOMP, respectively. All 3 treatment groups exhibited significantly reduced inflammation indicators (P<0.05). Of the 3, group C was the most effective (P<0.05).

Conclusions

Although all the combined treatment groups responded to therapy with significant resolution of the infection, adjunctive LCOMP therapy is more effective for periodontitis.

Effects of a single topical doxycycline administration adjunctive to mechanical debridement in patients with persistent/recurrent periodontitis but acceptable oral hygiene during supportive periodontal therapy

OBJECTIVES

To evaluate the efficacy of a slow release doxycycline gel (SRD) adjunctively administered to non-surgical therapy in subjects with recurrent or persistent periodontitis but acceptable oral hygiene during supportive periodontal care.

MATERIAL & METHODS

In this single blind, parallel group, multicentre study, 202 of 203 recruited periodontal maintenance subjects with recurrent or persistent periodontitis were randomly assigned to subgingival ultrasonic/sonic instrumentation (USI) with (test) or without (control) subsequent administration of SRD in all residual periodontal pockets ≥4 mm. Intergroup differences in probing depth, BOP reductions, treatment time, probing attachment levels were evaluated at 3, 6 and 12 months. The primary outcome was the inter-group difference in absolute change of probing pocket depth (PPD) 3, 6 and 12 months after intervention.

RESULTS

At baseline, the two groups were comparable. At 3 months, the test group showed a significantly higher decrease in mean probing depth than the control group at 3 months (mean difference = 0.11 mm, 95% CI 0.03-0.19 mm, p = 0.003). Administration of SRD resulted in significantly greater odds of transition of bleeding pockets ≥5 mm to a category of non bleeding sites with PPD ≤4 mm at 3 and 6 months (O.R. = 1.4, 95% CI 1.2-1.8 at 3 months). At 6 months, SRD benefit was observed only in the deeper pockets. 7.5% of subjects (no significant difference between test and control) showed disease progression (attachment loss ≥2 mm) and were exited from the study. No difference in the incidence of adverse events was observed between groups.

CONCLUSION

The trial results show that topically administered SRD may provide short-term benefit in controlling inflammation and deep pockets in treated periodontal patients participating in a secondary prevention programme and able to maintain a satisfactory level of oral hygiene.

Multiple applications of flurbiprofen and chlorhexidine chips in patients with chronic periodontitis: a randomized, double blind, parallel, 2-arms clinical trial

AIM

The aim of the present randomized, double blind, parallel, 2-arm clinical study was to examine the safety and efficacy of frequent applications of chlorhexidine chip (CHX) and flurbiprofen chip (FBP) in patients with chronic periodontitis.

METHODS

Sixty patients were randomized into CHX and FBP groups. Following OHI and scaling and root planing (SRP), baseline pocket depth (PD) measurements, gingival recession and bleeding on probing (BOP) were performed and repeated at week 4 and 8. The assigned chip was placed at weeks 0, 1, 2, 3, 5, 7.

RESULTS

Mean PD reduction in the CHX group was 2.08 mm (7.17 to 5.09, p < 0.0001). Mean PD reduction in the FBP group was 2.27 mm (6.72 to 4.45, p < 0.0001). Ninety-seven percentage and 95% of these sites exhibited PD reduction ≥1 mm, while 38% and 34% of the sites exhibited PD ≥3 mm (FBP and CHX, respectively). Clinical attachment level gain (1.66 and 1.95 mm, respectively) was statistically significant (p < 0.0001). Baseline BOP dropped from 98% and 100% to 24% and 30% for the CHX and FBP groups, respectively (p < 0.0001).

CONCLUSION

Frequent applications of CHX and FBP chips resulted in a significant improvement in the periodontal condition in these sites. Furthermore studies will be required to compare this new treatment regimen to SRP or SRP with single chip application.

Photodynamic therapy of persistent pockets in maintenance patients-a clinical study

The aim of this study was to compare the short-term performance of a session of single photodynamic therapy (PDT) and of a conventional ultrasonic debridement (UST) in persistent pockets of maintenance patients. In a prospective, randomized, controlled, single-blind clinical study, patients with chronic periodontitis with at least two persistent pockets (>4 mm) were enrolled. They were treated either with UST (n = 29) or PDT (n = 25). Clinical and microbiological examinations were performed at baseline and after 3 months. For UST, the mean probing depth was reduced from 5.3 to 4.5 mm (p = <0.001) and for PDT from 5.3 to 4.7 mm (p < 0.001) with no difference between the two treatment modalities. Microbial counts were significantly reduced about 30% to 40% immediately after debridement but returned to baseline values a 3 months irrespective of treatment. PDT is not superior to conventional mechanical treatment of persistent pockets, but it may be a meaningful therapeutic alternative; the clinical effects were too minor to draw a definitive conclusion.

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSION

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