Non-surgical pocket therapy: pharmacotherapeutics

Impact of local drug delivery and natural agents as new target strategies against periodontitis: new challenges for personalized therapeutic approach

Periodontitis is a persistent inflammation of the soft tissue around the teeth that affects 60% of the population in the globe. The self-maintenance of the inflammatory process can cause periodontal damage from the alveolar bone resorption to tooth loss in order to contrast the effects of periodontitis, the main therapy used is scaling and root planing (SRP). At the same time, studying the physiopathology of periodontitis has shown the possibility of using a local drug delivery system as an adjunctive therapy. Using local drug delivery devices in conjunction with SRP therapy for periodontitis is a potential tool since it increases drug efficacy and minimizes negative effects by managing drug release. This review emphasized how the use of local drug delivery agents and natural agents could be promising adjuvants for the treatment of periodontitis patients affected or not by cardiovascular disease, diabetes, and other system problems. Moreover, the review evidences the current issues and new ideas that can inspire potential later study for both basic research and clinical practice for a tailored approach.

An Overview of the Systematic Evidence on the Adjunctive Use of Laser Therapy in Non-surgical Periodontal Treatment

This overview aimed to recapitulate the evidence related to laser application in non-surgical periodontal treatment along with conventional periodontal treatment for optimum clinical practice based on the available systematic reviews (SRs). An advanced literature search in the English language was conducted in the PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), ScienceDirect, and Scopus databases from January 2000 to October 2022. Two independent reviewers screened all the databases and extracted the data in duplicate. The risk of bias in the selected studies was assessed with the Methodological Quality of Systematic Reviews 2 (AMSTAR 2) guideline for SRs. Cohen's kappa statistics were performed to assess the level of agreement for the assessment of the risk of bias. A total of 556 studies (PubMed = 115, Scopus = 66, ScienceDirect = 298, and MEDLINE = 77) were identified after the initial search using the keywords from different databases. After removing the duplicates and assessing the full manuscripts, a total of 24 studies were selected based on the inclusion criteria for the current overview. A total of three, four, 12, and five systematic reviews were classified as high, moderate, low, and critically low-quality SRs as per the AMSTAR 2 quality assessment tool. Cohen's Kappa statistics showed perfect (𝛋 =1.000) agreement between the two reviewers. Adjunctive laser therapy along with conventional non-surgical periodontal treatment might be effective in short-term treatment outcomes; however, evidence of long-term effects is still lacking.

Europe's contribution to the evaluation of the use of systemic antimicrobials in the treatment of periodontitis

This narrative review celebrates Europe's contribution to the current knowledge on systemically administered antimicrobials in periodontal treatment. Periodontitis is the most frequent chronic noncommunicable human disease. It is caused by dysbiotic bacterial biofilms and is commonly treated with subgingival instrumentation. However, some sites/patients do not respond adequately, and its limitations and shortcomings have been recognized. This has led to the development of alternative or adjunctive therapies. One is the use of antimicrobials to target bacteria in subgingival biofilms in the periodontal pocket, which can be targeted directly through the pocket entrance with a locally delivered antibiotic or systemically by oral, intravenous, or intramuscular methods. Since the early 20th century, several studies on systemic antibiotics have been undertaken and published, especially between 1990 and 2010. Europe's latest contribution to this topic is the first European Federation of Periodontology, S3-level Clinical Practice Guideline, which incorporates recommendations related to the use of adjuncts to treat stage I-III periodontitis. Understanding the etiopathogenesis of periodontal diseases, specifically periodontitis, has influenced the use of systemic periodontal antibiotic therapy. Randomized clinical trials and systematic reviews with meta-analyses have demonstrated the clinical advantages of adjunctive systemic antimicrobials. However, current recommendations are restrictive due to concerns about antibiotic misuse and the increase in microbial antibiotic resistance. European researchers have contributed to the use of systemic antimicrobials in the treatment of periodontitis through clinical trials and by providing rational guidelines. Nowadays, European researchers are exploring alternatives and directing clinical practice by providing evidence-based guidelines to limit the use of systemic antimicrobials.

A Placebo-Controlled Trial to Evaluate Two Locally Delivered Antibiotic Gels (Piperacillin Plus Tazobactam vs. Doxycycline) in Stage III-IV Periodontitis Patients

Background and objectives: this study aims to evaluate the clinical and microbiological effects of a single subgingival administration of a locally delivered antibiotic gel containing piperacillin plus tazobactam and compare it with a slow-release doxycycline (14%) gel and a placebo gel, following subgingival instrumentation (SI) in patients with severe periodontitis. Materials and methods: sixty-four patients diagnosed with stage III-IV periodontitis were enrolled, were randomly assigned into three groups, and were treated additionally with a single subgingival administration of piperacillin plus tazobactam gel (group A); doxycycline gel (group B); and placebo gel (group C). The primary outcome variable was the change in mean probing pocket depth (PPD) 6 months after the intervention. Secondary outcome variables were changes in mean full-mouth bleeding score (FMBS); full-mouth plaque score (FMPS); overall bleeding index (BOP); pocket closure; and clinical attachment level (CAL), along with changes in the numbers of five keystone bacteria: Aggregatibacter actinomycetemcomitans (A.a.), Porphyromonas gingivalis (P.g.), Prevotella intermedia (P.i.), Tannerella forsythia (T.f.), and Treponema denticola (T.d.). Intergroup and intragroup differences were evaluated at 3 and 6 months. Results: at baseline, the three groups were comparable. An improvement in clinical parameters such as PPD, CAL, and BOP between groups was observed at 3 and 6 months, but without statistical significance (p > 0.05). At 6 months, the intragroup analysis showed a significant reduction in clinical parameters. Even though the piperacillin plus tazobactam group showed slightly higher PPD reduction, this was not statistically significant when compared to both control groups. Conclusions: The groups had similar results, and subgingival instrumentation can be executed without adjunctive antimicrobials, reducing the costs for the patient and the working time/load of the professional.

A new era of Nano!!! Comparative evaluation of ganglioside polymeric nanoparticle coated satranidazole gel and 1% metronidazole gel for the treatment of periodontitis

Background:

The present study was intended to comparatively assess the efficacy of ganglioside polymeric nanoparticle-coated 0.25% satranidazole-loaded nanoparticles in gel form with that of the commercially available 1% metronidazole gel as a local drug delivery (LDD) agent for the treatment of periodontal pockets.

Materials and Methods:

A split-mouth randomized clinical trial was carried out in 46 chronic periodontitis patients with probing pocket depth (PPD) ≥4 mm or clinical attachment loss greater than 3 mm on both quadrants of the same arch. Full-mouth scaling and root planing (SRP) was performed for all the patients followed by application of 0.25% satranidazole-loaded nanoparticles in gel form on one site (Group 1) and commercially available 1% metronidazole gel on another site (Group 2). Clinical parameters (gingival index, plaque index, PPD, clinical attachment level gain, and bleeding on probing) and microbiological analysis of the subgingival plaque samples were performed and assessed at baseline, after SRP, 21^st day, and 90^th day post treatment. Unpaired “t”-test and ANOVA tests were used for intergroup and intragroup comparison of recorded parameters.

Results:

The results showed that the satranidazole-loaded nanoparticle group as an adjunct to SRP in chronic periodontitis showed a statistically significant improvement in all the clinical parameters and a fewer relapse of microbial flora in comparison with the metronidazole group as an LDD agent.

Conclusion:

The present study depicted that both the LDD agents showed an effective improvement of clinical as well as microbiological parameters, but the satranidazole group consistently produced better results than the metronidazole group and hence has a promising future as an LDD agent in treating periodontal pockets.

The effect of Er,Cr:YSGG laser on periodontopathic bacteria elimination: an in vitro study

In vitro bacterial elimination using the erbium, chromium: yttrium-scandium-gallium-garnet (Er,Cr:YSGG) laser against periodontopathic bacteria was investigated. Bacterial suspensions of Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis were spread on agar plates and the Er,Cr:YSGG laser was applied at 40 mJ pulse energy for durations of 30 s, 60 s, and 90 s. The agar plates were incubated, and growth inhibition zones were assessed. Optimal laser irradiation durations to achieve maximal bacterial elimination were evaluated using laser ablation on the bacterial colonies. The remaining viable bacteria were determined by the colony-forming unit (CFU) counting method. Growth inhibition zones were observed at all irradiation durations for both A. actinomycetemcomitans and P. gingivalis. Mean logarithmic values of CFU/ml after bacterial colony irradiation for 0 s (control), 12 s × 1 lap, 24 s × 1 lap, 48 s × 1 lap, and 24 s × 2 laps were 8.82 ± 0.35, 7.31 ± 0.94, 6.32 ± 0.61, 3.17 ± 2.90, and 0.00, respectively, for A. actinomycetemcomitans and 9.83 ± 0.50, 9.42 ± 0.11, 6.90 ± 1.60, 2.33 ± 3.19, and 0.00 for P. gingivalis. Significant differences were found between the control group and the two irradiated groups 48 s × 1 lap and 24 s × 2 laps (p < 0.05), and also between irradiated groups 12 s × 1 lap and 24 s × 2 laps (p < 0.05). An Er,Cr:YSGG laser with power setting 1.5 W and 30 Hz frequency showed potential for bacterial elimination against A. actinomycetemcomitans and P. gingivalis in vitro. Significant bacterial elimination (> 99.99%) was observed after 48 s of irradiation.

Local drug delivery systems as therapeutic strategies against periodontitis: A systematic review

Periodontitis is a chronic inflammation of the soft tissue surrounding and supporting the teeth, which causes periodontal structural damage, alveolar bone resorption, and even tooth loss. Its prevalence is very high, with nearly 60% of the global population affected. Hence, periodontitis is an important public health concern, and the development of effective healing treatments for oral diseases is a major target of the health sciences. Currently, the application of local drug delivery systems (LDDS) as an adjunctive therapy to scaling and root planning (SRP) in periodontitis is a promising strategy, giving higher efficacy and fewer side effects by controlling drug release. The cornerstone of successful periodontitis therapy is to select an appropriate bioactive agent and route of administration. In this context, this review highlights applications of LDDS with different properties in the treatment of periodontitis with or without systemic diseases, in order to reveal existing challenges and future research directions.

Antibiotic Use in Periodontal Therapy among French Dentists and Factors Which Influence Prescribing Practices

The aim of the present survey is to investigate the use of antibiotics during periodontal therapy among French dentists with a focus on exploring potential differences between various groups of practitioners. A self-administered questionnaire was distributed to different groups of practitioners including members of (i) the French Society of Periodontology and Implantology; (ii) the College of University Teachers in Periodontology and, (iii) private practitioners participating in the French general dental practice-based research network. 272 questionnaires were included in the analysis. Prescription patterns were globally in line with the current recommendations. Systemic antibiotics are most frequently used as a first-line therapy in necrotizing periodontitis (92%) and aggressive periodontitis (53.3% to 66.1%). However, malpractice still exists, including in the management of periodontal abscesses. Antibiotics are prescribed (i) less frequently for periodontal abscesses and (ii) more frequently for generalized aggressive periodontitis by members of the periodontal society and University college (p < 0.05). Amoxicillin (59.9%) and the amoxicillin + metronidazole (59.6%) combination were the most frequently prescribed molecules. Providing a high number of periodontal treatments per week, being more recently graduated, having a post-graduate certificate in periodontology and holding or having held an academic position/hospital practice were all factors associated with a better knowledge of and/or more adequate antibiotic use.

Rapid Release Polymeric Fibers for Inhibition of Porphyromonas gingivalis Adherence to Streptococcus gordonii

Active agents targeting key bacterial interactions that initiate biofilm formation in the oral cavity, may alter periodontitis progression; however, to date, specifically-targeted prophylactic and treatment strategies have been limited. Previously we developed a peptide, BAR (SspB Adherence Region), that inhibits oral P. gingivalis/S. gordonii biofilm formation in vitro and in vivo, and BAR nanoparticles that increase BAR effectiveness via multivalency and prolonged delivery. However, limited BAR loading and nanoparticle retention in the oral cavity can result in inadequate release and efficaciousness. Given this, an effective delivery platform that can release concentrations of BAR suitable for twice-daily applications, may offer an alternative that enhances loading, ease of administration, and retention in the oral cavity. With this in mind, the study objectives were to develop and characterize a rapid-release platform, composed of polymeric electrospun fibers (EFs) that encapsulate BAR, and to evaluate fiber safety and functionality against P. gingivalis/S. gordonii biofilms in vitro. Poly(lactic-co-glycolic acid) (PLGA), poly(L-lactic acid) (PLLA), and polycaprolactone (PCL) were electrospun alone or blended with polyethylene oxide (PEO), to provide high BAR loading and rapid-release. The most promising formulation, 10:90 PLGA:PEO EFs, provided 95% BAR release after 4 h, dose-dependent inhibition of biofilm formation (IC50 = 1.3 μM), disruption of established dual-species biofilms (IC50 = 2 μM), and maintained high cell viability. These results suggest that BAR-incorporated EFs may provide a safe and specifically-targeted rapid-release platform to inhibit and disrupt dual-species biofilms, that we envision may be applied twice-daily to exert prophylactic effect in the oral cavity.

Functional assessment of peptide-modified PLGA nanoparticles against oral biofilms in a murine model of periodontitis

The interaction of the periodontal pathogen Porphyromonas gingivalis (Pg) with commensal streptococci promotes Pg colonization of the oral cavity. Previously, we demonstrated that a peptide (BAR) derived from Streptococcus gordonii (Sg) potently inhibited adherence of Pg to streptococci and reduced Pg virulence in a mouse model of periodontitis. Thus, BAR may represent a novel therapeutic to control periodontitis by preventing Pg colonization of the oral cavity. However, while BAR inhibited the initial formation of Pg/Sg biofilms, much higher concentrations of peptide were required to disrupt an established Pg/Sg biofilm. To improve the activity of the peptide, poly(lactic-co-glycolic acid) (PLGA) nanoparticles were surface-modified with BAR and shown to more potently disrupt Pg/Sg biofilms relative to an equimolar amount of free peptide. The goal of this work was to determine the in vivo efficacy of BAR-modified NPs (BNPs) and to assess the toxicity of BNPs against human gingival epithelial cells. In vivo efficacy of BNPs was assessed using a murine model of periodontitis by measuring alveolar bone resorption and gingival IL-17 expression as outcomes of Pg-induced inflammation. Infection of mice with Pg and Sg resulted in a significant increase in alveolar bone loss and gingival IL-17 expression over sham-infected animals. Treatment of Pg/Sg infected mice with BNPs reduced bone loss and IL-17 expression almost to the levels of sham-infected mice and to a greater extent than treatment with an equimolar amount of free BAR. The cytotoxicity of the maximum concentration of BNPs and free BAR used in in vitro and in vivo studies (1.3 and 3.4 μM), was evaluated in telomerase immortalized gingival keratinocytes (TIGKs) by measuring cell viability, cell lysis and apoptosis. BNPs were also tested for hemolytic activity against sheep erythrocytes. TIGKs treated with BNPs or free BAR demonstrated >90% viability and no significant lysis or apoptosis relative to untreated cells. In addition, neither BNPs nor free BAR exhibited hemolytic activity. In summary, BNPs were non-toxic within the evaluated concentration range of 1.3-3.4 μM and provided more efficacious protection against Pg-induced inflammation in vivo, highlighting the potential of BNPs as a biocompatible platform for translatable oral biofilm applications.

BAR-encapsulated nanoparticles for the inhibition and disruption of Porphyromonas gingivalis-Streptococcus gordonii biofilms

Background

Porphyromonas gingivalis adherence to oral streptococci is a key point in the pathogenesis of periodontal diseases (Honda in Cell Host Microbe 10:423–425, 2011). Previous work in our groups has shown that a region of the streptococcal antigen denoted BAR (SspB Adherence Region) inhibits P. gingivalis/S. gordonii interaction and biofilm formation both in vitro and in a mouse model of periodontitis (Daep et al. in Infect Immun 74:5756–5762, 2006; Daep et al. in Infect immun 76:3273–3280, 2008; Daep et al. in Infect Immun 79:67–74, 2011). However, high localized concentration and prolonged exposure are needed for BAR to be an effective therapeutic in the oral cavity.

Methods

To address these challenges, we fabricated poly(lactic-co-glycolic acid) (PLGA) and methoxy-polyethylene glycol PLGA (mPEG-PLGA) nanoparticles (NPs) that encapsulate BAR peptide, and assessed the potency of BAR-encapsulated NPs to inhibit and disrupt in vitro two-species biofilms. In addition, the kinetics of BAR-encapsulated NPs were compared after different durations of exposure in a two-species biofilm model, against previously evaluated BAR-modified NPs and free BAR.

Results

BAR-encapsulated PLGA and mPEG-PLGA NPs potently inhibited biofilm formation (IC50 = 0.7 μM) and also disrupted established biofilms (IC50 = 1.3 μM) in a dose-dependent manner. In addition, BAR released during the first 2 h of administration potently inhibits biofilm formation, while a longer duration of 3 h is required to disrupt pre-existing biofilms.

Conclusions

These results suggest that BAR-encapsulated NPs provide a potent platform to inhibit (prevent) and disrupt (treat) P. gingivalis/S. gordonii biofilms, relative to free BAR.

Electronic supplementary material

The online version of this article (10.1186/s12951-018-0396-4) contains supplementary material, which is available to authorized users.

Sustained Release of Minocycline From Minocycline-Calcium-Dextran Sulfate Complex Microparticles for Periodontitis Treatment

It is important to address the periodontitis-associated bacteria in the residual subgingival plaque after scaling and root planing to successfully treat periodontitis. In this study, we explored the possibility of exploiting the ion pairing/complexation of minocycline, Ca²⁺, and sulfate/sulfonate-bearing biopolymers to develop an intrapocket delivery system of minocycline as an adjunct to scaling and root planing. Minocycline-calcium-dextran sulfate complex microparticles were synthesized from minocycline, CaCl₂, and dextran sulfate. They were characterized using Fourier-transform infrared spectroscopy, scanning electron microscopy, and energy-dispersive X-ray spectroscopy. An in vitro release study was conducted to evaluate the release kinetics of minocycline from these microparticles. Agar disk diffusion assays and biofilm-grown bacteria assays were used to assess antibacterial capability. High loading efficiency (96.98% ± 0.12%) and high loading content (44.69% ± 0.03%) for minocycline were observed for these complex microparticles. Mino-Ca-DS microparticles achieved sustained release of minocycline for at least 9 days at pH 7.4 and 18 days at pH 6.4 in phosphate-buffered saline, respectively. They also demonstrated potent antimicrobial effects against Streptococcus mutans and Aggregatibacter actinomycetemcomitans in agar disk diffusion and biofilm assays. These results suggested that the ion pairing/complexation of minocycline, Ca²⁺, and sulfonate/sulfate-bearing biopolymers can be exploited to develop complex microparticles as local delivery systems for periodontitis treatment.

Effectiveness of systemic antimicrobial therapy in combination with scaling and root planing in the treatment of periodontitis: a systematic review

BACKGROUND

The use of systemic antibiotics in conjunction with scaling and root planing (SRP) may improve the clinical outcome and even could be essential for a successful treatment of periodontitis. However, the effectiveness and clinical safety of this combination of therapy remain unclear. The authors of this study reviewed the available literature related to this hypothesis, evaluating the effectiveness of the use of systemic antimicrobials in combination with SRP versus SRP alone in the treatment of chronic periodontitis (CP) or aggressive periodontitis (AgP).

METHODS

The authors used 3 electronic databases and hand searched articles published from April 2001 through October 2013 in selected journals. The authors selected clinical trials with a minimum of 6 months follow-up during which patients with either CP or AgP had been treated with systemic antibiotics plus SRP in comparison with SRP alone or with placebo. The authors analyzed the gain in clinical attachment level (CAL), reduction in probing pocket depth (PPD), reduction in bleeding on probing (BOP), and patient-related variables (that is, adverse effects).

RESULTS

After the selection process, the authors included 23 clinical trials in this review. Assessment of the quality of the studies revealed the risk of bias as a common finding. Overall, there was a tendency toward improvement of the measured outcomes, CAL, PPD, and BOP in studies for which systemic antibiotics were used as adjunctive therapy with SRP.

CONCLUSION

Owing to the high level of heterogeneity of the studies included in this review, the authors could not establish definitive conclusions and guidelines regarding the use of adjunctive systemic antibiotics. However, within the limitations of this review, the use of systemic antibiotics with SRP may be beneficial for specific populations. Standardized clinical disease diagnostic criteria and additional randomized controlled clinical trials are necessary to verify the effectiveness of the use of adjunctive systemic antimicrobials with SRP.

PRACTICAL IMPLICATIONS

Owing to methodological differences and biases among clinical trials evaluating systemic antibiotics adjunctive to SRP, clinicians should base their decisions to prescribe on the results of weighing both benefits and risks for each patient.

Repair of Experimental Plaque-Induced Periodontal Disease in Dogs

Forty mongrel dogs were used in this study for induction of periodontal disease by placing subgingival silk ligatures affecting maxillary and mandibular premolar teeth during a 12-month period. Experimental premolar teeth received monthly clinical, radiographic, and histometric/pathologic assessments. The results demonstrated significant increases in scores and values of periodontal disease parameters associated with variable degrees of alveolar bone loss. The experimental maxillary premolar teeth exhibited more severe and rapid rates of periodontal disease compared with mandibular premolar teeth. Histometric analysis showed significant reduction in free and attached gingiva of the experimental teeth. Histopathological examination of buccolingual sections from experimental premolar teeth showed the presence of rete pegs within the sulcular epithelium with acanthosis and erosive changes, widening of the periodontal ligament, and alveolar bone resorption. Various methods for periodontal repair were studied in 194 experimental premolar teeth exhibiting different degrees of periodontal disease. The treatment plan comprised non-surgical (teeth scaling, root planing, and oral hygiene) and surgical methods (closed gingival curettage, modified Widman flap, and reconstructive surgery using autogenous bone marrow graft and canine amniotic membrane). The initial non-surgical treatment resulted in a periodontal recovery rate of 37.6 % and was found effective for treatment of early periodontal disease based on resolution of gingivitis and reduction of periodontal probing depths. Surgical treatment by closed gingival curettage to eliminate the diseased pocket lining resulted in a recovery rate of 48.8 % and proved effective in substantially reducing deep periodontal pockets. Open root planing following flap elevation resulted in a recovery rate of 85.4 % and was effective for deep and refractory periodontal pockets. Autogenous bone graft implantation combined with canine amniotic membrane as a biodegradable membrane was used in 18 premolar teeth and failed to improve advanced furcation defects in most teeth.

Tetracycline as local drug delivery in treatment of chronic periodontitis: A systematic review and meta-analysis

Background:

The aim of the present meta-analysis is to determine the efficacy of tetracycline group of antibiotics as local drug delivery agents in the treatment of chronic periodontitis.

Materials and Methods:

MEDLINE, EBSCO, Cochrane database, and Google Scholar were used to identify studies in English published up to January 31, 2017. An additional hand search of relevant journals and of the bibliographies of the paper identified was also performed. Articles retrieved were screened using specific inclusion criteria by two independent reviewers. Randomized control trials investigating the effect of tetracycline group of antibiotics as local drug delivery agents in chronic periodontitis were included in the study.

Results:

Ten relevant articles were selected for the meta-analysis, of which five articles were retrieved after electronic search, three articles were included after hand search, and two unpublished articles were included. The number of patients in studies ranged from 13 to 140 sites with mean age ranging from 20 to 75. A total of 588 sites were treated using tetracycline group of antibiotics as local drug delivery agents in the treatment of chronic periodontitis. The meta-analysis showed standard difference in mean −1.02 mm (95% confidence interval [CI] 0.28, 1.75) for clinical gain in attachment in favor of tetracycline group. Standard difference in mean for probing depth (PD) was 1.20 mm (95% CI 0.57, 1.87) in tetracycline group.

Conclusion:

The results of this meta-analysis showed a significant improvement in periodontal parameters such as CAL, PD, and sulcular bleeding index in favor of tetracycline as local drug delivery compared to placebo.

Efficacy of adjunctive laser in non-surgical periodontal treatment: a systematic review and meta-analysis

To evaluate the efficacy of the adjunctive laser therapy in conventional non-surgical treatment of chronic periodontitis, an electronic search was performed through the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, MEDLINE, EMBASE, Scopus, Web of Science, China National Knowledge Infrastructure (CNKI), and China Biology Medicine (CBM) Disc, for relevant randomized controlled trials (RCTs) or quasi-RCTs. All the 12 included studies (11 RCTs and 1 quasi-RCT) were qualified for descriptive and quantitative analysis. Outcomes were divided into two groups according to the length of follow-ups (long term and short term). Subgroup analyses were performed based on the mode of laser (inside and outside mode). Among all included researches, reduction in probing depth (PD) and gain in clinical attachment level (CAL) were presented with the mean value and 95 % confidence interval, while bleeding on probing (BOP) was assessed descriptively. Meta-analysis suggested that adjunctive laser therapy reduced PD at 3 months [mean difference (MD) = -0.26, 95 % confidence interval (CI) range = -0.43 to -0.09, p = 0.003] but did not demonstrate significant effect on the CAL at either 3 months (MD = -0.03, 95 % CI range = -0.25 to 0.19, p = 0.79) or 6 months (MD = -0.11, 95 % CI range = -0.38 to 0.16, p = 0.43). Subgroup analyses indicated that laser therapy would be more effective when the probes were set up outside the periodontal pockets.

Clinical and microbiological efficacy of 3% satranidazole gel as a local drug delivery system in the treatment of chronic periodontitis: A randomized, controlled clinical trial

AIM

The present clinical trial was designed to investigate the effectiveness of subgingivally delivered satranidazole (SZ) gel as an adjunct to scaling and root planing (SRP) in the treatment of chronic periodontitis.

MATERIALS AND METHODS

Seventy subjects with probing depth (PD) ≥5 mm were selected. Thirty-five subjects each were randomly assigned to SRP + placebo (Group 1) and SRP + SZ (Group 2). The clinical outcomes evaluated were plaque index, gingival index, clinical attachment level (CAL), and PD at baseline; 1 month, 3 months, and 6 months interval. Furthermore, microbial analysis using polymerase chain reaction was done to estimate the number of sites harboring periodontopathogens.

RESULTS

Sixty four subjects were evaluated up to 6 months. At 6 months, the Group 2 resulted in greater mean reduction (4.10 mm) in PD as compared to Group 1 (1.49 mm), and also a greater mean CAL gain (4.20 mm) in Group 2 as compared to Group 1 (1.13 mm). These subjects also showed a significant reduction in the number of sites harboring periodontopathogens.

CONCLUSION

The use of 3% SZ gel, when used as an adjunct to nonsurgical periodontal therapy in subjects with periodontitis, achieved better results than initial periodontal treatment alone.

The H2S-releasing naproxen derivative, ATB-346, inhibits alveolar bone loss and inflammation in rats with ligature-induced periodontitis

BACKGROUND

In experimental periodontitis, non-steroidal antiinflammatory drugs (NSAIDs) effectively inhibit the resultant alveolar bone loss. However, their deleterious gastric effects, observed in both animals and humans, dramatically limit their long-term use. It has been proven that the addition of a hydrogen sulfide (H2S)-releasing moiety to classical NSAID structures results in antiinflammatory compounds with improved gastric safeness. In this way, we decided to compare the effects of naproxen with its H2S-releasing derivative ATB-346 on ligature-induced periodontitis in rats.

METHODS

Male Holtzman rats had a cotton ligature placed subgingivally around the lower right first molar during 7 days. During this period, groups of animals were daily treated with Na2S (a spontaneous H2S donor) or equimolar oral doses of naproxen (10 mg/kg) or ATB-346 (16 mg/kg). The mandibles were finally collected for histological analysis, radiographical measurements of alveolar bone loss and micro-computed tomography (μCT) analysis. Interleukin (IL)-1β, IL-6 and IL-10 were quantified in gingiva samples, and the stomachs were also collected for scoring of tissue damage and measurement of myeloperoxidase (MPO, a marker of granulocyte infiltration).

RESULTS

Ligature-induced bone loss was significantly inhibited by all the treatments, although only ATB-346 treatment resulted in significant inhibition of bone defect and other histological characteristics (such as flatness of the gingival epithelium, chronic inflammatory cell infiltration and loss of connective tissue in the gingival papillae). Both naproxen and ATB-346 inhibited the increase of gingival IL-1β and IL-6 secondary to periodontitis, but IL-10 was unaffected. Significant damage and increased MPO contents were only found in the stomachs of the naproxen-treated animals.

CONCLUSION

The H2S-releasing moiety in the ATB-346 compound not only does not impair the effects of the parent naproxen on periodontitis, but also improves bone quality and prevents the gastric mucosa damage due to prostaglandin inhibition, thus configuring a potentially new adjuvant therapy for periodontal diseases.

Evaluation of the efficacy of 2% Ocimum sanctum gel in the treatment of experimental periodontitis

Introduction:

One of the options for the treatment of periodontitis is local drug delivery systems (LDD). Tulsi (Ocimum sanctum), a traditional herb, has many uses in medicine. It could be a suitable agent as LDD for the treatment of periodontitis.

Aim:

The aim was to formulate, evaluate the anti-inflammatory activity; assess duration of the action and the efficacy of 2% tulsi (O. sanctum) gel in the treatment of experimental periodontitis in Wistar Albino rat model.

Settings and Design:

Thirty six Wistar albino rats were randomly assigned to 3 groups. Periodontitis was induced using ligature model. Group 1-control; Group 2-Plain gel and Group 3-2% tulsi (O. sanctum) gel.

Materials and Methods:

2% tulsi (O. sanctum) gel were prepared. The anti-inflammatory activity and duration of action were assessed. Silk ligature 5-0 was used to induce periodontitis. Gingival index (GI) and probing pocket depth were measured. Treatment was done. The rats were sacrificed. Morphometric analysis was done using Stereomicroscope and ImageJ software.

Statistical Analysis Used:

ANOVA followed by Bonferroni's test, Wilcoxon's test for intergroup comparison, Mann-Whitney test for P value computation was used. The observations are mean ± standard deviation and standard error of the mean. P < 0.01 as compared to control was considered as statistically significant.

Results:

2% tulsi (O. sanctum) gel showed 33.66% inhibition of edema and peak activity was noted at 24 h. There was statistically significant change in the GI and probing pocket depth. Morphometric analysis did not show any significant difference between groups. No toxic effects were seen on oral administration of 2000 mg/kg of Tulsi extract.

Conclusions:

2% tulsi (O. sanctum) gel was effective in the treatment of experimental periodontitis.

Evaluation of the efficacy of 2% curcumin gel in the treatment of experimental periodontitis

CONTEXT

Local drug delivery (LDD) systems have been proposed for the treatment of periodontitis. Curcumin could be a suitable agent as LDD for the treatment of periodontitis.

AIM

To formulate, evaluate the anti-inflammatory activity and to assess the duration of the action and the efficacy of 2% curcumin gel in the treatment of experimental periodontitis in Wistar albino rat model.

SETTINGS AND DESIGN

Twenty-one Wistar albino rats were randomly assigned to three groups. Periodontitis was induced using ligature model. Group 1: Control; group 2: Plain gel, and group 3: 2% curcumin gel.

MATERIALS AND METHODS

About 2% curcumin gel was prepared. The anti-inflammatory activity and duration of action was assessed. Silk ligature 5-0 was used to induce periodontitis. Gingival index (GI) and probing pocket depth (PPD) were measured. Treatment was done. The rats were sacrificed. Morphometric analysis was performed using stereomicroscope and ImageJ software.

STATISTICAL ANALYSIS USED

Analysis of variance followed by Bonferroni's test, Wilcoxon's test for inter-group comparison, Mann-Whitney test for P value computation was used. The observations are mean ± standard deviation and standard error of the mean. P < 0.01 when compared to control was considered as statistically significant.

RESULTS

About 2% curcumin gel showed 42.98% inhibition of edema and peak activity was noted at 24 h. There was statistically significant change in the GI and PPD. Morphometric analysis did not show any significant difference between groups. No toxic effects were seen on oral administration of 2000 mg/kg of curcumin.

CONCLUSIONS

About 2% curcumin gel was effective in the treatment of experimental periodontitis.

Effects of ozone nano-bubble water on periodontopathic bacteria and oral cells - in vitro studies

The aims of the present study were to evaluate the bactericidal activity of a new antiseptic agent, ozone nano-bubble water (NBW3), against periodontopathogenic bacteria and to assess the cytotoxicity of NBW3 against human oral cells. The bactericidal activities of NBW3 against representative periodontopathogenic bacteria, Porphyromonas gingivalis (P. gingivalis) and Aggregatibacter actinomycetemcomitans (A. actinomycetemcomitans) were evaluated using in vitro time-kill assays. The cytotoxicity of NBW3 was evaluated using three-dimensional human buccal and gingival tissue models. The numbers of colony forming units (CFUs)/mL of P. gingivalis and A. actinomycetemcomitans exposed to NBW3 dropped to below the lower limit of detection (<10 CFUs mL^-1) after only 0.5 min of exposure. There were only minor decreases in the viability of oral tissue cells after 24 h of exposure to NBW3. These results suggest that NBW3 possesses potent bactericidal activity against representative periodontopathogenic bacteria and is not cytotoxic to cells of human oral tissues. The use of NBW3 as an adjunct to periodontal therapy would be promising.

Periodontal debridement: still the treatment of choice

Periodontal debridement (PD) remains a gold standard for the treatment of inflammatory periodontitis.

BACKGROUND/PURPOSE

The evidence base regarding the causal relationship between oral biofilm and the host inflammatory response to the etiology of periodontal disease has substantially increased over the years. What has not changed significantly during that time is the conservative manner in which the disease can be treated with periodontal debridement (PD). Since dental hygienists, in particular, specialize in providing these procedures it is important to evaluate the evidence that supports periodontal debridement as a primary and fundamental treatment modality.

METHOD

An extensive narrative literature review that included systematic reviews, examined traditional PD, the use of adjuncts to enhance PD and newer PD procedures to determine what are the best practices for achieving optimal clinical outcomes.

CONCLUSION

Compared to surgical therapy, PD results in maintenance of attachment levels over time, but is not as effective in the initial reduction of probing depths in deep pockets. Sustained release local drug delivery agents have some modest adjunctive effects when used with PD, as do systemic antibiotics in aggressive periodontitis cases. Reported analyses of the long term effects of chemotherapeutic agents usually do not extend beyond a few months to a year. While laser therapy is still under investigation it remains as a potential PD therapy. New instruments being refined to better visualize the root surface either non-surgically or with mini papilla reflection flaps, hold promise for the future when they become more affordable and accessible. Despite the development of new technology, it still appears that periodontal debridement (PD) remains the gold standard for the treatment of inflammatory periodontitis.

Cyclooxygenase-2 expression in gingival biopsies from periodontal patients is correlated with connective tissue loss

BACKGROUND

The objective of this study is to compare cyclooxygenase-2 (COX-2) protein expression in gingival biopsies from patients with chronic periodontitis (CP), patients with gingivitis (GV), and individuals with no periodontal disease (control group) and to establish its relationship with clinical variables and connective tissue loss in the lamina propria.

METHODS

A cross-sectional and analytic study was conducted in 108 gingival biopsies from 52 patients with CP, 39 with GV, and 17 controls. All biopsies were processed for conventional histopathologic study, immunohistochemical determination of COX-2 protein expression, and automatic quantification of connective tissue by image analysis.

RESULTS

The protein expression of COX-2, mainly produced by plasma cells and monocytes, was significantly related to the presence of periodontal disease, bleeding index, intensity of inflammatory infiltrate, and loss of connective tissue in the lamina propria of gingival biopsies (P <0.01, Spearman test). COX-2 expression was also directly correlated with attachment loss (P <0.05, Spearman test).

CONCLUSIONS

COX-2 protein expression is higher in patients with GV and CP than in individuals without periodontal disease and is inversely correlated with the amount of connective tissue in the lamina propria as determined by image analysis. This finding suggests that COX-2 participates in mechanisms and pathway signaling related to the destruction of fibrillar support structures of the periodontium.

Effects of a single episode of subgingival irrigation with tetracycline HCl or chlorhexidine: A clinical and microbiological study

Background:

The present study was designed to evaluate clinical and antimicrobial effects of a single episode of subgingival tetracycline or chlorhexidine (CHX) irrigation in the absence of scaling and root planing.

Materials and Methods:

Thirty patients diagnosed with chronic periodontitis were recruited for this study, each providing four non-adjacent untreated periodontal pockets with a probing depth equal to or exceeding 6 mm. The four deep periodontal pockets in each patient were assigned to be irrigated with 150 ml each of CHX digluconate 0.2% (group A), tetracycline HCl at concentrations of 10 and 50 mg/ml (groups B and C, respectively), or sterile saline (group D) in a single episode. Recordings of plaque index (PI), gingival index (GI), probing pocket depth (PD), clinical attachment level (CAL), and subgingival bacterial counts from paper point samples were made pre-irrigation (day 0), and at days 7, 28, 56, and 84, post-irrigation.

Results:

The mean PI and GI scores for all the four groups were reduced post-irrigation, the reduction being significantly higher in group C compared to the other groups. The reduction in the PD and CAL was more significant in group C from day 0 to day 7, whereas the other groups showed minimal changes during this period. The change in the bacterial count was altered towards one of the periodontal health, it being more significant and consistent in the group C.

Conclusion:

The results of this study suggest that subgingival irrigation with high concentrations of tetracycline may play a beneficial role in the management of chronic periodontitis patients.

Systemic detection of doxycycline after local administration

OBJECTIVES

Controlled release delivery (CRD) systems are used to extend the half-life of topical antibiotics in gingival crevicular fluid (GCF), while avoiding systemic contamination with antibiotics. When multiple periodontitis sites are treated by subgingival application of a one-component copolymer gel containing 14% doxycycline, it is likely that low levels of the antibiotic can be detected in blood by high performance liquid chromatography (HPLC).

METHODS

Twelve patients with severe periodontitis and one single defect per patient were treated with one single subgingival application of a new one-component doxycycline gel (14%) in each defect (the UNISITE group). Furthermore, 12 patients with between 3 and 9 periodontal defects were treated with a single application of the same doxycycline gel in each defect, resulting in 3-9 applications per patient (the MULTISITE group). Doxycycline was separated and quantitatively measured with HPLC using a UV detector.

RESULTS

In saliva, the maximum doxycycline concentration of the MULTISITE patients was nearly 10-fold higher than in the UNISITE group. In GCF specimens, maximum doxycycline concentrations were the same magnitude in both the MULTISITE and UNISITE groups. Only one UNISITE patient showed detectable levels of doxycycline in blood serum (maximum application: 0.18 µg/ml). Six MULTISITE patients exhibited measurable concentrations of doxycycline in their serum samples (maximum values: 0.12-0.76 µg/ml). The mean systemic concentration following application of the doxycycline-containing gel to multiple sites was as high as 160 ng/ml within minutes following application. Within approximately 1 h, this fell to levels below the limit of detection by HPLC (<50 ng/ml).

CONCLUSIONS

Systemic contamination with doxycycline after topical administration may occur even after unisite application if no periodontal dressing is used. Locally administered doxycycline can be identified in the systemic circulation at levels far below those expected to have antibacterial effects. Systemic concentration following application to a single site was always below levels capable of detection by HPLC.

Local Drug Delivery with Tetracycline Fiber : An Alternative to Surgical Periodontal Therapy

BACKGROUND

Scaling and root planing is the basic treatment modality for periodontal disease. Mechanical treatment is limited by physical impediments and biochemical considerations. Antimicrobial agents may be used as an adjunct to overcome limitations of mechanical therapy.

METHODS

A case-control study was carried out on 30 patients suffering from chronic periodontitis. In Group A only scaling and root planing was carried out whereas in Group B tetracycline fibers were used along with scaling and root planing.

RESULT

Tetracycline fibers as an adjunct to scaling and root planing was found to be more effective in reducing inflammation. The number of sites with bleeding on probing were 12 in Group A as compared to four in Group B after 30 days. The mean decrease in probing depth was more in Group B than Group A after 30 and 90 days. General linear model showed that decrease in probing depth was statistically significant with both mechanical therapy as well as adjunctive use of tetracycline fibers.

CONCLUSION

Local drug delivery with tetracycline fiber is an effective and simple non surgical method to improve periodontal health which can be practiced even by a general dental practitioner.

Adjunctive benefits of systemic etoricoxib in non-surgical treatment of aggressive periodontitis: short-term evaluation

BACKGROUND

This pilot study assessed the effect of short-duration treatment with etoricoxib as adjuvant therapy to scaling and root planing (SRP) on the clinical and radiographic parameters and prostaglandin E(2) (PGE(2)) levels in aggressive periodontitis.

METHODS

Subjects were randomly allocated to test or control treatment (n = 10 in each group) and submitted to SRP and treatment with etoricoxib, 120 mg/day, or placebo for 7 days. Probing depth, clinical attachment level (CAL), gingival recession, visible plaque index, bleeding on probing, linear distance (LD) from the cemento-enamel junction to the alveolar crest, and analysis of the gray levels were recorded before and 1 month after the therapies. The prostaglandin E(2) (PGE(2)) level in the gingival crevicular fluid (GCF) was measured by radioimmunoassay at the beginning of the study and 7 and 30 days after treatment.

RESULTS

No significant difference in the clinical parameters was observed between the groups at the end of the experimental period, although both groups presented significant improvement in all variables examined. There was a decrease in CAL from 5.54 +/- 0.47 mm to 3.59 +/- 0.53 mm in the test group and from 5.92 +/- 1.10 mm to 3.69 +/- 0.80 mm in the control group. A significant reduction in PGE(2) was found after 7 days of treatment. LD differed between the groups.

CONCLUSION

Etoricoxib did not promote additional improvement in the clinical parameters; however, it produced an initial reduction in the PGE(2) levels in the GCF, which could be related to the discrete improvement in the bone condition.

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

OBJECTIVE

To compare the short-term performance of subgingival local delivery of 2% minocycline gel and conventional subgingival debridement in supportive periodontal therapy (SPT) patients.

METHODS

Forty adult patients having completed active treatment for moderate to advanced chronic periodontitis were included in a randomized, controlled, single masked maintenance care pilot study. Sites with residual pocket probing depths > or =5 mm and bleeding on probing were treated with either minocycline gel (minocycline-group) or scaling and root planing only (debridement-group) at baseline, 3, 6, and 9 months. Clinical and microbiological examinations were performed at baseline, 3, 6, 9, and 12 months.

RESULTS

Full-mouth plaque and bleeding scores remained <10% and <20%, respectively, for both groups throughout the study. In both groups there was a persistent reduction in number of teeth and sites with probing pocket depths > or =5 mm (p<0.05) with no significant differences between the groups. The prevalence of Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola, Actinobacillus actinomycetemcomitans, Prevotella intermedia, and Prevotella nigrescens, remained at levels < or =10(5) in the majority of patients and sites in both groups.

CONCLUSION

This pilot study failed to show a difference between local delivery of 2% minocycline gel as mono-therapy and traditional subgingival debridement in patients on SPT.

The use of surrogate variables to reflect long-term tooth survivability

Clinical parameters used to monitor periodontal patients are usually measures of the disease process. They are considered surrogate variables because changes in their status are interpreted to have an impact on the ultimate goal of periodontal therapy, which is tooth retention. However, their ability to reflect tooth survivability has been questioned because there is a lack of long-term data to validate that stable or improved surrogates result in reduced tooth loss. Therefore, to clarify the utility of employing surrogates to reflect long-term tooth retention, a number of issues related to their use are discussed in this commentary: phraseology, benefits and shortcomings, biologic credibility, and their previous successful utilization in monitoring the effects of therapy. This commentary supports the reasonableness of using surrogates to monitor periodontal status and suggests that a combination of surrogates that represent "periodontal clinical health" should be considered a true endpoint of periodontal therapy, since this outcome provides a condition conducive to tooth retention.

The effect of periodontal therapy on uncontrolled type 2 diabetes mellitus in older subjects

OBJECTIVE

The purpose of this study was to examine the effect of periodontal therapy on glycemic control in older type 2 diabetic patients.

METHODS

Fifty-two diabetic patients, age 55-80 years (mean age = 61 years), with glycated hemoglobin (HbA1c) 7.5-11.0% (mean +/- s.d. = 8.98 +/- 0.88) and severe periodontitis were included in the present study. The treatment group received mechanical periodontal treatment combined with systemic doxycycline, 100 mg day(-1) for 14 days. The control group received neither periodontal treatment nor systemic doxycycline. Clinical periodontal parameters, fasting plasma glucose (FPG), and HbA1c levels were measures at baseline and 3 months.

RESULTS

Periodontal treatment significantly improved periodontal status of the treatment group (P < 0.05), however the reduction in the level of FPG and HbA1c did not reach significance. In the control group, no significant changes in clinical periodontal parameters, FPG and HbA1c levels were observed, except for significant increase in attachment loss (P < 0.05). Comparing the two groups, although the 3-month level of HbA1c of the treatment group was lower than that of the control group, the difference did not reach significance.

CONCLUSIONS

The results of the present study indicate that the periodontal condition of older Thais with uncontrolled diabetes is: (a) significantly improved 3 months after mechanical periodontal therapy with adjunctive systemic antimicrobial treatment, and (b) rapidly deteriorating without periodontal treatment. The effect of periodontal therapy on the glycemic control of older uncontrolled diabetics will require further studies that will have to include much larger sample sizes.

Protective effects of etoricoxib, a selective inhibitor of cyclooxygenase-2, in experimental periodontitis in rats

BACKGROUND

The purpose of the present study was to evaluate the effect of a potent selective cyclooxygenase-2 (COX-2) inhibitor, etoricoxib, on the prevention of alveolar bone loss in experimental periodontitis induced in rats.

METHODS

Ninety Wistar rats were separated into three experimental groups. Cotton ligatures were placed at the gingival margin level of lower right first molars. The rats were randomly assigned to one of the following groups: control received a daily oral dose of 1 ml/kg of saline solution; Eto1 received 6 mg/kg of etoricoxib; Eto2 received 12 mg/kg of etoricoxib. Serum levels of etoricoxib and white blood cells were determined. Standardized digital radiographs were taken after death at 3, 5, 10, 18 and 30 days to measure the amount of bone loss at the mesial root surface of the first molar tooth in each rat.

RESULTS

One-way analysis of variance (anova) indicated that groups treated with both doses of etoricoxib had significantly (p < 0.05) less alveolar bone loss when compared to controls. Furthermore, etoricoxib treatment significantly inhibited the leukocytosis observed 3 days after the induction of periodontitis.

CONCLUSION

These data provide evidence that systemic therapy with etoricoxib can retard alveolar bone loss in a ligature-induced periodontitis model in rats.

Preparation and characterization of triclosan nanoparticles for periodontal treatment

The aim of this work was to produce and characterize triclosan-loaded nanoparticles (NPs) by the emulsification-diffusion process, in an attempt to obtain a novel delivery system adequate for the treatment of periodontal disease. The NPs were prepared using poly(D,L-lactide-co-glycolide) (PLGA), poly(D,L-lactide) (PLA) and cellulose acetate phthalate (CAP). Poly(vinyl alcohol) (PVAL) was used as stabilizer. Batches were prepared with different amounts of triclosan (TCS) in order to evaluate the influence of drug on NP properties. Solid NPs of less than 500 nm in diameter were obtained. Entrapment efficiencies were higher than 63.8%. The characterization by scanning electron microscopy and light scattering indicated that high concentrations of TCS seemingly caused the increase of NP mean size. A decrease in the PLGA glass transition temperature was observed by differential scanning calorimetry. This could indicate that TCS in PLGA-NPs behaves as a non-conventional plasticizer. Subsequently, in vitro release studies were carried out under sink conditions using a device designed in our laboratory to allow a direct contact between the particles and the dissolution medium. A fast release of TCS from NPs was detected. A preliminary in vivo study in dogs with induced periodontal defects suggested that TCS-loaded NPs penetrate through the junctional epithelium.

Clinical and microbiological evaluation of the effectiveness of the Nd:Yap laser for the initial treatment of adult periodontitis. A randomized controlled study

BACKGROUND

Enhancement of the results obtained by scaling and planing is most often sought by using antimicrobial therapies. Laser beams have been shown to be bactericidal and could possibly target pathogens more effectively and with fewer compliance problems than antiseptic solutions.

METHODS

Thirty subjects 20-60 years old presenting periodontal pockets at least 5 mm deep in each quadrant received initial periodontal treatment. The study had a split-mouth design. The control side (SRP) only received scaling and planing, and the test side (SRP+laser) was treated by both SRP and Nd:Yap (yttrium aluminum perovskite doped with neodym) laser. Clinical conditions were evaluated at day 0 and day 90 using the plaque index, gingival index, bleeding on probing, pocket probing depth, and clinical attachment level. Microbial sampling was also performed on days 0 and 90, and the presence of Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Tannerella forsythensis, and Treponema denticola was analysed by polymerase chain reaction in a commercial laboratory. Post-operative pain or discomfort was measured by the patient using a linear visual scale. Pearson's chi-squared test was used to compare bacterial presence.

RESULTS

There was no statistically significant difference concerning clinical data between test and control groups at baseline. Both treatments enhanced the clinical situation compared to baseline; however, results were not significantly different between the two groups. T. forsythensis was the organism most numerous in both groups. Though initial treatment diminished the numbers of all the pathogens it did not do so statistically significantly. Differences between test and control groups were very small and bore no significance. Evaluation of the post-operative pain did not reveal any differences between the groups.

CONCLUSIONS

Scaling and root planing was effective in reducing levels of plaque, inflammation, and bleeding upon probing. No additional advantage was achieved by using the Nd:Yap laser.

Clinical Response of Azithromycin as an Adjunct to Non-Surgical Periodontal Therapy in Smokers

BACKGROUND

Antibiotic therapy can be used in very specific periodontal treatment situations such as in refractory cases of periodontal disease found to be more prevalent in smokers. This study was designed to determine the efficacy of azithromycin (AZM) when combined with scaling and root planing (SRP) for the treatment of moderate to severe chronic periodontitis in smokers.

METHODS

Thirty-one subjects were enrolled into a 6-month randomized, single-masked trial to evaluate clinical, microbial (using benzoyl- DL-arginine naphthylamine [BANA] assay), and gingival crevicular fluid (GCF) pyridinoline cross-linked carboxyterminal telopeptide of type I collagen (ICTP) levels in response to SRP alone or SRP + AZM. At baseline, patients who smoked > or =1 pack per day of cigarettes who presented with at least five sites with probing depths (PD) of > or =5 mm with bleeding on probing (BOP) were randomized into the test or control groups. At baseline and 3 and 6 months, clinical measurements (probing depth [PD], clinical attachment loss [CAL], and bleeding on probing [BOP]) were performed. GCF bone marker assessment (Ctelopeptide [ICTP] as well as BANA test analyses) were performed at baseline, 14 days, and 3 and 6 months.

RESULTS

The results demonstrated that both groups displayed clinical improvements in PD and CAL that were sustained for 6 months. Using a subject-based analysis, patients treated with SRP + AZM showed enhanced reductions in PD and gains in CAL at moderate (4 to 6 mm) and deep sites (>6 mm) (P <0.05). Furthermore, SRP + AZM resulted in greater reductions in BANA levels compared to SRP alone (P <0.05) while rebounds in BANA levels were noted in control group at the 6-month evaluation. No statistically significant differences between groups on mean BOP and ICTP levels during the course of the study were noted.

CONCLUSIONS

The utilization of AZM in combination with SRP improves the efficacy of non-surgical periodontal therapy in reducing probing depth and improving attachment levels in smokers with moderate to advanced attachment loss.

Selective cyclooxygenase-2 inhibition prevents bone resorption

The aim of the present work was to evaluate the effect of a selective cyclooxygenase-2 (COX-2) inhibitor (meloxicam) on the alveolar bone loss progression in experimentally induced periodontitis. Forty (40) Wistar rats were separated into 8 experimental groups (n = 5). Cotton ligatures were placed at the gingival margin level of the lower right first molars of some rats. Four groups were treated for 5 or 15 days with an oral dose of 15 mg/kg of body weight/day of the selective COX-2 inhibitor. The other groups were used as positive control (sham) or negative control in each experimental period. Standardized digital radiographs were taken after sacrifice at 5 and 15 days to measure the amount of bone loss at the mesial root surface of the first molar tooth in each rat. The treatment with meloxicam did not induce weight alteration or other visible systemic manifestations. One way analysis of variance (ANOVA) indicated that groups treated with meloxicam, after 5 days, had significantly less alveolar bone loss (p < 0.05) when compared with control groups. On the other hand, no significant differences in bone loss were observed after 15 days of treatment with meloxicam. These data provide evidence that systemic therapy with meloxicam can modify the progression of experimentally induced periodontitis in rats during the initial experimental period.

Comparison of the pharmacokinetic profiles of two locally administered doxycycline gels in crevicular fluid and saliva

BACKGROUND

Controlled-release delivery systems enable the clinician to extend the half-life period of locally administered antibiotics in gingival crevicular fluid (GCF) significantly. The aim of this split-mouth study was to compare the pharmacokinetic profile of two different doxycycline gels (DOXY and ATRI) for topical subgingival application. Pharmacokinetics of both doxycycline gels were analyzed in GCF and saliva.

METHODS

In 10 patients suffering from severe periodontitis, 10 pairs of contralateral defects (pocket depth > or =5 mm/bleeding on probing or > or =6 mm) were randomly assigned either to the first application of DOXY or ATRI. Fourteen days after the topical application of the first antibiotic gel, the application of the second gel in the contralateral defect took place. Clinical examinations at baseline showed no significant differences between sites treated with DOXY and ATRI. Samples of GCF and saliva were drawn baseline, 2, 5 and 24 h after application, 2, 3, 4, 7, 9 and 11 days after application. Separation and quantitative measurement of both doxycycline-gels was performed with HPLC- and UV-detection at lambda=260 nm.

RESULTS

In saliva specimens, time-dependent changes of mean doxycycline concentration were almost identical for both doxycycline-gels and declined from a maximum 2 h after application (ATRI: 6653.90+/-3096.14 microg/ml; DOXY: 5386.60+/-1542.02 microg/ml [arithmetic mean+/-SEM]) to zero values 9 days after application. In crevicular fluid specimens, sites treated with ATRI exhibited a faster decrease of mean doxycycline concentration (1085.30, 264.00, 273.94, and 258.00 microg/ml measured 2, 5, 24, and 48 h after application) than sites treated with DOXY (1388.38, 1300.40, 803.73, and 235.10 microg/ml). The faster decrease of ATRI compared with DOXY could not be proved to be statistically significantly different.

CONCLUSIONS

Both doxycycline gels showed pharmacokinetics of controlled-release delivery systems.

Local Anti-Infective Therapy: Mechanical and Physical Approaches. A Systematic Review

BACKGROUND

Although mechanical non-surgical therapy (scaling and root planing) is the most common means of initial treatment of periodontal diseases, the relative clinical efficacy of various methods, including manual versus machine-driven, with or without adjunctive agents, has not been determined.

RATIONALE

This systematic review analyzes the literature in an effort to identify the most effective therapies, based on both clinical and patient-centered outcomes.

FOCUSED QUESTION

In patients with periodontitis, what is the effect of mechanically-driven instrumentation (e.g., power-driven) and/or subgingival irrigation with and without manual instrumentation compared to manual instrumentation alone?

SEARCH PROTOCOL

Two investigators examined MEDLINE and the Cochrane Oral Health Group specialized registry for clinical trials published in English. Hand searches were performed of the International Journal of Periodontics & Restorative Dentistry, Journal of Clinical Periodontology, Journal of Periodontology, and Journal of Periodontal Research. Searches were performed for articles published through April 2002. Editors of these journals were asked to provide information on articles currently under review. In addition, an electronic discussion group on periodontal diseases and treatment was contacted, as were manufacturers of manual and mechanical instruments and of adjunctive agents.

SELECTION CRITERIA

INCLUSION CRITERIA

Only randomized clinical trials, cohort studies, or case-control studies at least 3 months long were included. All studies had to compare manual instrumentation (MI; scaling and root planing [SRP]) alone with some other form of non-surgical therapy. These included MI versus mechanically-driven instruments (MDI) alone; MI versus MI plus MDI; MI versus MDI plus an agent (e.g., chlorhexidine); and MI versus subgingival irrigation (SGI) delivered in conjunction with MI or MDI.

EXCLUSION CRITERIA

Studies not meeting the inclusion criteria or those treating periodontal diseases as a manifestation or complication of some other disease or disorder were not included.

DATA COLLECTION AND ANALYSIS

Probing depth, clinical attachment level, bleeding on probing, and gingival recession were the primary outcomes. Because of the heterogeneity of the patient populations, treatments, and outcome measures, meta-analysis was not appropriate. Only in-study data were compared. Four of the studies required extrapolating data from figures and graphs, resulting in questionable accuracy.

MAIN RESULTS

1. Nine studies, representing a study population of 129, were included in the review. 2. Five studies compared MI with MDI alone. The other 4 compared MI alone to MI plus SGI or subgingival tissue treatment. 3. There was comparable efficacy between MI and MDI when treating single-rooted teeth. 4. The use of SGI or subgingival tissue treatment as an adjunct to MI provided no additional benefit compared to MI alone. 5. Findings reported in the review must be interpreted with considerable caution, as lack of study heterogeneity made meta-analysis unfeasible and the need to extrapolate outcomes values from graphs and figures may have resulted in some inaccuracy.

REVIEWERS' CONCLUSIONS

1. Manual and mechanically-driven instrumentation appears comparable in affecting improved clinical outcomes. 2. Instrumentation time for MI and MDI were similar, except for 1 study in which MDI was significantly shorter. 3. Adjunctive SGI plus MI and subgingival tissue treatment result in similar clinical outcomes when compared to MI alone. 4. If study data are to be effectively and analytically combined to facilitate meaningful comparisons of treatment outcomes, detailed and standardized study designs must be developed and used consistently in clinical trials.

Systemic antimicrobials in the treatment of chronic periodontal diseases: a dilemma

The use of systemic antimicrobials in the treatment of acute and chronic periodontal diseases must be viewed as a dilemma. On the one hand, the approach is attractive because of the microbial nature of periodontal diseases but, on the other hand, evidence of benefit of these agents is equivocal for the majority of periodontal diseases and antimicrobials have the potential to cause harm. The disadvantages of systemic antimicrobials can be grouped under the headings of allergic reactions, superinfection, toxicity, drug interactions, patient compliance and, perhaps of most widespread importance, bacterial resistance. Mechanical debridement methods, including drainage of pus for acute periodontal abscesses, should be considered the first line treatment for most periodontal diseases. Systemic antimicrobials should be considered as adjuncts to mechanical debridement methods and, in chronic disease, never used alone as they can predispose to abscess formation. Adjunctive systemic antimicrobials may be considered in acute disease where debridement or drainage of pus is difficult, where there is local spread or systemic upset. In chronic periodontal diseases, adjunctive antimicrobials should be considered in early onset or rapidly progressive disease or in advanced chronic adult disease where mechanical therapies have failed or surgery is not a preferred option. Inadequate oral hygiene and tobacco smoking are contraindications to the use of antimicrobials. The value of systemic antimicrobials, where other systemic risk factors co-exist, has still to be established. The role of microbial diagnosis and sensitivity testing for antimicrobial selection at this time must be questioned.

Locally delivered antimicrobials for the treatment of chronic periodontitis

The basic treatment of chronic periodontitis is a mechanical debridement of periodontal pockets by scaling and root planing (S/RP) in combination with efficient plaque control. Locally delivered antiseptics (LDA) have been proposed to practitioners and, while subgingival irrigation of antiseptics is still used in clinical practice, the introduction in our therapy of a slow release and sub-gingival delivery of tetracycline has changed the rationale from a mechanical treatment towards a combined therapy for full mouth/sites disinfection. Various antibiotics, antiseptics and resorbable carriers are now proposed with similar targets to arrest disease progression. In chronic periodontitis, LDA cannot be used routinely in combination with S/RP, because of the limited clinical benefit, even if an increased percentage of deep sites may show an improvement. Prospective multicenter studies considering risk factors for disease progression have to be designed to identify patients who may benefit the most from LDA. For non-responding sites or recurrent pockets, the controversies are limited, because a combined S/RP and LDA may avoid the need for surgery. However, the patient cost/benefit ratio needs to be estimated as well as adverse effects in particular antibiotics.

A systematic review on the effect of systemic antimicrobials as an adjunct to scaling and root planing in periodontitis patients

BACKGROUND

Scaling and root planing (SRP) are the bases of non-surgical therapy in the treatment of periodontitis. However, results from this therapy are often unpredictable and dependable from many different factors.

OBJECTIVES

The aim of this systematic review was to evaluate the effectiveness of the adjunctive use of systemic antimicrobials with scaling and root planing (SRP) vs. SRP alone in the treatment of chronic (CP) or aggressive periodontitis (AgP).

SEARCH STRATEGY

Use of computerized databases, namely MEDLINE, the Cochrane Oral Health Group Specialty Trials Register and EMBASE; reference lists from relevant articles were hand-searched; and a hand-search of selected journals until April 2001.

SELECTION CRITERIA

Studies were selected if they were designed as controlled clinical trials in which systemically healthy patients with either AgP or CP were treated with SRP plus systemic antimicrobials in comparison with SRP alone or with placebo, for a minimum of 6 months. Main outcome measures were clinical attachment level (CAL) change and probing pocket depth (PPD) change.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted independently information regarding quality and study characteristics, in duplicate. Kappa scores determined their agreement. Main results were collected and grouped by drug, disease and PPD category. For the quantitative data synthesis, the data was pooled (when mean differences and standard errors were available), and either a Fixed Effects or Random Effects meta-analysis was used for the analysis.

RESULTS

After an initial selection, 158 papers were identified by the manual and electronic searches; 25 papers were eligible for inclusion. Their quality assessment showed that randomization and allocation concealment methods were seldom reported and blindness was usually not defined clearly. In general, selected studies showed high variability and lack of relevant information for an adequate assessment. Overall, SRP plus systemic antimicrobial groups demonstrated better results in CAL and PPD change than SRP alone or with placebo groups. Only limited meta-analyses could be performed, due to the difficulties in pooling the studies and the lack of appropriate data. This analysis showed a statistically significant additional benefit for spiramycin (PPD change) and amoxicillin/metronidazole (CAL change) in deep pockets.

CONCLUSION

Systemic antimicrobials in conjunction with SRP, can offer an additional benefit over SRP alone in the treatment of periodontitis, in terms of CAL and PPD change, and reduced risk of additional CAL loss. However, differences in study methodology and lack of data precluded an adequate and complete pooling of data for a more comprehensive analyses. It was difficult to establish definitive conclusions, although patients with deep pockets, progressive or 'active' disease, or specific microbiological profile, can benefit more from this adjunctive therapy.

Effect of selective cyclooxygenase-2 inhibition on the development of ligature-induced periodontitis in rats

BACKGROUND

The purpose of this study was to evaluate the effect of a selective cyclooxygenase-2 inhibitor on the progression of alveolar bone loss in an experimental periodontitis model in rats.

METHODS

One hundred eighty (180) Wistar rats were separated into 3 experimental groups. Cotton ligatures were placed at the gingival margin level of lower right first molars. The rats were randomly assigned to one of the following groups that received: a daily oral dose of 10 mg/kg body weight of celecoxib (Ce1); 20 mg/kg body weight of celecoxib (Ce2); or 10 ml/kg of saline solution (C). Serum levels of celecoxib and white blood cell count were determined. Standardized digital radiographs were taken after sacrifice at 3, 5, 10, 18, and 30 days to measure the amount of bone loss around the mesial root surface of the first molar tooth in each rat.

RESULTS

Two-way analysis of variance (ANOVA) indicated that groups treated with celecoxib had significantly less bone loss compared to controls (P < 0.0001) and that there was a significant interaction between treatment with celecoxib and time (P < 0.03). Post-hoc comparisons showed that in both groups treated with celecoxib, the bone loss became significant only after 10 days of ligature placement, while in the control group it was already significant after 5 days. However, differences in mean bone loss between control and Ce1 were significant only at 18 days and, between control and Ce2, at 5 and 18 days. There was no significant difference in bone loss among experimental groups at the end of the experimental period.

CONCLUSION

These data provide evidence that systemic therapy with celecoxib can modify the progression of experimentally induced periodontitis in rats.

Pharmacokinetic profile of a locally administered doxycycline gel in crevicular fluid, blood, and saliva

BACKGROUND

With the help of so-called controlled release delivery systems, the half-life period of locally administered antibiotics in gingival crevicular fluid (GCF) can be extended significantly. The aim of this study was to characterize the delivery profile of a new one-component 14% doxycycline free amine gel for local application. Pharmacokinetics of doxycycline (DOXY) were analyzed in GCF, saliva, and serum.

METHODS

Twenty patients with persisting or recurring pockets (probing depths > or = 5 mm and bleeding on probing) after mechanical treatment (surgical or non-surgical) took part in the study. In each patient 1 periodontal defect was treated with DOXY gel. Samples of GCF, saliva, and serum were obtained before application of DOXY gel; 15 minutes after application; at 2 and 5 hours; and at 1, 2, 3, 4, 7, 9, and 11 days after application. Separation and quantitative measurement of DOXY was performed with high performance liquid chromatography and UV detection at lambda = 260 nm.

RESULTS

Coefficients of variation were lower than 2% (intraassay) and 4% (interassay), respectively. For concentrations between 50 to 1000 microg/ml, we found a linear relationship between expected and measured DOXY values (linear coefficient of correlation: r = 0.998). Within the first 5 hours after application, concentration of DOXY in GCF (maximum after 15 minutes 19.97 +/- 5.85 mg/ml) and saliva (maximum after 15 minutes 17.83 +/- 2.84 mg/ml) was similar. Then concentration fell to a lower level (28.90 +/- 19.44 microg/ml) compared to GCF (577.41 +/- 127.34 microg/ml) after 3 days. Up to 10 days after application, the concentration of DOXY in GCF was 34.24 microg/ml. With the exception of 1 patient, all serum samples were DOXY-negative.

CONCLUSIONS

1) After subgingival application of biodegradable 14% doxycycline gel, mean doxycycline levels in GCF that exceeded 16 microg/ml could be maintained for at least 12 days. Thus, the antimicrobial agent may be classified as a controlled release device. 2) The antibiotic effect was limited mainly to the subgingival sites of application of the doxycycline gel. 3) The doxycycline gel possesses the pharmacokinetic and clinical properties to deliver efficacious levels of antibiotics to the periodontal pocket and to maintain these levels for at least 1 week without the need of further drug retention by a periodontal dressing.