A double-masked Randomized Clinical Trial (RCT) comparing four periodontitis treatment strategies: 5-year clinical results

Five-year radiological findings from a randomized controlled trial of four periodontitis treatment strategies

Radiographic findings from long-term studies of periodontitis treatment have rarely been reported. Although bone destruction is a prominent feature of periodontitis, the long-term effect on alveolar bone levels of different treatment strategies, with or without adjunctive metronidazole (MTZ), has not been reported. We investigated the 5-year radiographic outcome of therapy in patient groups treated with conventional scaling and root planing (SRP) or same-day full-mouth disinfection (FDIS), with or without adjunctive MTZ. Following a 3-month oral hygiene phase, 184 periodontitis patients were randomly allocated to one of four treatment regimens: (i) FDIS+MTZ; (ii) FDIS+placebo; (iii) SRP+MTZ; or (iv) SRP+placebo. Following active treatment, patients received biannual maintenance. In total, 161 patients (87.5%) completed the 5-year follow-up examination, at which the radiographic bone level (RBL), clinical attachment level, probing pocket depth, presence of plaque, and bleeding were recorded again. At the 5-year follow up examination, minor radiological bone loss was observed in the intervention groups FDIS+placebo, SRP+MTZ, and SRP+placebo; by contrast, the FDIS+MTZ group did not show any change in RBL. Full-mouth disinfection did not generally perform better than conventional SRP performed over a period of 2 to 4 weeks.

Efficacy of Periodontal Endoscopy during Subgingival Debridement to Treat Periodontitis: A Systematic Review of Randomized Clinical Trials

This study aims to evaluate the clinical efficacy of periodontal endoscopy (PEND) during subgingival debridement to treat periodontitis. A systematic review of randomized clinical trials (RCTs) was performed. The search strategy included four databases: PubMed, Web of Sciences, Scopus, and Scielo. The initial online exploration generated 228 reports, and 3 RCTs met the selection criteria. These RCTs described a statistically significant decrease in probing depth (PD) in the PEND group compared to controls after 6 and 12 months of follow-up. The improvement in PD was 2.5 mm for PEND and 1.8 mm for the control groups, respectively (p < 0.05). It was also described that the PEND group presented a significantly inferior proportion of PD 7 to 9 mm at 12 months (0.5%) as compared to the control group (1.84%) (p = 0.03). All RCTs noted improvements in clinical attachment level (CAL). It was described as having significant differences in bleeding on probing (BOP) in favor of PEND, with an average reduction of 43% versus 21% in the control groups. Similarly, it was also presented that they were significant differences in plaque indices in favor of PEND. PEND during subgingival debridement to treat periodontitis demonstrated efficacy in reducing PD. Improvement was also observed in CAL and BOP.

Tooth preservation vs. extraction and implant placement in periodontally compromised patients: A systematic review and analysis of studies

PURPOSE

The aim of this systematic review was to identify studies with a minimum of 5-years follow-up, reporting on the management of periodontally compromised teeth with either extraction and subsequent implant placement or teeth preservation with conventional periodontal treatment and application of regenerative procedures. The outcomes of these two approaches, based on clinical and radiographic data and the incidence of tooth- and implant-loss, were also investigated.

MATERIAL AND METHODS

A systematic search for studies reporting on clinical and radiographic outcomes of periodontal treatment or replacement of periodontally compromised teeth with implants was conducted in 3 electronic databases, followed by a hand-search in 8 journals. Only randomized controlled trials (RCTs), cohort studies, and case series with prospective design were included.

RESULTS

The initial search resulted in 1080 papers. After the first two screenings, 24 publications were selected for inclusion in this systematic review. The treatment protocols for the teeth preservation group contained nonsurgical and/or surgical periodontal treatment with or without regeneration procedures. The implant studies included extraction of periodontally involved teeth and implant placement with or without bone and soft tissue augmentation, followed by restoration with fixed dental prostheses (FDPs). Survival rates ranged between 81.8% and 100% in the tooth retention group, and between 94.8% and 100% in the implant group. In the extraction group, no complications were reported for 76.09% of the implants. Similarly, no complications were reported for 86.83% of the tooth retention group. The lack of standardized comparable studies prohibited conduction of a metaanalysis.

CONCLUSION

Both treatment approaches, treatment of periodontally compromised teeth, or tooth extraction followed by implant placement, present high survival rates. The application of bone regeneration techniques improves the long-term prognosis of periodontally involved teeth. Hence, treatment of periodontally involved teeth with subsequent application of a rigorous maintenance protocol can be a viable alternative for a number of years, before proceeding to extraction and replacement with dental implants. More well-designed randomized controlled trials are needed in order to draw definite conclusions on the subject.

Full-mouth treatment modalities (within 24 hours) for periodontitis in adults

BACKGROUND

Periodontitis is a highly prevalent, chronic inflammation that causes damage to the soft tissues and bones supporting the teeth. Conventional treatment is quadrant scaling and root planing (the second step of periodontal therapy), which comprises scaling and root planing of teeth in one quadrant of the mouth at a time, with the four different sessions separated by at least one week. Alternative protocols for anti-infective periodontal therapy have been introduced to help enhance treatment outcomes: full-mouth scaling (subgingival instrumentation of all quadrants within 24 hours), or full-mouth disinfection (subgingival instrumentation of all quadrants in 24 hours plus adjunctive antiseptic). We use the older term 'scaling and root planing' (SRP) interchangeably with the newer term 'subgingival instrumentation' in this iteration of the review, which updates one originally published in 2008 and first updated in 2015.

OBJECTIVES

To evaluate the clinical effects of full-mouth scaling or full-mouth disinfection (within 24 hours) for the treatment of periodontitis compared to conventional quadrant subgingival instrumentation (over a series of visits at least one week apart) and to evaluate whether there was a difference in clinical effects between full-mouth disinfection and full-mouth scaling.

SEARCH METHODS

An information specialist searched five databases up to 17 June 2021 and used additional search methods to identify published, unpublished and ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) lasting at least three months that evaluated full-mouth scaling and root planing within 24 hours, with or without adjunctive use of an antiseptic, compared to conventional quadrant SRP (control). Participants had a clinical diagnosis of (chronic) periodontitis according to the International Classification of Periodontal Diseases from 1999. A new periodontitis classification was launched in 2018; however, we used the 1999 classification for inclusion or exclusion of studies, as most studies used it. We excluded studies of people with systemic disorders, taking antibiotics or with the older diagnosis of 'aggressive periodontitis'.

DATA COLLECTION AND ANALYSIS

Several review authors independently conducted data extraction and risk of bias assessment (based on randomisation method, allocation concealment, examiner blinding and completeness of follow-up). Our primary outcomes were tooth loss and change in probing pocket depth (PPD); secondary outcomes were change in probing attachment (i.e. clinical attachment level (CAL)), bleeding on probing (BOP), adverse events and pocket closure (the number/proportion of sites with PPD of 4 mm or less after treatment). We followed Cochrane's methodological guidelines for data extraction and analysis.

MAIN RESULTS

We included 20 RCTs, with 944 participants, in this updated review. No studies assessed the primary outcome tooth loss. Thirteen trials compared full-mouth scaling and root planing within 24 hours without the use of antiseptic (FMS) versus control, 13 trials compared full-mouth scaling and root planing within 24 hours with adjunctive use of an antiseptic (FMD) versus control, and six trials compared FMS with FMD. Of the 13 trials comparing FMS versus control, we assessed three at high risk of bias, six at low risk of bias and four at unclear risk of bias. We assessed our certainty about the evidence as low or very low for the outcomes in this comparison. There was no evidence for a benefit for FMS over control for change in PPD, gain in CAL or reduction in BOP at six to eight months (PPD: mean difference (MD) 0.03 mm, 95% confidence interval (CI) -0.14 to 0.20; 5 trials, 148 participants; CAL: MD 0.10 mm, 95% CI -0.05 to 0.26; 5 trials, 148 participants; BOP: MD 2.64%, 95% CI -8.81 to 14.09; 3 trials, 80 participants). There was evidence of heterogeneity for BOP (I² = 50%), but none for PPD and CAL. Of the 13 trials comparing FMD versus control, we judged four at high risk of bias, one at low risk of bias and eight at unclear risk of bias. At six to eight months, there was no evidence for a benefit for FMD over control for change in PPD or CAL (PPD: MD 0.11 mm, 95% CI -0.04 to 0.27; 6 trials, 224 participants; low-certainty evidence; CAL: 0.07 mm, 95% CI -0.11 to 0.24; 6 trials, 224 participants; low-certainty evidence). The analyses found no evidence of a benefit for FMD over control for BOP (very low-certainty evidence). There was no evidence of heterogeneity for PPD or CAL, but considerable evidence of heterogeneity for BOP, attributed to one study. There were no consistent differences in these outcomes between intervention and control (low- to very low-certainty evidence). Of the six trials comparing FMS and FMD, we judged two trials at high risk of bias, one at low risk of bias and three as unclear. At six to eight months, there was no evidence of a benefit of FMD over FMS for change in PPD or gain in CAL (PPD: MD -0.11 mm, 95% CI -0.30 to 0.07; P = 0.22; 4 trials, 112 participants; low-certainty evidence; CAL: MD -0.05 mm, 95% CI -0.23 to -0.13; P = 0.58; 4 trials, 112 participants; low-certainty evidence). There was no evidence of a difference between FMS and FMD for BOP at any time point (P = 0.98; 2 trials, 22 participants; low- to very low-certainty evidence). There was evidence of heterogeneity for BOP (I² = 52%), but not for PPD or CAL. Thirteen studies predefined adverse events as an outcome; three reported an event after FMD or FMS. The most important harm identified was an increase in body temperature. We assessed the certainty of the evidence for most comparisons and outcomes as low because of design limitations leading to risk of bias, and the small number of trials and participants, leading to imprecision in the effect estimates.

AUTHORS' CONCLUSIONS

The inclusion of nine new RCTs in this updated review has not changed the conclusions of the previous version of the review. There is still no clear evidence that FMS or FMD approaches provide additional clinical benefit compared to conventional mechanical treatment for adult periodontitis. In practice, the decision to select one approach to non-surgical periodontal therapy over another should include patient preference and the convenience of the treatment schedule.

Adjunctive efficacy of systemic metronidazole in the surgical treatment of periodontitis: a double-blind parallel randomized clinical trial

OBJECTIVES

The purpose of this study was to evaluate the clinical and microbiological impact of adjunctive metronidazole to periodontal surgery.

MATERIALS AND METHODS

Systemically healthy patients, with stages III-IV, grades B-C periodontitis, were randomly assigned to receive metronidazole or placebo adjunctive to periodontal surgery, after subgingival instrumentation. Clinical variables were recorded at the initial visit, 6 weeks after subgingival instrumentation, and 3, 6, and 12 months after surgery. Microbiological samples were taken at initial and final visits and analyzed by quantitative polymerase chain reaction.

RESULTS

Our results showed no statistically significant differences in the reduction of probing depth between the initial and final (1 year) visits in the two treatment groups. Additionally, no statistically significant differences were observed between study groups when comparing the post-subgingival instrumentation and final visits. However, 3 months after surgery, probing depth (mean difference, MD = 0.31 mm, 95% confidence interval, CI [0.13; 0.49]; p = 0.001) and clinical attachment level (MD = 0.64 mm, 95% CI [0.02; 1.27]; p = 0.044) were significantly lower in the test group.

CONCLUSIONS

The adjunctive use of systemic metronidazole to periodontal surgery has a limited clinical and microbiological impact in the present study, and therefore, its use is not recommended.

CLINICAL RELEVANCE

There are no studies that have evaluated the clinical and microbiological impact of the adjunctive use of systemic metronidazole to periodontal surgery (step 3 of periodontal therapy). The results of the present study do not support the adjunctive use of systemic metronidazole to periodontal surgery.

A lingering mouthwash with sustained antibiotic release and biofilm eradication for periodontitis

Dental plaque biofilms are believed to be one of the principal virulence factors in periodontitis resulting in tooth loss. Traditional mouthwashes are limited due to the continuous flow of saliva and poor drug penetration ability in the biofilm. Herein, we fabricated an antibiotic delivery platform based on natural polysaccharides (chitosan and cyclodextrin) as a novel mouthwash for the topical cavity delivery of minocycline. The penetration and residence mechanisms demonstrate that the platform can prolong the residence time up to 12 h on biofilms. Furthermore, sustained release can enhance the penetration of drugs into biofilms. In vitro antibiofilm experimental results indicated that the mouthwash effectively kills bacteria and eradicate biofilms. Effective treatment in vivo was confirmed by the significantly reduced dental plaque and alleviated inflammation observed in a rat periodontitis model. In summary, this novel platform can improve antibiofilm efficiency and prevent drugs from being washed away by saliva, which may provide benefits for many oral infectious diseases.

Adjunctive systemic antimicrobials for the non-surgical treatment of periodontitis

BACKGROUND

Systemic antimicrobials can be used as an adjunct to mechanical debridement (scaling and root planing (SRP)) as a non-surgical treatment approach to manage periodontitis. A range of antibiotics with different dosage and combinations are documented in the literature. The review follows the previous classification of periodontitis as all included studies used this classification.

OBJECTIVES

To assess the effects of systemic antimicrobials as an adjunct to SRP for the non-surgical treatment of patients with periodontitis.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases to 9 March 2020: Cochrane Oral Health's Trials Register, CENTRAL, MEDLINE, and Embase. The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) which involved individuals with clinically diagnosed untreated periodontitis. Trials compared SRP with systemic antibiotics versus SRP alone/placebo, or with other systemic antibiotics.

DATA COLLECTION AND ANALYSIS

We selected trials, extracted data, and assessed risk of bias in duplicate. We estimated mean differences (MDs) for continuous data, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included 45 trials conducted worldwide involving 2664 adult participants. 14 studies were at low, 8 at high, and the remaining 23 at unclear overall risk of bias. Seven trials did not contribute data to the analysis. We assessed the certainty of the evidence for the 10 comparisons which reported long-term follow-up (≥ 1 year). None of the studies reported data on antimicrobial resistance and patient-reported quality of life changes. Amoxicillin + metronidazole + SRP versus SRP in chronic/aggressive periodontitis: the evidence for percentage of closed pockets (MD -16.20%, 95% CI -25.87 to -6.53; 1 study, 44 participants); clinical attachment level (CAL) (MD -0.47 mm, 95% CI -0.90 to -0.05; 2 studies, 389 participants); probing pocket depth (PD) (MD -0.30 mm, 95% CI -0.42 to -0.18; 2 studies, 389 participants); and percentage of bleeding on probing (BOP) (MD -8.06%, 95% CI -14.26 to -1.85; 2 studies, 389 participants) was of very low certainty. Only the results for closed pockets and BOP showed a minimally important clinical difference (MICD) favouring amoxicillin + metronidazole + SRP. Metronidazole + SRP versus SRP in chronic/aggressive periodontitis: the evidence for percentage of closed pockets (MD -12.20%, 95% CI -29.23 to 4.83; 1 study, 22 participants); CAL (MD -1.12 mm, 95% CI -2.24 to 0; 3 studies, 71 participants); PD (MD -1.11 mm, 95% CI -2.84 to 0.61; 2 studies, 47 participants); and percentage of BOP (MD -6.90%, 95% CI -22.10 to 8.30; 1 study, 22 participants) was of very low certainty. Only the results for CAL and PD showed an MICD favouring the MTZ + SRP group. Azithromycin + SRP versus SRP for chronic/aggressive periodontitis: we found no evidence of a difference in percentage of closed pockets (MD 2.50%, 95% CI -10.19 to 15.19; 1 study, 40 participants); CAL (MD -0.59 mm, 95% CI -1.27 to 0.08; 2 studies, 110 participants); PD (MD -0.77 mm, 95% CI -2.33 to 0.79; 2 studies, 110 participants); and percentage of BOP (MD -1.28%, 95% CI -4.32 to 1.76; 2 studies, 110 participants) (very low-certainty evidence for all outcomes). Amoxicillin + clavulanate + SRP versus SRP for chronic periodontitis: the evidence from 1 study, 21 participants for CAL (MD 0.10 mm, 95% CI -0.51 to 0.71); PD (MD 0.10 mm, 95% CI -0.17 to 0.37); and BOP (MD 0%, 95% CI -0.09 to 0.09) was of very low certainty and did not show a difference between the groups. Doxycycline + SRP versus SRP in aggressive periodontitis: the evidence from 1 study, 22 participants for CAL (MD -0.80 mm, 95% CI -1.49 to -0.11); and PD (MD -1.00 mm, 95% CI -1.78 to -0.22) was of very low certainty, with the doxycycline + SRP group showing an MICD in PD only. Tetracycline + SRP versus SRP for aggressive periodontitis: we found very low-certainty evidence of a difference in long-term improvement in CAL for the tetracycline group (MD -2.30 mm, 95% CI -2.50 to -2.10; 1 study, 26 participants). Clindamycin + SRP versus SRP in aggressive periodontitis: we found very low-certainty evidence from 1 study, 21 participants of a difference in long-term improvement in CAL (MD -1.70 mm, 95% CI -2.40 to -1.00); and PD (MD -1.80 mm, 95% CI -2.47 to -1.13) favouring clindamycin + SRP. Doxycycline + SRP versus metronidazole + SRP for aggressive periodontitis: there was very low-certainty evidence from 1 study, 27 participants of a difference in long-term CAL (MD 1.10 mm, 95% CI 0.36 to 1.84); and PD (MD 1.00 mm, 95% CI 0.30 to 1.70) favouring metronidazole + SRP. Clindamycin + SRP versus metronidazole + SRP for aggressive periodontitis: the evidence from 1 study, 26 participants for CAL (MD 0.20 mm, 95% CI -0.55 to 0.95); and PD (MD 0.20 mm, 95% CI -0.38 to 0.78) was of very low certainty and did not show a difference between the groups. Clindamycin + SRP versus doxycycline + SRP for aggressive periodontitis: the evidence from 1 study, 23 participants for CAL (MD -0.90 mm, 95% CI -1.62 to -0.18); and PD (MD -0.80 mm, 95% CI -1.58 to -0.02) was of very low certainty and did not show a difference between the groups. Most trials testing amoxicillin, metronidazole, and azithromycin reported adverse events such as nausea, vomiting, diarrhoea, mild gastrointestinal disturbances, and metallic taste. No serious adverse events were reported.

AUTHORS' CONCLUSIONS

There is very low-certainty evidence (for long-term follow-up) to inform clinicians and patients if adjunctive systemic antimicrobials are of any help for the non-surgical treatment of periodontitis. There is insufficient evidence to decide whether some antibiotics are better than others when used alongside SRP. None of the trials reported serious adverse events but patients should be made aware of the common adverse events related to these drugs. Well-planned RCTs need to be conducted clearly defining the minimally important clinical difference for the outcomes closed pockets, CAL, PD, and BOP.

Non-Surgical Periodontal Therapy - Evidence and Opinion

Effective non-surgical periodontal therapy is fundamental to achieve and maintain periodontal health, particularly in individuals who are susceptible to periodontitis. This article aims to highlight current evidence and published guidance, together with personal insights and suggestions from the author's clinical experience to help with management of patients utilising this common treatment modality.

Long-term assessment of periodontal disease progression after surgical or non-surgical treatment: a systematic review

The primary aim of this systematic review was to assess the evidence on periodontal disease progression after treatment in patients receiving supportive periodontal therapy (SPT) and to identify predictors of clinical attachment level (CAL) loss. A protocol was developed to answer the following focused question: In adult patients treated for periodontitis, what is the disease progression in terms of CAL loss after surgical or non-surgical treatment? Randomized controlled clinical trials, prospective cohort studies, and longitudinal observational human studies with a minimum of 5 years of follow-up after surgical or non-surgical treatment that reported CAL and probing depth changes were selected. Seventeen publications reporting data from 14 investigations were included. Data from 964 patients with a follow-up range of 5-15 years was evaluated. When the CAL at the latest follow-up was compared to the CAL after active periodontal therapy, 10 of the included studies reported an overall mean CAL loss of ≤0.5 mm, 3 studies reported a mean CAL loss of 0.5-1 mm, and 4 studies reported a mean CAL loss of >1 mm. Based on 7 publications, the percentage of sites showing a CAL loss of ≥2 mm varied from 3% to 20%, and a high percentage of sites with CAL loss was associated with poor oral hygiene, smoking, and poor compliance with SPT. The outcomes after periodontal therapy remained stable over time. Disease progression occurred in a reduced number of sites and patients, mostly associated with poor oral hygiene, poor compliance with SPT, and smoking.

Oral hygiene phase revisited: How different study designs have affected results in intervention studies

Every periodontal researcher have been taught, and every textbook in periodontics have advocated, that a phase in which the patient is meticulously motivated and instructed in proper oral hygiene-the oral hygiene phase-must be included in any periodontal intervention. However, how is this oral hygiene phase actually portrayed in periodontal intervention studies, and how much space have this important phase received in the planning and carry-through of intervention studies? The purpose of this letter to the editor was to review current literature in the period 1975/01/01-2017/12/31 on periodontal, mechanical intervention studies in order to see what focus the oral hygiene phase had received in these articles. The result showed that the oral hygiene phase is variable in length and content, variable in claimed result, insufficiently described, and invariably amalgamated with the scaling and root planing which is the intervention or part of an intervention. The consequences of these findings are discussed and suggestions proposed for more harmonized and calibrated oral hygiene phase introduced to avoid biased and inflated results of interventions.

Behavioural interventions that have the potential to improve self-care in adults with periodontitis: a systematic review

AIM

To evaluate behavioural and educational interventions used to improve self-care in adult periodontitis patients in comparison with conventional instruction.

METHODS

A systematic electronic search of empirical studies that were published up to June 2017 using the MEDLINE database was performed. The reference lists of all of the included studies and articles from six separate journals were manually searched.

RESULTS

A total of 1806 articles were identified. Six articles fulfilled the inclusion and exclusion criteria. The interventions used in periodontal treatment had theoretical backgrounds of cognitive behavioural approach, self-regulation theory of Leventhal, motivational interviewing and a client self-care commitment model. The control group in each study was described receiving conventional information. The outcomes of the interventions were classified into three categories: 1) clinical findings 2) self-reported self-care and 3) patient evaluations of the intervention. The behavioural intervention groups seemed to perform slightly better than the control groups when clinical outcome measures such as the presence of plaque or number of periodontal pockets were used. Furthermore, behavioural interventions increased patient reported compliance (e.g. effectiveness of self-care and frequency of interdental cleaning). The different behavioural techniques all seemed to work more effectively than conventional instruction. No behavioural technique could be identified superior to the other.

CONCLUSIONS

The behavioural interventions seem to be beneficial for patient adherence and may therefore improve periodontal treatment success. However, there is a need to further explore the use of different methods in studies with larger sample sizes, longer follow-up times and both behavioural and clinical outcome measures.