The effect of non-surgical periodontal and adjunctive minocycline-HCL treatments on the activity of salivary proteases

Adjunctive systemic antimicrobials for the non-surgical treatment of periodontitis

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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

INTRODUCTION

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Decreased circulating neopterin is associated with increased arterial elasticity: a beneficial role of periodontal treatment

BACKGROUND

The aim of this study was to evaluate the effect of periodontal treatment on arterial elasticity and circulating neopterin in patients with moderate to severe periodontitis in a Chinese population.

METHODS

One hundred and eight patients with moderate to severe periodontitis were eligible to take part in the study and were randomized into two groups. The treatment group received intensive periodontal treatment, while the control group received control periodontal treatment. All parameters, including brachial-ankle pulse wave velocity (baPWV), ankle brachial index (ABI), serum neopterin (NP), high-sensitivity C-reactive protein (hs-CRP), Interleukin-6 (IL-6), were evaluated before treatment and 1 month after treatment.

RESULTS

The parameters including NP, hs-CRP, IL-6 and baPWV decreased significantly after 1 month in the treatment group (p < 0.05 for all comparisons) but not in the control group (p > 0.05). There was no significant difference in the change of ABI between the two groups (p = 0.231). A positive correlation was found between the decreased circulating NP and increased arterial elasticity in the treatment group (r = 0.947, p < 0.001).

CONCLUSIONS

This study demonstrates for the first time that the fall in circulating NP induced by periodontal treatment contributes to increased arterial elasticity in patients with moderate and severe periodontitis.

Minocycline containing local drug delivery system in the management of chronic periodontitis: A randomized controlled trial

Background:

The role of chemotherapeutic agents in periodontal therapy as adjuncts to mechanical debridement maybe justified by the inherent limitations of mechanical therapy. The aim of this study was to evaluate the long term efficacy of a locally delivered 2% minocycline gel as an adjunct to scaling and root planing in managing chronic periodontitis.

Materials and Methods:

This was a randomized controlled trial using a split-mouth study design. Twenty two pairs of sites with similar probing depths were randomly allocated to test and control groups. All sites received thorough scaling and root planing followed by minocycline gel application in the test sites. Probing depths, relative attachment levels, plaque index, and microbiological parameters were evaluated for both the groups over a 9-month period.

Results:

Overall parameters improved from baseline in both the test and control groups. For most parameters, the differences between test and control groups were not significant at different time intervals. The probing depth values in the test group at six (3.64±0.83 mm) and nine months (3.81±0.79 mm) were significantly less than control group(4.24±0.95 mm at six and 4.63±0.94 mm at nine months), these differences being significant at P<0.05 and <0.01, respectively. At the end of nine months, the number of non-motile bacilli in test group (21.65±3.74) were significantly less than control group (25.5±3.01), the difference being significant at P<0.02.

Conclusion:

The overall view of results in our investigation did not show any significant advantage of using 2% minocycline gel over scaling and root planning as an effective local drug delivery system and calls for further clinical trials to objectively evaluate its adjunctive in treatment of periodontitis.

Modulation of clinical expression of plaque-induced gingivitis. I. Background review and rationale

OBJECTIVES

The purpose of this article is to provide the necessary background and rationale for the accompanying studies, which are ultimately aimed at identifying genetic and environmental factors determining gingivitis susceptibility.

MATERIALS AND METHODS

The literature on factors reported to modify the clinical expression of gingivitis, i.e., factors that determine individual variability in gingival inflammatory response to plaque, is presented.

RESULTS

Clinical evidence suggests that the gingival inflammatory response to plaque accumulation may differ substantially among individuals. However, most of the available studies are of small scale and not purposely designed to address the issue. Systemic factors implicated in modulation of the clinical expression of gingivitis include metabolic, genetic, environmental and other factors. The significance of such factors in designing and conducting a large-scale experimental gingivitis trial and means to account for them are discussed.

CONCLUSION

Although several factors have been implicated, genetic or environmental factors underlying differences in gingivitis expression are not fully elucidated. The accompanying studies aim to identify and characterize, among participants in a specifically designed large-scale experimental gingivitis trial, subjects that differ significantly in their gingival inflammatory response to plaque. This is the first step in an effort to determine genetic or environmental factors underlying such differences.

Periodontal host modulation with antiproteinase, anti-inflammatory, and bone-sparing agents. A systematic review

BACKGROUND

The use of modulating agents, including inhibition of matrix metalloproteinases (MMPs) with antiproteinases, blocking production of proinflammatory cytokines and prostaglandins with anti-inflammatory drugs, and inhibiting activation of osteoclasts with bone-sparing agents, has been postulated to be of therapeutic value as an adjunctive therapy to the management of chronic periodontitis.

RATIONALE

The objective of this systematic review of the literature was to assess the adjunctive efficacy of antiproteinase, anti-inflammatory, and bone-sparing host-modulating agents in the treatment of gingivitis, aggressive periodontitis, and chronic periodontitis. FOCUSED QUESTIONS: 1. In patients with periodontal diseases, what is the effect of host-modulation agents, alone or combined with conventional therapy, compared to conventional therapy alone as assessed by clinical, radiographic, adverse, and patient-centered outcomes? 2. In patients with dental implants, what is the effect of host-modulation agents on implant success assessed by clinical, radiographic, adverse, and patient-centered outcomes?

SEARCH PROTOCOL

MEDLINE, Embase, and the Cochrane Library databases were searched without language restrictions through April 1, 2002 for studies that used tetracycline (TET)-related matrix metalloproteinase (MMP) inhibitors, or non-steroidal anti-inflammatory drugs (NSAIDs) and bisphosphonate anti-osteolytic agents. The investigation also included hand searching of journals and contacting authors and industry experts.

SELECTION CRITERIA

INCLUSION CRITERIA

Only human studies (randomized controlled clinical trials, cohort studies, case-control studies, cross-sectional studies, and case series) were selected. Studies were on subjects with gingivitis, aggressive or chronic periodontitis, or dental implants. Interventions included TET-related MMP inhibitors, NSAIDs, or bisphosphonate anti-osteolytic agents.

EXCLUSION CRITERIA

Studies that used MMP tissue inhibitors as diagnostic or prognostic indicators of periodontal disease or that evaluated short-term systemic antibodies or locally delivered levels of drugs with antiproteinase activity were excluded.

DATA COLLECTION AND ANALYSIS

The primary outcomes for assessment were changes in bone or clinical attachment levels (CAL); secondary outcomes included clinical measures of plaque, gingival inflammation, probing depth (PD), and mobility. Summary data appropriate for meta-analysis were pooled using a weighted average and analyzed using a standardized difference; the results were checked with both fixed-effects and random-effects models.

MAIN RESULTS

1. A meta-analysis done on the studies reporting changes in CAL and PD following administration of sub-antimicrobial doses of doxycycline (SDD) in conjunction with scaling and root planing (SRP) in patients with periodontitis showed a statistically significant beneficial adjunctive effect. 2. There were insufficient data to provide meta-analyses on periodontal patients treated with other host-modulating agents; descriptive tables are included. 3. NSAIDS show promise in their ability to slow periodontal disease. 4. Preliminary data on bisphosphonate agents indicate there is a potential role for these agents in periodontitis management. 5. There are a very limited number of studies on host-modulating agents and dental implants and no analyses were possible. 6. Because the treatment methodologies and clinical variables differed considerably among the studies, it is difficult to summarize the information and identify a reliable total patient population.

REVIEWERS' CONCLUSIONS

1. Large multi-center trials are needed to evaluate the role of host-modulating agents in the treatment of periodontitis. 2. NSAIDS and bisphosphonate drugs may have a potential adjunctive role in periodontal therapy. 3. The adjunctive use of SDD with SRP is statistically more effective than SRP alone in reducing PD and in achieving CAL gain.

Systemic anti-infective periodontal therapy. A systematic review

BACKGROUND

Periodontal diseases are infections and thus systemically administered antibiotics are often employed as adjuncts for their control. There are conflicting reports as to whether these agents provide a therapeutic benefit.

RATIONALE

The purpose of this systematic review is to determine whether systemically administered antibiotics improve a primary clinical outcome measure, periodontal attachment level change.

FOCUSED QUESTION

In patients with periodontitis, what is the effect of systemically administered antibiotics as compared to controls on clinical measures of attachment level?

SEARCH PROTOCOL

The Pub/Med database was searched from 1966 to May 2002. Searches were limited to human studies published in English. Hand searches were performed on the Journal of Clinical Periodontology, Journal of Periodontology, and Journal of Periodontal Research. References in relevant papers and review articles were also examined.

SELECTION CRITERIA

INCLUSION CRITERIA

Trials were selected if they met the following criteria: randomized controlled clinical trials, quasi-experimental studies, and cohort studies of > 1 month duration with a comparison group; subjects with aggressive, chronic, or recurrent periodontitis and periodontal abscess; use of a single or a combination of systemically administered antibiotics(s) versus non-antibiotic therapy; and a primary outcome of mean attachment level change (AL).

EXCLUSION CRITERIA

Studies involving the use of low-dose doxycycline, combinations of locally plus systemic antibiotics, or where the control group included a systemically administered antibiotic were excluded.

DATA COLLECTION AND ANALYSIS

A mean difference in AL between groups was available for all papers used in the meta-analysis. A standard deviation (SD) for the difference was used if provided or calculated from the SD or standard error of the mean (SEM) when provided for single measurements. Data were subset by antibiotic employed, type of adjunctive therapy, and disease type. Results were assessed with both fixed-effects and random-effects models.

MAIN RESULTS

1. Twenty-nine studies, 26 RCTs and 3 quasi-experimental (36 comparisons), met the entry criteria. Total study population, both control and test groups, was estimated at over 1,200. 2. Twenty-two studies (27 comparisons) were used in the meta-analysis, evaluating if the antibiotics provided a consistent benefit in mean AL change for different patient populations, for different therapies, and for different antibiotics. 3. For the majority of the comparisons, systemically administered antibiotics exhibited a more positive attachment level change than the control group in the study. The combined results were statistically significant (P < 0.001). 4. The systemic antibiotics were uniformly beneficial in providing an improvement in AL when used as adjuncts to scaling and root planing (SRP) and were consistently beneficial, although of borderline significance, when used as adjuncts to SRP plus surgery or as a stand alone therapy. 5. When examining the effects of individual or combinations of antibiotics, it was found that there were statistically significant improvements in AL for tetracycline, metronidazole, and an effect of borderline statistical significance for the combination of amoxicillin plus metronidazole. 6. Improvements in mean AL were consistent for both chronic and aggressive periodontitis subjects, although the aggressive periodontitis patients benefited more from the antibiotics.

REVIEWERS' CONCLUSIONS

1. The use of systemically administered adjunctive antibiotics with and without SRP and/or surgery appeared to provide a greater clinical improvement in AL than therapies not employing these agents. 2. The data supported similar effect sizes for the majority of the antibiotics; therefore, the selection for an individual patient has to be made based on other factors. 3. Due to a lack of sufficient sample size for many of the antibiotics tested, it is difficult to provide guidance as to the more effective ones.

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.

Inhibition of trypsin-like cysteine proteinases (gingipains) from Porphyromonas gingivalis by tetracycline and its analogues

Extracellular cysteine proteinases, referred to as gingipains, are considered important virulence factors for Porphyromonas gingivalis, a bacterium recognized as a major etiologic agent of chronic periodontitis. We investigated the effect of tetracycline and its analogues, doxycycline and minocycline, on the enzymatic activities of gingipains. Tetracyclines at 100 microM totally inhibited the amidolytic activity of arginine-specific gingipains (HRgpA and RgpB). In contrast, inhibition of Kgp was less efficient and required a somewhat higher concentration of the antibiotic to achieve the same effect. Among tetracycline derivatives, the most potent gingipain inhibitor was doxycycline, followed by tetracycline and minocycline. RgpB was inhibited by doxycycline in an uncompetitive and reversible manner with a 50% inhibitory concentration of 3 microM. Significantly, inhibition was unaffected by calcium, excluding the chelating activity of tetracyclines as the mechanism of gingipain inactivation. In contrast, the inhibitory activities of the tetracyclines were reduced by cysteine, a reducing agent, suggesting an interference of the drug at the oxidative region with the catalytic system of the enzyme. Doxycycline, at 10 microM, significantly inhibited the RgpB-mediated production of vascular permeability-enhancing activity from human plasma, thus proving an effective inhibition of gingipain in vivo. These results indicate a new activity of tetracyclines as cysteine proteinase inhibitors and may explain the therapeutic efficiency of these antibiotics in the treatment of periodontitis.

Controlled and targeted drug delivery strategies towards intraperiodontal pocket diseases

Advances in the understanding of the aetiology, epidemiology, pathogenesis and microbiology of periodontal pocket flora have revolutionized the strategies for the management of intraperiodontal pocket diseases. Intra-pocket, sustained release, drug delivery devices have been shown to be clinically effective in the treatment of periodontal infections. Several degradable and non-degradable devices are under investigation for the delivery of antimicrobial agents into the periodontal pocket including non-biodegradable fibres, films (biodegradable and non-biodegradable), bio-absorbable dental materials, biodegradable gels/ointments, injectables and microcapsules. With the realization that pocket bacteria accumulate as biofilms, studies are now being directed towards eliminating/killing biofilm concentrations rather than their planktonic (fluid phase) counterparts. Intraperiodontal pocket drug delivery has emerged as a novel paradigm for the future research. Similarly, bioadhesive delivery systems are explored that could significantly improve oral therapeutics for periodontal disease and mucosal lesions. A strategy is to target a wide range of molecular mediators of tissue destruction and hence arrest periodontal disease progression. Research into regenerating periodontal structures lost as a result of disease has also shown substantial progress in the last 25 years.