Effects of metronidazole plus amoxicillin as the only therapy on the microbiological and clinical parameters of untreated chronic periodontitis

Antibacterial activity of mulberry extracts and purified fractions against oral pathogenic bacteria

OBJECTIVES

This study aimed to isolate antibacterial compounds active against periodontopathic bacteria from mulberry (Morus alba) leaves.

METHODS

The acetone-soluble fraction of mulberry leaves was extracted from the oil layer by oil/water separation. The extract was purified using silica gel open-column chromatography. The minimum inhibitory concentration (MIC) of the crude extract or purified fractions against Porphyromonas gingivalis was measured at each step.

RESULTS

The MIC of the crude extract against P. gingivalis was 62.5-125 μg/mL. The fractions showing activity against P. gingivalis were designated Cf K and Cf P. The MICs of Cf K against P. gingivalis, Fusobacterium nucleatum, Prevotella intermedia, and Streptococcus mutans were 6.25 μg/mL, 25 μg/mL, 12.5 μg/mL, and 12.5 μg/mL, respectively. In contrast, the MICs of Cf P against P. gingivalis, F. nucleatum, P. intermedia, and S. mutans were 25.0 μg/mL, >50 μg/mL, 50 μg/mL, and 12.5-25.0 μg/mL, respectively.

CONCLUSIONS

Mulberry leaves contain antibacterial components against periodontopathic bacteria such as P. gingivalis, F. nucleatum, and P. intermedia.

Analysis of the Oral Microbiome in a Patient with Cardiofaciocutaneous Syndrome and Severe Periodontal Disease: Impact of Systemic Antibiotic Therapy

An 8-year-old girl diagnosed with cardiofaciocutaneous syndrome presented to our department with gingival pain, inflammation, and bleeding. Her medical history included hypoplasia of the corpus callosum, intellectual disability, trichothiodystrophy, global developmental delay, myopia, laryngomalacia, hypothyroidism, and osteoporosis. A diagnosis was reached of "periodontitis as a direct manifestation of systemic diseases". During 9 years of follow-up, there were exacerbation episodes with spontaneous gum bleeding, ulcers in the interdental papilla, tooth mobility, and progressive tooth loss. Some of these exacerbation episodes resolved clinically with the administration of amoxicillin and metronidazole. We therefore proposed an oral microbiome study (subgingival and saliva samples) before and after antibiotic therapy. The most abundant genera at the subgingival level before administering antibiotics were Prevotella, Streptococcus, Fusobacterium, Leptotrichia, and Aggregatibacter. Of the 94 genera sequenced, 57 were less abundant in the post-treatment state than at baseline, particularly certain Gram-negative periodontal pathogens such as Porphyromonas, Treponema, Aggregatibacter, Fusobacterium, and Campylobacter. In contrast, other genera related to oral health, such as Haemophilus, Granulicatella, and Abiotrophia, showed an increase after administering the antibiotic. In conclusion, periodontitis exacerbations as a direct manifestation of systemic disease can occasionally be controlled exclusively with systemic antibiotics, without the need for performing mechanical periodontal therapy. This clinical recovery is correlated to substantial changes in the oral microbiome, which lead to the recovery of eubiosis of the microbiota.

Fusobacterium nucleatum: The Opportunistic Pathogen of Periodontal and Peri-Implant Diseases

Peri-implant diseases are considered to be a chronic destructive inflammatory destruction/damage occurring in soft and hard peri-implant tissues during the patient’s perennial use after implant restoration and have attracted much attention because of their high incidence. Although most studies seem to suggest that the pathogenesis of peri-implant diseases is similar to that of periodontal diseases and that both begin with microbial infection, the specific mechanism of peri-implant diseases remains unclear. As an oral opportunistic pathogen, Fusobacterium nucleatum (F. nucleatum) has been demonstrated to be vital for the occurrence and development of many oral infectious diseases, especially periodontal diseases. More notably, the latest relevant studies suggest that F. nucleatum may contribute to the occurrence and development of peri-implant diseases. Considering the close connection between peri-implant diseases and periodontal diseases, a summary of the role of Fusobacterium nucleatum in periodontal diseases may provide more research directions and ideas for the peri-implantation mechanism. In this review, we summarize the effects of F. nucleatum on periodontal diseases by biofilm formation, host infection, and host response, and then we establish the relationship between periodontal and peri-implant diseases. Based on the above aspects, we discuss the importance and potential value of F. nucleatum in peri-implant diseases.

Effects of Periodontal Endoscopy-Assisted Nonsurgical Treatment of Periodontitis: Four-Month Results of a Randomized Controlled Split-Mouth Pilot Study

Objective. Although the therapeutic effects of nonsurgical periodontal therapy (NSPT) are well established, the clinical benefits of the additional use of periodontal endoscopy (PE) remain controversial. Therefore, this randomized controlled split-mouth pilot study evaluated the effect of NSPT using PE versus NSPT without nPE on bleeding on probing (BOP) in sites with probing depth (PD)≥4 mm (primary outcome), PD, clinical attachment level (CAL), number of hard deposits (HDs), and treatment time per tooth (TrT). Methods. Two calibrated operators performed NSPT in twenty periodontitis patients, randomized into two quadrants for PE or nPE treatment. BOP, PD, and CAL were recorded at the first visit for NSPT (T0) and during reevaluation (T1: mean (SD) 119.7 (24.6) days after T0). The average TrT and the number of sites with HDs were documented at T0. Results. For BOP, no significant differences were found at the patient’s level (10/10 (male/female); aged 54.3 (10.9) years) neither within or between the groups. At tooth surface level, a lower number of surfaces with BOP $\left(p=0.026\right)$ was observed in nPE. CAL and PD improved significantly during NSPT in both groups $\left(p\le 0.001\right)$ , with higher PD reduction $\left(p<0.001\right)$ and CAL gain $\left(p<0.001\right)$ in nPE. There are significantly longer TrT $\left(p<0.001\right)$ and more surfaces with subgingival HDs evident in PE at T0 $\left(p=0.001\right)$ . Conclusion. Whereas subgingival HDs can be visually detected with PE during NSPT, no additional clinical benefits regarding BOP, PD, or CAL were notable compared to conventional systematic periodontal instrumentation. Additionally, PE-assisted NSPT required a longer treatment time.

Effectiveness of Chlorhexidine and Metronidazole Gels in the management of gingivitis. A clinical trial

Objectives:

The purpose of the present study was to compare the topical application of chlorohexidine (CHX) and Metronidazole (MTZ) gels, individually and in combination in patients with gingivitis for up to 12 weeks follow-up.

Methods:

The clinical trial was conducted at Liaquat University of Medical Health Sciences (LUMHS) Jamshoro and Hyderabad, Institute of Dentistry from 1^st March 2019 to 1^st March 2020. Patients were selected based on inclusion criteria. Out of 125 screened patients, ninety-nine patients agreed to participate in the study. At the beginning of study all patients were assessed for gingival inflammation by using gingival index (GI) (Loe and silness, 1963). Scaling root planning (SRP) was performed in all patients. Subjects were randomly selected in three groups (n=33 each). In Group-A CHX gel was applied, Group-B Metronidazole gel was applied and the combination of two was applied to patients of Group-C. Patient follow up was done and gingival parameters were assessed at baseline, fourth week and twelve weeks. Apart from the clinical evaluation, a subjective evaluation was also undertaken. Significance level of 0.05 and a desired study power of at least 80% was estimated. Analysis of Variance (ANOVA) test for comparison was used within groups.

Results:

A significant improvement in gingival scores was noted in all groups from baseline. At 4 weeks CHX (1.25±0.21) MTZ (1.81±0.38) CHX+MTZ (1.29±0.34) compared to baseline CHX (2.77±0.24) MTZ (2.84±0.54) CHX+MTZ (2.74±0.31) demonstrated substantial improvement (p<0.001). However, gingival scores showed inclination at 12 weeks CHX (1.18±0.41) MTZ (1.21±0.48) CHX+MTZ (1.11±0.14) with no significant difference to week 4 (p>0.001).

Conclusion:

Local MTZ gel and MTZ+CHX gel showed effectiveness similar to CHX gel application adjunct to scaling and root planning in the treatment of gingivitis.

Peri-implantitis is not periodontitis: Scientific discoveries shed light on microbiome-biomaterial interactions that may determine disease phenotype

Peri-implantitis is an immune-mediated biological complication that is attributed to bacterial biofilms on the implant surface. As both periodontitis and peri-implantitis have similar inflammatory phenotypes when assessed cross-sectionally, treatment protocols for peri-implantitis were modeled according to those used for periodontitis. However, lack of efficacy of antimicrobial treatments targeting periodontal pathogens coupled with recent discoveries from open-ended microbial investigation studies create a heightened need to revisit the pathogenesis of peri-implantitis compared with that of periodontitis. The tale of biofilm formation on intraoral solid surfaces begins with pellicle formation, which supports initial bacterial adhesion. The differences between implant- and tooth-bound biofilms appear as early as bacterial adhesion commences. The electrostatic forces and ionic bonding that drive initial bacterial adhesion are fundamentally different in the presence of titanium dioxide or other implant alloys vs mineralized organic hydroxyapatite, respectively. Moreover, the interaction between metal surfaces and the oral environment leads to the release of implant degradation products into the peri-implant sulcus, which exposes the microbiota to increased environmental stress and may alter immune responses to bacteria. Clinically, biofilms found in peri-implantitis are resistant to beta-lactam antibiotics, which are effective against periodontal communities even as monotherapies and demonstrate a composition different from that of biofilms found in periodontitis; these facts strongly suggest that a new model of peri-implant infection is required.

Primer on etiology and treatment of progressive/severe periodontitis: A systemic health perspective

Periodontology is an infectious disease-based discipline. The etiopathology of progressive/severe periodontitis includes active herpesviruses, specific bacterial pathogens, and proinflammatory cytokines. Herpesviruses and periodontopathic bacteria may interact synergistically to produce periodontal breakdown, and periodontal herpesviruses may contribute to systemic diseases. The infectious agents of severe periodontitis reside in deep pockets, furcation lesions, and inflamed gingiva, sites inaccessible by conventional (purely mechanical) surgical or nonsurgical therapy but accessible by systemic antibiotic treatment. This brief overview presents an effective anti-infective treatment of severe periodontitis, which includes systemic chemotherapy/antibiotics against herpesviruses (valacyclovir [acyclovir]) and bacterial pathogens (amoxicillin + metronidazole or ciprofloxacin + metronidazole) plus common antiseptics (povidone-iodine and sodium hypochlorite) and select ultrasonic scaling. The proposed treatment can cause a marked reduction or elimination of major periodontal pathogens, is acceptably safe, and can be carried out in minimal time with minimal cost.

Investigation of the antimicrobial activity of Bilberry (Vaccinium myrtillus L.) extract against periodontopathic bacteria

OBJECTIVE

The purpose of this study was to isolate the active antibacterial compounds from Bilberry (Vaccinium myrtillus L.) against periodontopathic bacteria.

METHODS

The acetone soluble fraction of Bilberry was extracted from the oil layer by oil/water separation. The extract was then purified by a silica gel open column chromatography. The minimum inhibitory concentration (MIC) of the total extract or purified fractions against bacteria was measured at each step.

RESULTS

The MIC of the total extract against Porphyromonas gingivalis was 500 μg/mL. The fraction exhibiting antibacterial activity against P. gingivalis was called NU4-TDC, and its MICs against P. gingivalis, Fusobacterium nucleatum, and Prevotella intermedia were 26.0 ± 7.8 μg/mL, 59.0 ± 10.4 μg/mL, and 45.1 ± 16.5 μg/mL, respectively. The MIC against Streptococcus mutans was >62.5 μg/mL.

CONCLUSION

Bilberry contains antibacterial components against periodontopathic bacteria, such as P. gingivalis, F. nucleatum, and P. intermedia.

Periodontal herpesvirus morbidity and treatment

Four billion individuals worldwide have a history of periodontitis, with the poorest people in society most affected. Periodontitis can lead to unsightly drifting of teeth and tooth loss that may interfere with the wellbeing of daily living and has also been linked to at least 57 medical diseases and disabilities. The etiology of severe periodontitis includes active herpesviruses, specific bacterial pathogens, and destructive immune responses, but herpesviruses seem to be the major pathogenic determinant. Periodontal herpesviruses that disseminate via the systemic circulation to nonoral sites may represent a major link between periodontitis and systemic diseases. Current treatment of periodontitis focuses almost exclusively on bacterial biofilm and will require revision. Periodontal therapy that targets both herpesviruses and bacterial pathogens can provide long-term clinical improvement and potentially reduces the risk of systemic diseases. Molecular diagnostic tests for periodontal pathogens may enable early microbial identification and preemptive therapy. This review details an efficient and reliable anti-infective treatment of severe periodontitis that can be carried out in minimal time with minimal cost.

What is the influence of tonsillectomy on the level of periodontal pathogens on the tongue dorsum and in periodontal pockets

BACKGROUND

For periodontal treatment, the full mouth disinfection approach suggests disinfection of oral soft tissues, such as tongue and tonsils concomitant to scaling and root planning since patients might benefit from treatment of these oral niches either. Periodontopathogenes in tonsillar tissue support this hypothesis. This prospective controlled clinical study investigated the change in the oral flora of patients who underwent tonsillectomy. Pockets were tested for eleven bacterial species before and six weeks after the surgical intervention.

METHODS

Fifty generally healthy adults were included in this study. The test group consisted of 25 patients with tonsillectomy. The control group included 25 patients with otorhinolarynologic surgery without involvement of the oral cavity. Clinical parameters such as probing pocket depth, bleeding-on-probing index and plaque index were registered the evening before surgery. Also bacterial samples from the gingival sulcus and dorsum linguae were taken, and an additional sample from the removed tonsils in the test group. Six weeks after the intervention microbial samples of pockets and tongue were taken again. Data were tested for significant differences using Wilcoxon rank and Whitney-u-test.

RESULTS

No relevant intra- or intergroup differences were found for the change of the eleven investigated species.

CONCLUSION

Based on the results of the present study, tonsillectomy does not seem to have an immediate relevant effect on the bacterial flora of tongue or periodontium. This study design was approved by the ethical committee of Zurich (KEK-ZH-Nr.2013-0419).

TRIAL REGISTRATION

The trial was retrospectively registered in the German Clinical Trials Register ( DRK00014077 ) on February 20, 2018.

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.

The concomitant administration of systemic amoxicillin and metronidazole compared to scaling and root planing alone in treating periodontitis: =a systematic review=

Background

The treatment of periodontitis begins with a non-surgical phase that includes scaling and root planing(SRP) and on occasion the use of systemic antibiotics. The goal was to systematically evaluate in systemic healthy adults the effect of the concomitant administration of amoxicillin (amx) and metronidazole (met) adjunctive to SRP compared to SRP alone.

Methods

The PubMed-MEDLINE, Cochrane-CENTRAL and EMBASE databases were searched up to November 2014 to identify appropriate studies. Probing Pocket Depth (PD), Clinical Attachment Level (CAL), Bleeding on Pocket Probing(BOP) and Plaque Indices(PI) were selected as outcome variables. Based on the extracted data a meta-analysis was conducted.

Results

A total of 526 unique articles were found, 20 studies met the eligibility criteria. A meta-analysis showed that SRP + amx + met provided significantly better effects overall and more pronounced PD reduction in periodontal pockets initially measuring ≥6 mm (DiffM:-0.86 mm, p < 0.00001) and gain in CAL(DiffM:+0.75 mm, p = 0.0001). The meta-analysis for the secondary inflammatory parameter BOP showed that SRP + amx + met provided full mouth significantly greater reduction in BOP than SRP alone (DiffM:-6.98 %, p = 0.0001).

Conclusion

Adjunctive systemic amoxicillin and metronidazole medication to SRP significantly improved the clinical outcomes with respect to mean PD, CAL and BOP compared to SRP alone. There is moderate to strong evidence in support of the recommendation that adjunctive amx + met therapy to SRP significantly improves the clinical outcomes, with respect to mean PD and CAL compared to SRP alone especially in initially deep (≥6 mm) pockets. No major side effects associated with the intake of amx + met were reported. This treatment regimen is an efficacious, minimally invasive, practical and inexpensive approach for periodontitis therapy. The key components are mechanical tooth and pocket debridement, supportive treatment of the disease with systemic antibiotics and attention to proper self-care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12903-015-0123-6) contains supplementary material, which is available to authorized users.

Should Antibiotics Be Prescribed to Treat Chronic Periodontitis?

Although scaling and root planing is a cost-effective approach for initial treatment of chronic periodontitis, it fails to eliminate subgingival pathogens and halt progressive attachment loss in some patients. Adjunctive use of systemic antibiotics immediately after completion of scaling and root planing can enhance the degree of clinical attachment gain and probing depth reduction provided by nonsurgical periodontal treatment. This article discusses the rationale for prescribing adjunctive antibiotics, reviews the evidence for their effectiveness, and outlines practical issues that should be considered before prescribing antibiotics to treat chronic periodontitis.

Non-surgical periodontal therapy supplemented with systemically administered azithromycin: a systematic review of RCTs

BACKGROUND

Azithromycin may be an alternative adjunctive systemic antibiotic in non-surgical periodontal therapy.

OBJECTIVE

This study aims to identify randomized controlled trials evaluating non-surgical periodontal treatment of chronic and/or aggressive periodontitis supplemented with systemically administered azithromycin.

MATERIALS AND METHODS

A systematic literature search was performed for publications published by 31 March 2014 using electronic databases and hand search. Randomized controlled trials published in English or German language, with a follow-up ≥6 months were included. From 231 titles identified, nine publications were eligible for inclusion.

RESULTS

Among the studies included, showing some risk of bias, seven reported on patients with chronic periodontitis and two with aggressive periodontitis. Minor adverse events were described in five studies. A synthesis of results using a vote counting method was applied. Significant (p < 0.05) beneficial effects of azithromycin were shown in six studies for probing depth changes and in five studies for clinical attachment level changes.

CONCLUSION

In contrast to aggressive periodontitis patients, data from this analysis indicate a potential benefit of systemic azithromycin as adjunctive to non-surgical periodontal therapy in chronic periodontitis patients.

CLINICAL RELEVANCE

When contraindications for the standard antibiotics are present, azithromycin (AZM) may be considered as alternative systemically administered antibiotic drug in selected cases of chronic periodontitis.

Full mouth periodontal debridement with or without adjunctive metronidazole gel in smoking patients with chronic periodontitis: A pilot study

BACKGROUND AND OBJECTIVE

The evidence of effectiveness of metronidazole (Mtz) as an adjunct therapy to periodontal procedure in the treatment of patients with chronic periodontitis is not conclusive. The aim of this study was to compare the effect of Mtz (delivered locally as a gel or systemically as a tablet) as an adjunctive therapy with full mouth periodontal debridement (1 h of ultrasonic calculus/plaque removal) in smokers with chronic periodontitis.

MATERIAL AND METHODS

This pilot study involved 30 smokers with at least six teeth with a clinical attachment loss of ≥ 5 mm and probing pocket depth (PPD) of ≥ 5 mm. They were randomly assigned into one of three groups (n = 10): (i) 3 g daily of placebo gel applied topically (using a dental tray with the gel overnight) + periodontal debridement; (ii) 3 g daily of a 15% Mtz benzoate gel applied topically (using a dental tray with the gel overnight) + periodontal debridement; and (iii) a daily single dose of 750 mg Mtz (Flagyl(®)) + periodontal debridement. Clinical parameters (visible plaque index, gingival bleeding index [GBI], relative attachment level and PPD) and quantitative analysis (by real-time polymerase chain reaction) of Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis and Tannerella forsythia were assessed at baseline and at 1, 3 and 6 mo after periodontal debridement.

RESULTS

There was no statistically significant difference in the average GBI and visible plaque index values at baseline between the groups (p ≥ 0.05). There was no significant difference between groups in all parameters evaluated (p ≥ 0.05). Significant reductions in GBI at 3 and 6 mo were observed in all groups (p < 0.05). Significant reductions in both PPD and relative attachment level at 1, 3 and 6 mo were observed in all groups (p < 0.05). Significant reductions in bacterial levels at 7 and 30 d were observed in all groups (p < 0.05).

CONCLUSION

Adjunctive use of Mtz (gel or tablet) to periodontal debridement had similar clinical and microbiological improvement compared to treatment with placebo + periodontal debridement in smokers with chronic periodontitis up to 6 mo post-treatment. Further studies are necessary to confirm the clinical relevance of these findings.

Effects of azithromycin, metronidazole, amoxicillin, and metronidazole plus amoxicillin on an in vitro polymicrobial subgingival biofilm model

Chronic periodontitis is one of the most prevalent human diseases and is caused by dysbiosis of the subgingival microbiota. Treatment involves primarily mechanical disruption of subgingival biofilms and, in certain cases, adjunctive use of systemic antibiotic therapy. In vitro biofilm models have been developed to study antimicrobial agents targeting subgingival species. However, these models accommodate a limited number of taxa, lack reproducibility, and have low throughput. We aimed to develop an in vitro multispecies biofilm model that mimics subgingival plaque, to test antimicrobial agents. Biofilms were cultivated using the Calgary Biofilm Device and were exposed to amoxicillin (AMX), metronidazole (MTZ), azithromycin (AZM), and AMX-MTZ at four different concentrations for 12, 24, or 36 h. Chlorhexidine (CHX) (0.12%) was used as the positive control. The compositions of the biofilms were analyzed by checkerboard DNA-DNA hybridization, and the percent reduction in biofilm metabolic activity was determined using 2,3,5-triphenyltetrazolium chloride and spectrophotometry. Thirty-five of the 40 species used in the inoculum were consistently recovered from the resulting in vitro biofilms. After 36 h of exposure at the 1:27 dilution, AMX-MTZ reduced metabolic activity 11% less than CHX (q = 0.0207) but 54% more than AMX (q = 0.0031), 72% more than MTZ (q = 0.0031), and 67% more than AZM (q = 0.0008). Preliminary evidence of a synergistic interaction between AMX and MTZ was also observed. In summary, we developed reproducible biofilms with 35 subgingival bacterial species, and our results suggested that the combination of AMX and MTZ had greater antimicrobial effects on these in vitro multispecies biofilms than expected on the basis of the independent effects of the drugs.

Treatment of aggressive periodontitis

Despite etiological differences between aggressive and chronic periodontitis, the treatment concept for aggressive periodontitis is largely similar to that for chronic periodontitis. The goal of treatment is to create a clinical condition that is conducive to retaining as many teeth as possible for as long as possible. When a diagnosis has been made and risk factors have been identified, active treatment is commenced. The initial phase of active treatment consists of mechanical debridement, either alone or supplemented with antimicrobial drugs. Scaling and root planing has been shown to be effective in improving clinical indices, but does not always guarantee long-term stability. Antimicrobials can play a significant role in controlling aggressive periodontitis. Few studies have been published on this subject for localized aggressive periodontitis, but generalized aggressive periodontitis has been subject to more scrutiny. Studies have demonstrated that systemic antibiotics as an adjuvant to scaling and root planing are more effective in controlling disease compared with scaling and root planing alone or with supplemental application of local antibiotics or antiseptics. It has also become apparent that antibiotics ought to be administered with, or just after, mechanical debridement. Several studies have shown that regimens of amoxicillin combined with metronidazole or regimens of clindamycin are the most effective and are preferable to regimens containing doxycycline. Azithromycin has been shown to be a valid alternative to the regimen of amoxicillin plus metronidazole. A limited number of studies have been published on surgical treatment in patients with aggressive periodontitis, but the studies available show that the effect can be comparable with the effect on patients with chronic periodontitis, provided that proper oral hygiene is maintained, a strict maintenance program is followed and modifiable risk factors are controlled. Both access surgery and regenerative techniques have shown good results in patients with aggressive periodontitis. Once good periodontal health has been obtained, patients must be enrolled in a strict maintenance program that is directed toward controlling risk factors for disease recurrence and tooth loss. The most significant risk factors are noncompliance with regular maintenance care, smoking, high gingival bleeding index and poor plaque control. There is no evidence to suggest that daily use of antiseptic agents should be part of the supportive periodontal therapy for aggressive periodontitis.

Lessons learned and unlearned in periodontal microbiology

Periodontal diseases are initiated by bacterial species living in polymicrobial biofilms at or below the gingival margin and progress largely as a result of the inflammation elicited by specific subgingival species. In the past few decades, efforts to understand the periodontal microbiota have led to an exponential increase in information about biofilms associated with periodontal health and disease. In fact, the oral microbiota is one of the best-characterized microbiomes that colonize the human body. Despite this increased knowledge, one has to ask if our fundamental concepts of the etiology and pathogenesis of periodontal diseases have really changed. In this article we will review how our comprehension of the structure and function of the subgingival microbiota has evolved over the years in search of lessons learned and unlearned in periodontal microbiology. More specifically, this review focuses on: (i) how the data obtained through molecular techniques have impacted our knowledge of the etiology of periodontal infections; (ii) the potential role of viruses in the etiopathogenesis of periodontal diseases; (iii) how concepts of microbial ecology have expanded our understanding of host-microbe interactions that might lead to periodontal diseases; (iv) the role of inflammation in the pathogenesis of periodontal diseases; and (v) the impact of these evolving concepts on therapeutic and preventive strategies to periodontal infections. We will conclude by reviewing how novel systems-biology approaches promise to unravel new details of the pathogenesis of periodontal diseases and hopefully lead to a better understanding of their mechanisms.

Concentrations of metronidazole in human plasma and saliva after tablet or gel administration

OBJECTIVES

The aim of this study was to determine the pharmacokinetic profile of metronidazole (Mtz) tablet and to compare Mtz gel and tablet concentrations in both blood plasma and saliva.

METHODS

In this randomized cross-over study with a 1-week washout period, 13 volunteers randomly received one (a single oral dose of 750 mg Mtz (Flagyl®--tablet) and 2) 3 g of 15% Mtz benzoate gel (applied by using a dental tray). The HPLC with ultraviolet detection was used to quantify plasma and saliva concentrations of Mtz. The pharmacokinetic parameters (PPs) areas under the curves from 0 to 48 h (AUC0-48) and from 0 to infinity (AUC0-∞), the maximum plasma concentration (C(max)), the time to C(max), volume of distribution and renal clearance were determined for Mtz tablet.

KEY FINDINGS

Considering the Mtz tablet, plasma showed higher Mtz concentration from 6 to 24 h after drug administration and the highest values concerning AUC0-48 h and AUC0-∞ than those obtained in saliva (P < 0.05). No significant differences were observed between plasma and saliva concentrations for Mtz gel.

CONCLUSIONS

The study showed that some PPs were higher in plasma (P < 0.05) than in saliva concerning Mtz tablet. Gel formulation had similar Mtz bioavailability in plasma and saliva resulting in systemic absorption.

Periodontal disease as a risk factor for bisphosphonate-related osteonecrosis of the jaw

BACKGROUND

Previous case reports and animal studies suggest that periodontitis is associated with bisphosphonate-related osteonecrosis of the jaw (BRONJ). This case-control study is conducted to evaluate the association between clinical and radiographic measures of periodontal disease and BRONJ.

METHODS

Twenty-five patients with BRONJ were matched with 48 controls. Trained examiners measured probing depth, clinical attachment level (CAL), and bleeding on probing on all teeth except third molars and gingival and plaque indices on six index teeth. Alveolar bone height was measured from orthopantomograms. Most patients with BRONJ were using antibiotics (48%) or a chlorhexidine mouthrinse (84%) at enrollment. Adjusted comparisons of patients with BRONJ versus controls used multiple linear regression.

RESULTS

The average number of bisphosphonate (BP) infusions was significantly higher in patients with BRONJ compared with controls (38.4 versus 18.8, P = 0.0001). In unadjusted analyses, patients with BRONJ had more missing teeth (7.8 versus 3.1, P = 0.002) and higher average CAL (2.18 versus 1.56 mm, P = 0.047) and percentage of sites with CAL ≥3 mm (39.0 versus 23.3, P = 0.039) than controls. Also, patients with BRONJ had lower average bone height (as a fraction of tooth length, 0.59 versus 0.62, P = 0.004) and more teeth with bone height less than half of tooth length (20% versus 6%, P = 0.001). These differences remained significant after adjusting for age, sex, smoking, and number of BP infusions.

CONCLUSIONS

BRONJ patients have fewer teeth, greater CAL, and less alveolar bone support compared with controls after adjusting for number of BP infusions. Group differences in antibiotics and chlorhexidine rinse usage may have masked differences in the other clinical measures.

Low-cost periodontal therapy

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

Microbial sampling process can change results of microbiological analysis in periodontitis diagnosis. A minireview

This minireview aims to verify the supposition that the microbial sampling process can change results of microbiological analysis in periodontitis diagnosis. The literature search via Pubmed yielded 52 appropriate articles for analysis. Of which 38% (20/52) described that the sampling sites were isolated from saliva, whereas 62% (32/52) did not. Also, 29% (15/52) declared that the microbial sampling was performed before probing pocket depth (PPD), whereas 71% (37/52) did not. Comparison of the results of microbiological analysis in these studies showed that the bacteria most frequently detected in periodontal pockets was variable. Therefore, a sampling process that includes both the microbial sample being taken before PPD and saliva isolation of the sampling sites is needed to ensure the accuracy of microbiological analysis in periodontitis diagnosis.

Novel and often bizarre strategies in the treatment of periodontal disease

Treatment of periodontal disease involves complex mechanical, surgical, and medical modalities. Some of the treatment regimens are patient centered, some involve a great amount of technical expertise and competence from a practitioner, and often involve complex procedures like use of tissue-engineered products. In spite of several advances, treatment of periodontal disease depends on scaling and root planing and various surgical procedures as the mainstay, but results of treatment are not always predictable and are often frustrating. The ultimate aim of periodontal treatment is regeneration of periodontal tissues and more particularly lost alveolar bone support. The treatment options include a myriad of approaches and scientists and researchers have tried various tools and agents to improve alveolar bone status and improve periodontal health. These approaches vary from simple monotherapy with systemic antibiotic usage to exotic and novel procedures like shock wave therapy, photodynamic therapy and application.

The clinical effect of scaling and root planing and the concomitant administration of systemic amoxicillin and metronidazole: a systematic review

BACKGROUND

The treatment of periodontitis frequently begins with a non-surgical phase that includes scaling and root planing (SRP) and, on occasion, the use of systemic antibiotics. The goal of this review is to systematically evaluate the data concerning the effect of the concomitant administration of amoxicillin and metronidazole adjunctive to SRP in adults who are otherwise healthy.

METHODS

The PubMed-MEDLINE, Cochrane-Central, and EMBASE databases were searched to April 1, 2012, to identify appropriate studies. Probing depth (PD), clinical attachment level (CAL), bleeding on probing, and plaque index were selected as outcome variables. Based on the extracted mean values and number of individuals, changes in weighted means were calculated and a meta-analysis conducted.

RESULTS

The search yielded 526 unique titles and abstracts. Ultimately, 35 studies were selected, describing 28 clinical trials meeting the eligibility criteria. The full-mouth weighted mean change for PD showed an improvement of 1.41 mm. The full-mouth weighted mean change for CAL showed a gain of 0.94 mm.

CONCLUSION

Systemic antimicrobial therapy using a combination of amoxicillin and metronidazole as an adjunct to SRP can enhance the clinical benefits of non-surgical periodontal therapy in adults who are otherwise healthy.

Effects of systemic sitafloxacin on periodontal infection control in elderly patients

OBJECTIVE

To evaluate the microbiological and clinical effects of the systemic administration of sitafloxacin (STFX) on periodontal pockets in elderly patients receiving supportive periodontal therapy (SPT).

BACKGROUND

Periodontitis is a risk factor for atherosclerosis. Better periodontal health contributes to reduce atherosclerosis-related diseases in elderly population.

MATERIALS AND METHODS

Forty-four patients undergoing SPT were randomly assigned to two groups: a test group took 100 mg/day of STFX for five consecutive days, or a control group received scaling and root planing (SRP) under local anaesthesia. Microbiological and clinical parameters were examined at baseline and at 1 and 3 months after therapy.

RESULTS

The presence of Porphyromonas gingivalis, Treponema denticola and Tannerella forsythia was significantly reduced at 1 month after treatment in both groups. The median reductions of the bacteria between the baseline and 1 month were 3.08 and 2.54% in the STFX- and SRP-treated groups, respectively. Both treatments significantly decreased the probing depth at 1 and 3 months compared to the baseline.

CONCLUSION

The systemic administration of STFX is effective at improving periodontal health during SPT and could be an alternative to SRP for elderly patients who cannot undergo anaesthesia or are at risk of tissue injury.

Effectiveness of systemic amoxicillin/metronidazole as an adjunctive therapy to full-mouth scaling and root planing in the treatment of aggressive periodontitis: a systematic review and meta-analysis

BACKGROUND

The systemic use of combined amoxicillin and metronidazole (AMX/MET) as an adjunctive treatment to full-mouth scaling and root planing (FMSRP) has been proposed for the treatment of generalized aggressive periodontitis; however, its effectiveness and clinical safety remain to be defined. The purpose of the present meta-analysis is to assess the effectiveness of FMSRP + AMX/MET compared to FMSRP alone.

METHODS

An electronic search of eight databases and a hand-search of 10 international dental journals were conducted through September 11, 2011. Gain in clinical attachment level (CAL), reduction in probing depth (PD), secondary outcomes, and adverse events were analyzed. A random-effect model was used to pool the extracted data. The weighted mean difference (MD) with 95% confidence interval (CI) was calculated for continuous outcomes, whereas risk difference (RD) with 95% CI was used for dichotomous data; heterogeneity was assessed with the χ(2)-based Cochran Q test and I(2) statistic. The level of significance was set at P <0.05.

RESULTS

After the selection process, six randomized clinical trials were included. Results of the meta-analysis showed significant CAL gain (MD, 0.42; 95% CI, 0.23 to 0.61; P <0.05) and PD reduction (MD, 0.58; 95% CI, 0.39 to 0.77; P <0.05) in favor of FMSRP + AMX/MET; moreover, no significant RD was found in the occurrence of adverse events (RD, 0.01; 95% CI, -0.02 to 0.04; P >0.05).

CONCLUSION

The findings of the meta-analysis seem to support the effectiveness and the clinical safety of FMSRP + AMX/MET; however, future studies are needed to confirm these results.

The impact of antimicrobial photodynamic therapy in an artificial biofilm model

The susceptibility of bacterial cultures in biofilm formations is important for a variety of clinical treatment procedures. Therefore, the aim of the study was to assess the impact of laser-induced antimicrobial photodynamic therapy on the viability of Streptococcus mutans cells employing an artificial biofilm model. Using sterile chambered coverglasses, a salivary pellicle layer was formed in 40 chambers. Streptococcus mutans cells were inoculated in a sterile culture medium. Employing a live/dead bacterial viability kit, bacteria with intact cell membranes stained fluorescent green. Each pellicle-coated test chamber was filled with 0.7 ml of the bacterial suspension and analysed using a confocal laser scanning microscope within a layer of 10 μm at intervals of 1 μm from the pellicle layer. Phenothiazine chloride was used as a photosensitizer in all 40 test chambers. A diode laser (wavelength 660 nm, output power 100 mW) was used to irradiated 20 chambers for 2 min. Fluorescence values in the test chambers after laser irradiation (median 2.1 U, range 0.4-3.4 U) were significantly lower than baseline values after adding the photosensitizer (median 3.6 U, range 1.1-9.0; p < 0.05). The non-irradiated control chambers showed no change in fluorescence at the end of an additional photosensitizer residence time of 2 min without laser irradiation (median 1.9 U, range 0.7-3.6; median 1.9 U, range 0.8-6.0, respectively; p > 0.05). The present study indicated that laser irradiation is an essential part of antimicrobial photodynamic therapy to reduce bacteria within a layer of 10 μm. Further studies are needed to evaluate the maximum biofilm thickness that still allows a toxic effect on microorganisms.

Effects of toluidine blue-mediated photodynamic therapy on periopathogens and periodontal biofilm: in vitro evaluation

Photodynamic therapy (PDT) is a selective modality of killing targeted cells, mostly known for its application in neoplasms. PDT can be considered to be an alternative method for the elimination of periodontal bacteria from the pocket without harms for the resident tissues. Therefore, PDT may replace systemic antibiotics and enhance the effect of mechanical treatments of periodontal defects. This effort focused on the in vitro sensitization of periopathogens (Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Fusobacterium nucleatum and Prevotella intermedia ) Toluidine Blue mediated and on the use of a Diode laser emitting source. The objective of this research was to evaluate the bactericidal in vitro effect of laser diodes 830 nm (as the light source) after photosensitization with Toluidine Blue (TBO) on the following periopathogenic bacteria: Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Fusobacterium nucleatum and Prevotella intermedia. After evaluating the effect on the single bacterial strain, the ability of Diode Laser to disrupt the structure of biofilms produced by A. actinomycetemcomitans after photosensitization with TBO was also analyzed. The study suggests that the association of TBO and diode laser light 830 nm is effective for the killing of bacteria strains and determines the photoinactivation of Aggregatibacter biofilms. In summary, photodynamic therapy has effectively shown its capabilities and, therefore, it can be considered a valid alternative approach to antimicrobial therapy of periodontitis.

Periodontal treatment did not prevent complications of pregnancy

DESIGN

A randomised controlled trial (RCT) was conducted.

INTERVENTION

Women found to have a periodontal disease were randomly allocated to receive periodontal treatment in midpregnancy (this was the treatment group; n = 542) or after the pregnancy was concluded (the control group; n = 540). Periodontal disease was defined as presence of periodontal pockets of 4 mm or greater in depth at 12 or more probing sites in fully erupted teeth (typically excluding wisdom teeth). Treatments were conducted either by the hygienists or periodontists and included nonsurgical debridement of the subgingival and supragingival plaque, removal of local predisposing factors such as calculus, root planing, and adjustment of overhanging restorations. Comprehensive oral hygiene instructions and motivation were provided at each visit at a minimum of three weekly visits, with further visits if required.

OUTCOME MEASURE

The primary outcomes were preterm birth or other major complications of pregnancy.

RESULTS

There were no differences between the control and treatment groups in terms of: preterm birth [9.3% compared with 9.7%; odds ratio (OR), 1.05; 95% confidence interval (CI), 0.7-1.58; P 0.81); birthweight (3450 g versus 3410 g; P 0.12); pre-eclampsia (4.1% versus 3.4%; OR, 0.82; 95% CI, 0.44-1.56; P 0.55); or other obstetric endpoints. There were four unexplained stillbirths in the control group and no pregnancy losses in the treated group (P 0.12). Measures of foetal and neonatal wellbeing were similar in the two groups, including abnormalities in foetal heart rate recordings (P 0.26), umbilical artery flow studies (P 0.96), and umbilical artery blood gas values (P 0.37). The periodontal treatment was highly successful in improving health of the gums (P<0.01).

CONCLUSIONS

The evidence provided by the present study does not support the hypothesis that treatment of periodontal disease during pregnancy in this population prevents preterm birth, foetal growth restriction, or pre-eclampsia. Periodontal treatment was not hazardous to the women or their pregnancies.

Antimicrobial therapy in periodontitis: the use of systemic antimicrobials against the subgingival biofilm

OBJECTIVES

The aim was to answer three relevant questions: can systemic antimicrobials be efficacious if the biofilm is not disrupted? Can the type of debridement of the subgingival biofilm impact upon the clinical outcomes of the adjunctive antimicrobial therapy? Is the efficacy of the adjunctive systemic antimicrobial therapy dependent on the quality of the debridement of the subgingival biofilm and the sequence debridement-antibiotic usage?

MATERIAL AND METHODS

Relevant papers were searched, critically analysed and their data were extracted.

RESULTS

For the first question, studies assessing susceptibility of bacteria in biofilms, and clinical studies evaluating systemic antimicrobials as monotherapy, were reviewed. For the second question, clinical studies comparing systemic antimicrobials as adjuncts to non-surgical debridement or to periodontal surgery and clinical trials using systemic antibiotics with periodontal surgery were evaluated. For the third question, a previous systematic review was updated.

CONCLUSION

If systemic antimicrobials are indicated in periodontal therapy, they should be adjunctive to mechanical debridement. There is not enough evidence to support their use with periodontal surgery. Indirect evidence suggests that antibiotic intake should start on the day of debridement completion, debridement should be completed within a short time (preferably <1 week) and with an adequate quality, to optimize the results.

Controlling systematic perioperative anaerobic contamination during sinus-lift procedures by using metronidazole: an innovative approach

BACKGROUND AND OBJECTIVES

Analysis of tomodensitometric controls following sinus grafts clearly demonstrates a quite systematic lack of homogeneity. Sinus contamination by anaerobic bacteria seems almost unavoidable during bone graft surgery, and this problem may jeopardize the healing process. The aim of this study was to characterize in a systematic way the nonhomogeneities observed at 1, 2, or 3 months postsurgery within allogenous sinus grafts, and to assess the possible influence of a 0.5% sterile solution of metronidazole incorporated in the sinus bone graft.

MATERIALS

This clinical study was conducted on 72 patients treated with single or bilateral sinus-lifts: 94 sinus elevations performed with freeze-dried bone allograft (Phoenix, TBF, Mions, France), with (test group) or without (control group) metronidazole. In the test group, each bone graft was hydrated with 2 mL of a 0.5% metronidazole solution, i.e., only 10 mg of metronidazole. All the patients went through a first presurgical computerized tomography (CT)-scan followed by a second scan performed at 1, 2, or 3 months postsurgery (which was used as the preimplant reference scan). For 11 patients, 2 postsurgical CT-scans were performed respectively at 10 days and 2 months. Using an arbitrary gray scale (Arbitrary Densitometric Unit) which functions according to the Hounsfield unit principle, the degree of radiographic homogeneity of the grafts was established. Density scattering provides some information on the homogeneity or nonhomogeneity of the bone graft.

RESULTS

The 12 grafts performed without metronidazole show significant nonhomogeneities at 1, 2, or 3 months. Moreover, when a CT-scan is performed during the first postoperative days (at 10 days), the presence of air bubbles in the graft is confirmed. The tomodensitometric aspects of all grafts treated with metronidazole in this series are absolutely identical: they show a high degree of homogeneity. Sixty-three cases (76.8%) are homogeneous, and 19 cases (23.2%) are significantly homogeneous. The time at which the control scan is performed (10 days, 1, 2, or 3 months) does not seem to influence significantly the degree of homogeneity assessed. In the control group, some inflammatory events associated with facial oedema were observed in 25% of the cases. In the test group, no such event was recorded for the 82 sinus-lifts treated with metronidazole.

CONCLUSION

A possible correlation may exist between the occurrence of non homogeneities within the bone grafts and the anaerobic bacterial contamination. The local use of a very small quantity of metronidazole (equivalent to only 1/20 of a common 200 mg oral tablet) could provide more security when performing sinus-lift procedures and an improved quality of the graft. This protocol should not be considered as an antibiotherapy, but only as way to limit the initial contamination of bone graft.

Comparison Between Full-Mouth Scaling and Root Planing and Quadrant-Wise Basic Therapy of Aggressive Periodontitis: 6-Month Clinical Results

BACKGROUND

The aim of this study was to test the hypothesis that there are no differences in clinical parameters in generalized aggressive periodontitis patients after full-mouth scaling and root planing (FRP) or quadrant-wise basic periodontal therapy (BPT) when combined with an antibiotic regimen.

METHODS

Patients were allocated randomly to BPT (N = 15; mean age: 29.5 +/- 5.7 years) or FRP (N = 15; mean age: 28.4 +/- 5.7 years). All subjects received oral hygiene instructions including the use of a 0.12% chlorhexidine mouthrinse solution twice a day for 2 months. Patients also received amoxicillin, 500 mg, and metronidazole, 250 mg, three times a day for 7 days. Probing depth (PD), clinical attachment level, visible plaque, and bleeding on probing were recorded at baseline and at 2, 4, and 6 months post-therapy. Statistically significant changes within and between groups were determined using the general linear model repeated measures procedure.

RESULTS

Both groups showed a significant improvement in all clinical parameters post-therapy, which was particularly evident at 2 months in the sites that had been deepest at baseline. For instance, the mean PD at sites with mean PD > or =7 mm at baseline had decreased 3.9 mm in the BPT group and 3.6 mm in the FRP group. At 6 months, the percentage of sites with PD > or =7 mm decreased from 13.2% +/- 3.2% to 0% in the BPT group and from 13.3% +/- 3.5% to 0.2% +/- 0.1% in the FRP group. No statistically significant differences were observed between groups for most clinical parameters.

CONCLUSION

Within the limits of the present investigation, FRP and BPT caused comparable clinical effects in aggressive periodontitis patients when an adjunctive combined antibiotic regimen was included.

Clinical changes following four different periodontal therapies for the treatment of chronic periodontitis: 1-year results

OBJECTIVE

To compare clinical changes occurring in chronic periodontitis subjects receiving SRP alone or with systemically administered azithromycin, metronidazole or a sub-antimicrobial dose of doxycycline.

MATERIAL AND METHODS

92 chronic periodontitis subjects were randomly assigned to receive SRP alone (N=23) or combined with 500 mg azithromycin per day for 3 days (N=25), 250 mg metronidazole tid for 14 days (N=24) or 20 mg doxycycline bid for 3 months (N=20). Gingival redness, bleeding on probing, suppuration, pocket depth and attachment level were measured at baseline and 3, 6 and 12 months post therapy. The significance of changes in clinical parameters within groups over time was sought using the Friedman test and among groups using ANCOVA or the Kruskal Wallis test.

RESULTS

All groups showed clinical improvements at 12 months, with subjects receiving adjunctive agents showing a somewhat better response. Sites with initial pocket depth > 6 mm showed significantly greater pocket depth reduction and greater attachment gain in subjects receiving metronidazole or azithromycin than subjects in the other groups. Some subjects showed attachment loss at 12 months in each group ranging from 15% to 39% of subjects in the SDD and SRP only groups respectively.

CONCLUSION

This study, demonstrated that periodontal therapy provides clinical benefits and that antibiotics provide a clinical benefit over SRP alone, particularly at initially deeper periodontal pockets.

Psychological approaches may improve oral hygiene behaviour

DATA SOURCES

The Cochrane Oral Health Group's Trials Register, Cochrane Central Register of Controlled Trials, Medline, Embase, Psychinfo, Ingenta and Cumulative Index to Nursing and Allied Health Literature were searched, along with the reference lists from relevant articles. The authors of eligible trials were contacted to identify further studies and obtain additional information. Four journals were searched by hand (Journal of Health Psychology, Psychology and Health, Psychology Health and Medicine, Health Psychology - Update). No language restriction was applied.

STUDY SELECTION

Randomised controlled trials were selected that tested the effectiveness of interventions based on psychological models, comparing them with educational, attention or no active intervention controls, to improve adherence to oral hygiene in adults with either gingivitis or periodontitis. Only trials with at least 3 weeks' followup were included. Interventions aimed at encouraging smoking cessation were not included.

DATA EXTRACTION AND SYNTHESIS

Titles and abstracts of studies that were potentially relevant to the review were independently screened by two review authors. Those that were clearly ineligible were rejected. For the remaining studies, the full paper was reviewed by two review authors and, where necessary, further information was sought from the author to verify eligibility. The quality of included studies was assessed using standard criteria.

RESULTS

Four studies (of 344 participants) were found in which a psychological model or theory had been explicitly used as the basis for the design of the intervention. The overall quality of trials was low. Because of the heterogeneity of studies, both in terms of outcome measures and psychological models adopted, a meta-analysis was not possible. The four studies adopted four different theoretical frameworks, although there was some overlap in that three of the studies incorporated elements of Operant and Classical Conditioning. Psychological interventions resulted in improved plaque scores compared with no-intervention groups, and in one study compared with an attention control group. One study found decreased gingival bleeding in the active intervention group but no change in pocket depth or attachment loss after 4 months. Psychological interventions were associated with improved self-reported brushing and flossing in both the studies that assessed these behaviours. Only one study explored the impact of psychological interventions on beliefs and attitudes: the psychological intervention, when compared with educational and no-intervention controls, showed improved self-efficacy beliefs in relation to flossing, but no effect on dental knowledge or self-efficacy beliefs in relation to tooth brushing.

CONCLUSIONS

There is some evidence from low-quality studies that psychological approaches to behaviour management, such as the use of reinforcement, goal setting and the provision of feedback, can improve oral hygiene and oral hygiene-related behaviours. The design of the interventions was weak and limited, however, and ignored key aspects of the theories. All the studies reported here also relied upon the provision of guidance by personnel other than the practitioner. There is no evidence that the use of such an approach by the practitioner with his or her patients would be beneficial. Thus, there is a need for greater methodological rigour in the design of trials in this area.

No evidence to support the use of low-dose doxycycline as an adjunct to nonsurgical therapy in smokers

DESIGN

This was a randomised, placebo-controlled trial with 6 months of follow-up.

INTERVENTION

Patients received nonsurgical periodontal therapy and 3 months of the test treatment (low-dose doxycycline; LDD) or control (inactive identical placebo).

OUTCOME MEASURE

The primary outcome was the change in the clinical attachment level (CAL) recorded from the cemento-enamel junction to the base of the probing pocket using a graduated UNC-15 probe (Hu Friedy, Chicago, Illinois, USA). Secondary outcomes included pocket depth, gingival recession and bleeding on probing recorded at six sites per tooth with the manual probe and ICTP (terminal carboxytelopeptide of type 1 collagen).

RESULTS

The velocity of change was statistically significantly greater for the test group for CAL [-0.19 mm/ month; 95% confidence interval (CI), -0.34- -0.04; P 0.012] and probing depth (0.30 mm/ month; 95% CI, -0.42- -0.17; P 0.001). No differences were observed, however, for absolute change in clinical or biochemical markers at 6 months.

CONCLUSIONS

Nonsurgical periodontal therapy in smokers can produce a substantial improvement in periodontal health but there is no evidence to support the use of LDD as an adjunct to their nonsurgical therapy. Quitting tobacco use continues to be of fundamental importance in improving the periodontal health of these individuals.