Clinical efficacy of subgingivally‐delivered 0.75% boric acid gel as an adjunct to mechanotherapy in chronic periodontitis: A randomized, controlled clinical trial

Boric acid alleviates periodontal inflammation induced by IL-1β in human gingival fibroblasts

BACKGROUND

Boric acid (BA) has been found to have therapeutic effects on periodontal disease through beneficially affecting antibacterial, anti-viral, and anti-inflammatory actions.

METHODS

This study was conducted to determine the effect of BA on cell viability and on mRNA expressions of proinflammatory and anti-inflammatory cytokines and on oxidative stress enzymes induced by IL-1β (1 ng/mL) in Human Gingival Fibroblasts (HGF) cultured for 24 and 72 h in DMEM media. The BA concentrations added to the media were 0.09 %, 0.18 %, 0.37 %, and 0.75 %.

RESULTS

All of the BA concentrations increased the viability of cell cultured in DMEM media only, indicating that these concentrations were not toxic and actually beneficial to cell viability. The addition of 1 ng/m: of IL-1β decreased cell viability that was overcome by all concentrations of BA at both 24 and 72 h. The IL-1β addition to the media increased the expressions of the proinflammatory cytokines IL-1β, IL-6, IL-8, and IL-17; the anti-inflammatory cytokine IL-10; and the oxidative stress enzymes superoxide dismutase (SOD0 and glutathione peroxidase (GPX). The IL-1β induced increase mRNA expression of IL-1β was decreased at 24 h by the 0.37 % and 0.75 % BA additions to the media and decreased in a dose-dependent manner by all concentrations of BA at 72 h. The IL-1β induced increase in the expression of IL-6 was decreased in dose-dependent manner at 72 h by BA. All BA concentrations decreased the IL-1β induced expression of IL-8 at both 24 and 72 h. The induced increase in IL-17 by IL-1β was not significantly affected by the BA additions. The increase in the anti-inflammatory cytokine IL10 induced by IL-1β was increased further by all BA additions in dose dependent manner at both 24 and 72 h. The mRNA expressions of SOD and GPX increased by IL-1β were further increased by the 0.37 % and 0.75 % BA concentrations at 72 h.

CONCLUSIONS

These findings indicate that BA can significantly modulate the cytokines that are involved in inflammatory stress and reactive oxygen species action and thus could be an effective therapeutic agent in the treatment of periodontal disease.

Gels as adjuvant to non-surgical periodontal therapy: A systematic review and meta-analysis

Objective

This systematic review and meta-analysis evaluated the effect of the use of available drugs loaded gels used as adjunct to non-surgical periodontal therapy.

Methods

Systematic research on PubMed/MEDLINE, Cochrane Central register of Controlled Trials, and Embase databases up to December 2021 was performed. Randomized clinical trials (RCT) which compared the outcomes of scaling and root planing (SRP) + local adjuvant administration (gel) versus SRP + placebo or SRP alone in Humans were included. The primary outcome measures were PPD and CAL changes at 3 months.

Results

After articles screening, 77 articles were included and assessed for quality. Then, a meta-analysis was conducted in studies with at least 3 months of follow-up. Clinical improvements were found to be significant for tetracyclines (-0.51 [-0.71;-0.31] p < 0.001), macrolides (-0.71 [-1.04;-0.38] p < 0.001), statins (-0.84 [-0.98;-0.70] p < 0.001), metformin (-1.47 [-1.66;-1.29] p < 0.001) and hyaluronan (-1.61 [-2.28;-0.94] p < 0.001) loaded gels, but non-significant for chlorhexidine (-0.48 [-1.10; 0.14] p = 0.13), metronidazole (-0.50 [-1.20; 0.20] p = 0.16) and bisphosphonates (-0.42 [-1.39; 0.54] p = 0.539) gels.

Conclusion

Adjunctive use of drugs loaded gels to non-surgical periodondal treatment could improve PPD reduction at 3 months. However, huge disparities remain when comparing the outcomes of the differents drugs used. Future comparative studies should be considered to determine precisely short and long term benefits of such treatments.

Adjunctive use of locally delivered host-modulators in intra-bony defects as part of step 2 periodontal therapy: systematic review, meta-analysis and trial sequential analysis

BACKGROUND

This systematic review and meta-analysis aimed at investigate the role of locally delivered host-modulators in combination with step 2 of periodontal therapy in reducing probing pocket depth, improving clinical attachment level and reducing bone defect depth in intra-bony defects.

HIGHLIGHT

RCT with at least 6 months follow-up were included in this study. Risk of bias assessment was performed with Cochrane collaboration tool and Grade GRADEpro. In addition, meta-analysis and trial sequential analysis were used to aggregate the available evidence. 22 studies met the inclusion criteria and were included in this systematic review. At 6 months locally delivered host-modulators significantly improved PD and CAL and bone defect depth.

CONCLUSION

Considering the emerging role of host-inflammatory response in the treatment of periodontitis, several studies are exploring the role of locally delivered host modulators as an adjunct to step 2 of periodontal therapy.

Antimicrobial and bone repair effects of boric acid in a rat model of dry socket (alveolar osteitis) following dental extraction

BACKGROUND

Alveolitis occurs after dental extraction without blood clot formation, leading to an inflammatory process and bacterial contamination. Boric acid (BA) demonstrates anti-inflammatory, antimicrobial, and osteogenic properties. This study aims to evaluate the possible antimicrobial effects and bone repair of BA in a rat model of alveolitis (dry socket).

METHODS

33 male Wistar rats were submitted to the extraction of the upper right incisor and dry socket induction. They were first divided into two groups: dry socket (n = 17) and dry socket + 0.75 % BA (n = 16). Samples for the microbiological analysis were collected immediately after dental extraction, at the detection of clinical alveolitis, 7, and 14 days after BA application. For microCT and histological analysis, samples from euthanized rats were used in 14 and 28 days after alveolitis detection.

RESULTS

Higher bacterial counts were found in 4-5 days after alveolitis induction, compared to the baseline in both experimental groups, decreasing significantly after 7 and 14 days of treatment with BA (P < 0.05). The microCT evaluation displayed increased bone volume, bone volume fraction, trabecular thickness, and bone mineral density in a time-dependent manner, regardless of BA treatment. On the other hand, the number of trabeculae and total bone porosity decreased over the 28 days of the experiment in the dry-socket group and both groups, respectively (P < 0.05). Histological analysis did not differ on bone repair in both experimental groups.

CONCLUSION

This was the first report investigating the effects of BA in a rat model of alveolitis regarding microbiological and bone repair aspects. The BA local application decreased the total aerobic and facultative bacteria counts and does not seem to benefit the bone repair after alveolitis development. This study paves the way for more studies involving alveolitis and different BA applications.

A thermosensitive gel with an active hyaluronic acid ingredient that contains an octenidine preservation system as an adjunct to scaling and root planning: a randomized prospective clinical study

OBJECTIVES

To evaluate the adjunctive effect of a thermosensitive gel formulation that contains 0.8% oligo hyaluronic acid (HA) combined with a preservation system of octenidine HCl 0.625% and phenoxyethanol to scaling and root planing (SRP) as compared with SRP alone in the treatment of residual pockets of patients with stage 3 periodontitis.

MATERIALS AND METHODS

Thirty-four patients (21 males and 13 females) aged 29-78 years (51.3 ± 13.1) with stage 3 periodontitis were recruited to participate in the present split-mouth study. None of the patients has been previously treated for periodontitis. Plaque index (PI), probing depth (PD), clinical attachment level (CAL), and bleeding on probing (BOP) were evaluated at baseline and at 3 and 6 months post treatment. Full-mouth SRP was performed in all residual pockets ≥ 5 mm. Treatment was performed by means of ultrasonic and hand instruments and lasted 45-60 min. The gel was applied subgingivally in the test sites immediately after SRP (baseline) and 1 month later. The paired t-test for two means was applied to test the statistical significance of the change from baseline within each arm and determine the difference between groups. The level of significance was set at 0.05 for all tests.

RESULTS

Mean PD reductions between baseline and 3 and 6 months were 1.98 mm and 2.79 mm for the test and 1.22 mm and 1.50 mm for the control group, respectively. Comparisons between the test and control groups revealed that SRP + gel yielded statistically significantly higher PD reductions compared to SRP alone (p < 0.0001). Compared to baseline, CAL and BOP values improved statistically significantly in both groups, although the test group presented statistically significantly higher CAL gains and BOP reductions than the control group (P < 0.0001).

CONCLUSION

In residual pockets of stage 3 periodontitis patients, the local application of a thermosensitive gel with an active HA ingredient and a preservation system of octenidine HCl 0.625% in conjunction with SRP may additionally improve the clinical outcomes obtained with SRP alone.

CLINICAL RELEVANCE

A novel HA and octenidine containing thermosensitive gel effectively improved the clinical parameters in stage 3 periodontitis patients over a 6-month period.

Periodontal Bifunctional Biomaterials: Progress and Perspectives

Periodontitis is a chronic infectious disease that destroys periodontal supportive tissues and eventually causes tooth loss. It is attributed to microbial and immune factors. The goal of periodontal therapy is to achieve complete alveolar bone regeneration while keeping inflammation well-controlled. To reach this goal, many single or composite biomaterials that produce antibacterial and osteogenic effects on periodontal tissues have been developed, which are called bifunctional biomaterials. In this review, we summarize recent progress in periodontal bifunctional biomaterials including bioactive agents, guided tissue regeneration/guided bone regeneration (GTR/GBR) membranes, tissue engineering scaffolds and drug delivery systems and provide novel perspectives. In conclusion, composite biomaterials have been greatly developed and they should be chosen with care due to the risk of selection bias and the lack of evaluation of the validity of the included studies.

Unusual Findings in Trials Evaluating Adjuncts to Scaling and Root Planing: Meta-analysis (Part 1)

BACKGROUND

A number of studies in patients with periodontitis have compared scaling and root planning (SRP) combined with an adjunctive treatment to SRP alone. Within that literature, an array of studies with overlapping investigators has consistently yielded substantially greater effects of adjunctive treatments than had been previously noted. This report investigates discrepancies between that cluster of research and the most recent American Dental Association (ADA) systematic review.

METHODS

This review was preregistered at https://osf.io/4meyd/. A search using the Scopus platform identified 32 articles published from 2010 to 2017 by investigators affiliated with the Government Dental College and Research Institute (GDCRI) in Bangalore, India. The primary outcome used in this meta-analysis was the change in clinical attachment level (CAL) after 6 mo. Effect sizes were estimated using Comprehensive Meta-Analysis software after categorizing agents into groups based on pharmacologic similarity.

RESULTS

The search identified 32 studies encompassing 5 sets of adjunctive agents. Across the GDCRI studies, the CAL averaged 1.67 mm (95% confidence interval [CI]: 1.43-1.91 mm), substantially exceeding values reported in the ADA review (mean: 0.39 mm, 95% CI: 0.27-0.51 mm). For categories of studies in which comparable subgroup estimates were available, the evaluations yielded overlapping estimates of SRP alone, but CAL estimates were discrepant for both locally delivered antimicrobials (GDCRI studies: mean: 1.45 mm, 95% CI: 0.63-2.27 mm; ADA review: mean: 0.38 mm, 95% CI: 0.16 -0.60 mm) and systemic antibiotics (GDCRI studies: mean: 1.35 mm, 95% CI: 0.97-1.73 mm; ADA review: mean: 0.39 mm, 95% CI: 0.21-0.57 mm).

CONCLUSION

In the literature on adjunctive agents supplementing SRP, findings from investigators linked to GDCRI stand out as having significantly more favorable estimated effects. Meanwhile, some agents studied by GDCRI-linked investigators have not been investigated by other researchers. In the absence of a clear explanation for discrepant results, it is recommended that unusually favorable reported effects of adjunctive agents be viewed with caution.

KNOWLEDGE TRANSFER STATEMENT

The present meta-analysis observed an unusually large effect size of adjunctive agents to scaling and root planning in studies conducted by the same research group. These results were not consistent with trials on adjunctive agents and previous reports. As this research group has exclusively tested most of the agents, their results must be viewed with caution until other independent groups replicate the studies and reproduce the effect size.

Efficacy of Preprocedural Boric Acid Mouthrinse in Reducing Viable Bacteria in Dental Aerosols Produced during Ultrasonic Scaling

INTRODUCTION

Aerosols and droplets contaminated with bacteria and blood are produced during ultrasonic scaling. Measures to control aerosol contamination in dental clinics are recommended by the Centers for Disease Control and Prevention. This study aimed to evaluate the efficacy of preprocedural boric acid (BA) mouthrinse in reducing bacterial contamination in dental aerosols generated during ultrasonic scaling.

MATERIALS AND METHODS

This was a randomised clinical trial in 90 systemically healthy subjects (25-55 yrs) diagnosed with chronic periodontitis who were allocated into three groups of 30 subjects each to receive, Group A - 0.12% chlorhexidine (CHX), Group B - 0.75% BA and Group C-water, as a preprocedural rinse for 1 min. The aerosol generated while performing ultrasonic scaling for 30 min was collected at three locations on blood agar plates. Incubation of the blood agar plates at 37°C for next 48 h for aerobic culture was performed and subsequently colony-forming units (CFUs) were counted.

RESULTS

CFUs in Group A were significantly reduced compared with Group B (P < 0.001). When we compare CFUs in all the three groups, CFUs in Groups A and B were statistically significantly reduced compared with Group C (P < 0.001). Furthermore, it was also observed that the assistant's chest area had lowest CFUs whereas patient's chest area had highest.

CONCLUSION

This study recommends routine use of preprocedural mouthrinse as a measure to reduce bacterial aerosols generated during ultrasonic scaling and that 0.12% CHX gluconate is more effective than 0.75% BA mouthwash in reducing CFUs count.

Boric acid as an adjunct to periodontal therapy: A systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy of boric acid as an adjunct to non-surgical periodontal therapy, in comparison with a placebo adjunct, in terms of changes in probing pocket depth (PPD) and clinical attachment level (CAL), in patients with periodontitis.

METHODS

Four electronic databases were searched from inception to May 2020 (PubMed, Cochrane CENTRAL, EMBASE via OVID and Web of Science). Clinical outcomes were extracted, pooled and meta-analyses conducted using mean difference with standard deviations.

RESULTS

For PPD, a mean additional reduction of 0.58 mm (95% CI: -0.03-1.19 mm, p = 0.06) was observed at 3 months and a mean additional reduction of 1.18 mm (95% CI: 0.97-1.40 mm, p < 0.05) at 6 months, compared with placebo. For CAL, a mean additional gain of 0.62 mm (95% CI: -0.07-1.32 mm, p = 0.08) was observed at 3 months and a mean additional gain of 1.24 mm (95% CI: 0.89-1.58 mm, p < 0.05) at 6 months, compared with placebo. No adverse events were reported in any studies.

CONCLUSIONS

The adjunctive use of boric acid in non-surgical periodontal therapy results in improved treatment outcomes at 3 and 6 months, with no adverse events reported.

Antiseptics as adjuncts to scaling and root planing in the treatment of periodontitis: a systematic literature review

Background

Periodontitis is microbially-associated, host-mediated inflammatory condition that results in loss of periodontal attachment. The goals of periodontal therapy include arresting the disease progression, establishing healthy, stable, maintainable periodontal conditions. A fundamental strategy of treating periodontitis is scaling and root planning (SRP), however its efficacy may be restricted in areas inaccessible for mechanical instrumentation. As periodontitis is infectious in nature, it might be helpful to use additional antimicrobial adjuncts, in order to eliminate or inactivate pathogenic microflora. The aim of this study is to evaluate the current evidence regarding the potential clinical benefits of using additional antiseptics for SRP in nonsurgical periodontal therapy.

Methods

An electronic literature search was conducted in the MEDLINE (Ovid) and Cohrane Central Register of Controlled Trials (CENTRAL) databases for articles published between January 1, 2000 and September 22, 2019. Randomized controlled clinical trials in English that compare the effectiveness of one or more antiseptic agents as adjuncts to SRP with a follow-up of ≥6 months were included. A meta-analysis using the random-effects model was performed on the selected qualifying articles.

Results

The search resulted in 12 articles that met the inclusion criteria. Based on the vehicle employed to deliver the antiseptic agent, studies were divided into adjunctive sustained-release antiseptics (gels, chips and varnish) and adjunctive irrigation with antiseptics. The meta-analysis demonstrated significant improvements in probing depth (PD) reduction (p = 0.001), clinical attachment level (CAL) gain (p = 0.001), and bleeding on probing (BOP) values (p = 0.001) following the adjunctive subgingival application of sustained-release antiseptics. Additional subgingival irrigation with antiseptics failed to show significant improvements in PD (p = 0.321), CAL (p = 0.7568), or BOP values (p = 0.3549) over SRP alone.

Conclusions

Adjunctive subgingivally delivered antiseptics with a sustained-release delivery have significant clinical benefits compared to SRP alone.

Comparative Evaluation of Boric Acid Gel versus Chlorhexidine Gel in the Treatment of Chronic Periodontitis: Randomized, Placebo-Controlled Clinical Study

Background:

Over the years, various antimicrobials have been tried and tested in the treatment of periodontitis. Chlorhexidine (CHX) has emerged as the gold standard. In recent years, trend has shifted toward the use of agents with antibacterial, anti-inflammatory, and osteoblastic activity. Boric acid (BA) is one such agent which possess all such properties and thus been evaluated in the treatment of periodontitis.

Aim and Objective:

The aim of the study is to compare and evaluate the efficacy of 0.75% BA gel versus 1% CHX gel as an adjunct to scaling and root planing in patients with chronic periodontitis both clinically and microbiologically.

Materials and Methods:

The present study was a randomized, placebo-controlled clinical trial where 45 systemically healthy patients with chronic periodontitis were included in the study. About 15 patients each were divided into three groups, that is, Group I received BA gel, Group II received CHX gel, and Group III received placebo gel as a local drug delivery agent. Clinical parameters such as gingival index, plaque index, modified sulcus bleeding index, probing pocket depth, and clinical attachment level were evaluated at baseline and 6-month follow-up. Microbiological analysis to check for mixed anaerobic flora was done using subgingival plaque samples at baseline and 3 months after treatment.

Results:

Significant reduction was seen in all clinical parameters in both BA and CHX gel groups as compared to control group (P < 0.05). However, on comparing BA gel group with CHX gel, the results were statistically insignificant (P > 0.05).

Conclusion:

BA gel and CHX gel both were equally effective in improving the clinical and microbiologic parameters in patients with chronic periodontitis when used as a local drug delivery agent.