Treatment of periodontal disease based on microbiological diagnosis. A 5-year follow-up on individual patterns

Microbiological and host-derived biomarker evaluation following non-surgical periodontal therapy with short-term administration of systemic antimicrobials: secondary outcomes of an RCT

Nonsurgical periodontal therapy with adjunctive use of systemic antimicrobials (for 7-14 days) showed improved clinical, microbiological and immunological results over the mechanical protocol alone. Considering the increasing risk for antimicrobial resistance with longer antibiotic regimes, it is important to establish the optimal antibiotic protocol with a maximum antimicrobial benefit and minimum risk for adverse effects. The aim of the study was to evaluate the microbiological and inflammatory outcomes 12-months after a 3-/7-day systemic antibiotic protocol [amoxicillin (AMX) + metronidazole (MET)] adjunctive to subgingival debridement in severe periodontitis compared to mechanical treatment alone. From the initially treated 102 patients, 75 subjects (Placebo group: n = 26; 3-day AMX + MET group: n = 24; 7-day AMX + MET group: n = 25) completed the 12-month examination. Clinical parameters, eight periodontal pathogens and inflammatory markers were determined at baseline and 3-, 6-, 12-months after therapy using real-time PCR and ELISA respectively. After 6 months, several periodontopathogens were significantly more reduced in the two antibiotic groups compared to placebo (p < 0.05). After 1 year, both antibiotic protocols showed significant reductions and detection of the keystone pathogen P. gingivalis compared to placebo. Antibiotic protocols, smoking, disease severity, baseline-BOP, -CAL and -IL-1β, as well as detection of T. denticola at 12-months significantly influenced the residual number of deep sites. The present data indicate that the systemic use of both short and longer antibiotic protocols (AMX + MET) adjunctive to nonsurgical periodontal therapy lead to higher microbiological improvements compared to subgingival debridement alone. The two investigated antibiotic protocols led to comparable microbiological and inflammatory results.

Microbial colonization of the periodontal pocket and its significance for periodontal therapy

The aim of this paper was to evaluate strategies for periodontal therapy from the perspective of periodontal disease being a consequence of microbial colonization of the periodontal pocket environment. In classic bacterial infections the diversity of the microbiota decreases as the disease develops. In most cases of periodontitis, however, the diversity of the flora increases. Most incriminating bacteria are thought to harm tissues significantly only if present in high numbers over prolonged periods of time. Clinical trials have repeatedly demonstrated that scaling and root planing, a procedure that aims to remove subgingival bacterial deposits by scraping on the tooth surface within the periodontal pocket, is effective. At present, for the therapy of any form of periodontal disease, there exists no protocol with proven superiority, in terms of efficiency or effectiveness, over scaling and root planing plus systemic amoxicillin and metronidazole. Some exponents advocate rationing these drugs for patients with a specific microbial profile. However, the evidence for any benefit of bacteriology-assisted clinical protocols is unsatisfactory. Treated sites are subject to recolonization with a microbiota similar to that present before therapy. The degree and speed of recolonization depends on the treatment protocol, the distribution patterns of periodontal microorganisms elsewhere in the oral cavity and the quality of the patient's oral hygiene. To limit the use of antibiotics and to avoid accumulation of harmful effects by repeated therapy, further efforts must be made to optimize procedures addressing the microbial colonization and recolonization of the periodontal pocket.

Comparison of adjunctive azithromycin and amoxicillin/metronidazole for patients with chronic periodontitis: preliminary randomized control trial

BACKGROUND

There are insufficient guidelines for the use of adjunctive systemic antibiotics for patients with periodontal disease. The aim of this study was to compare clinical outcomes for patients with moderate-advanced chronic periodontitis treated with: scaling and root planing (SRP), SRP with amoxicillin and metronidazole (A+M), SRP with Azithromycin (Az).

METHODS

Thirty-seven non-smokers with generalized moderate to advanced chronic periodontitis were divided into three treatment groups: SRP, A+M and Az. Patients received the medications after the last SRP session and were reviewed three months later. Changes in clinical parameters were compared between the groups. Separate analyses were executed for: 'all sites', 'molar sites', 'sites with different PPD severities' and 'number of sites with shallow, moderate and deep PPD'.

RESULTS

The three groups exhibited improvements in most clinical parameters. At three months, A+M showed a higher reduction in PPD compared to Az in the 'all sites analysis'. Molars exhibited better reduction in BOP and PPD with A+M than SRP. Pocket depth of the 4-6 mm category reduced more in the A+M than SRP. A+M experienced a higher increase in the number of sites with PPD 1-3 mm than Az.

CONCLUSIONS

Adjunctive systemic antibiotics in the initial phase of treatment may result in improved clinical outcomes.

One year results of a randomized controlled clinical study evaluating the effects of non-surgical periodontal therapy of chronic periodontitis in conjunction with three or seven days systemic administration of amoxicillin/metronidazole

BACKGROUND

To evaluate the clinical outcomes 12 months after systemic administration of amoxicillin (AMX) and metronidazole (MET) adjunctive to subgingival debridement (SD) in patients with severe chronic periodontitis (sChP).

MATERIAL AND METHODS

102 patients with sChP were treated randomly as follows: SD within 2 consecutive days and placebo for 7 days (group A), SD+AMX+MET (both 500mg x3 times daily TID) for 3 days (group B), SD+AMX+MET (both 500mg x 3 TID) for 7 days (group C). At baseline, at 3-, 6-, and 12-months post-treatment probing pocket depth (PD), clinical attachment level (CAL), furcation involvement, bleeding on probing (BOP), full-mouth plaque score (FMPS) were determined. The reduction in the number of sites with PD≥6mm was defined as main outcome variable.

RESULTS

75 patients completed the study. At 12 months, all three treatment groups showed statistically significant improvements (p<0.001) of mean PD, CAL, BOP and number of sites with PD≥6mm compared to baseline. Mean residual PD were statistically significantly lower and CAL gain statistically significantly greater in the two antibiotic groups as compared to placebo. While PD reductions (p = 0.012) and CAL gain (p = 0.017) were statistically significantly higher in group C compared to group A, only the 3-day AB group showed statistically significantly fewer sites with PD≥6mm at 12 m (p = 0.003). The reduction in the number of sites with PD≥6 mm (primary outcome) showed no statistical significant differences between the 3 treatment groups. However, in both antibiotic groups significantly more patients compared to the placebo group reached a low risk for disease progression at 12 months (≤4 sites with PD≥5mm).

CONCLUSION

At 12 months, both adjunctive antibiotic protocols resulted in statistically significantly greater clinical improvements compared to placebo.

Surgical and nonsurgical periodontal therapy. Learned and unlearned concepts

This review aims to highlight concepts relating to nonsurgical and surgical periodontal therapy, which have been learned and unlearned over the past few decades. A number of treatment procedures, such as gingival curettage and aggressive removal of contaminated root cementum, have been unlearned. Advances in technology have resulted in the introduction of a range of new methods for use in nonsurgical periodontal therapy, including machine-driven instruments, lasers, antimicrobial photodynamic therapy and local antimicrobial-delivery devices. However, these methods have not been shown to offer significant benefits over and above nonsurgical debridement using hand instruments. The method of debridement is therefore largely dependent on the preferences of the operator and the patient. Recent evidence indicates that specific systemic antimicrobials may be indicated for use as adjuncts to nonsurgical debridement in patients with advanced disease. Full-mouth disinfection protocols have been proven to be a relevant treatment option. We have learned that while nonsurgical and surgical methods result in similar long-term treatment outcomes, surgical therapy results in greater probing-depth reduction and clinical attachment gain in initially deep pockets. The surgical technique chosen seems to have limited influence upon changes in clinical attachment gain. What has not changed is the importance of thorough mechanical debridement and optimal plaque control for successful nonsurgical and surgical periodontal therapy.

Detection ofTannerella forsythiaand/orPrevotella intermediaMight Be Useful for Microbial Predictive Markers for the Outcome of Initial Periodontal Treatment in Koreans

A proportion of diseased sites in periodontal disease do not respond to the initial treatment, which might be due in part to the presence of specific microbial pathogens. The aim of this study was to clarify the value of microbial screening for predicting the outcome of periodontal treatment in Koreans using a polymerase chain reaction (PCR). This study enrolled 32 adults with periodontal disease. Microbial and clinical examinations were performed at the baseline and after the initial treatment (professional toothbrushing, scaling, and root planing). Subgingival plaque samples were taken from four sites in each subject (total 128 samples). PCR was used to detect the four putative pathogenic bacteria. There was an improvement in the average of each clinical measurement after the initial treatment. However, approximately half of the sites exhibiting bleeding upon probing (BOP) at the baseline still exhibited bleeding after treatment. There was a close association between the presence of BOP and the presence of Tannerella forsythia (formerly Bacteroides forsythus) and/or Prevotella intermedia. Furthermore, the sites harboring both T. forsythia and P. intermedia at the baseline had a poorer response to treatment than the sites where these two species were not detected. Therefore, microbial screening for T. forsythia and P. intermedia might be useful for predicting the treatment outcome in Koreans.

Diminished treatment response of periodontally diseased patients infected with the JP2 clone of Aggregatibacter (Actinobacillus) actinomycetemcomitans

This longitudinal study evaluated the response to periodontal treatment by subjects infected with either JP2 (n = 25) or non-JP2 (n = 25) Aggregatibacter (Actinobacillus) actinomycetemcomitans. Participants were treated during the first 4 months by receiving (i) scaling and root planing, (ii) systemic antibiotic therapy, and (iii) periodontal surgery. Probing depth (PD), clinical attachment level (CAL), and gingival and plaque indices (GI and PI, respectively) were monitored at baseline and at 12 months, along with DNA-PCR-based subgingival detection of JP2 or non-JP2 A. actinomycetemcomitans. At baseline, PD, CAL, and GI scores were statistically higher in the JP2 strain-positive group than the non-JP2-strain-positive group. At 12 months, PD, CAL, and GI scores had decreased significantly for both groups, but the reduction rates of PD and CAL were higher in the non-JP2-strain-positive group. Among JP2-strain-positive patients in the baseline, patients who remained JP2 strain positive at 12 months showed significantly higher GIs than did the patients who had lost the detectable JP2 clone. Patients who remained JP2 strain positive at 12 months appeared to be more resistant to mechanical-chemical therapy than did those who were still non-JP2 strain positive, while the elimination of JP2 A. actinomycetemcomitans remarkably diminished gingival inflammation. Early identification and elimination of the JP2 clone of A. actinomycetemcomitans will enable practitioners to effectively predict the outcome of treatments applied to periodontal patients.

Risk ofPorphyromonas gingivalisRecolonization During the Early Period of Periodontal Maintenance in Initially Severe Periodontitis Sites

BACKGROUND

Porphyromonas gingivalis is considered a critical pathogen of periodontal diseases including recurrent periodontitis. The profound effects of active periodontal treatment (APT) on P. gingivalis elimination were previously demonstrated and revealed that the subsequent P. gingivalis-free or -suppressed status seems to be maintained during early periodontal maintenance (PMT). The aim of the present study was to show the occurrence of microbial recolonization during this early PMT period.

METHODS

In total, 128 sites from 11 generalized chronic periodontitis patients and one generalized aggressive periodontitis patient underwent clinical and microbiologic examination at baseline (Exam-I), after APT (Exam-II), and in PMT (Exam-III). Exam-III was carried out an average of 4.5 +/- 3.5 months after Exam-II. Detection and quantification of putative pathogens were performed using a polymerase chain reaction-based method.

RESULTS

The PMT used was effective in maintaining the clinical conditions improved by APT. However, in microbiological examinations, Exam-III showed higher detection frequency and levels of P. gingivalis than Exam-II. This suggests that a P. gingivalis recolonization started in the early PMT period. P. gingivalis-increased sites then showed significantly more severe signs of periodontitis in Exam-I than P. gingivalis-stable sites (bleeding on probing frequency: 76.7% versus 56.5%; suppuration frequency: 41.9% versus 12.9%). On the other hand, in Exam-II, no significant differences of clinical parameters were noted between P. gingivalis-increased and -stable sites.

CONCLUSION

Severe periodontitis sites before APT seemed to place them at risk of P. gingivalis recolonization in the early PMT period, and this microbial restoration could be a cause of recurrent periodontitis.

Microbiological diagnostics in oral diseases

Most infections of the oral cavity, including the major dental diseases caries and periodontitis, are opportunistic in nature. They are caused or maintained by microorganisms of the resident or transient flora normally present in low numbers and not pathogenic, but in certain circumstances develop infections. Mucosal infections have some degree of specificity [e.g. Candida spp., Staphylococcus aureus, and enterics] and a microbiological test can be interpreted accurately for clinical diagnosis and choice of treatment. Subepithelial or deep infections, however, include a number of species from the resident flora, mainly anaerobes whose role in the infections is difficult to interpret. However, microbiological tests and the presence of certain bacterial species could be used for treatment control, risk-evaluation and even for patient motivation in the prevention of these diseases. Microbiological diagnosis can be used in general practice for several purposes and in various situations that can be of great value for the dental patient.

Topical and systemic antibiotics in the management of periodontal diseases

Both systemic and topical antibiotics are increasingly used in the management of periodontal infections. Whilst these drugs are used mostly on an empirical basis, some contend that rational use of antibiotics should be the norm due to their wide abuse and consequential global emergence of antibiotic resistance organisms. Here we review the rationale and principles of antimicrobial therapy, treatment goals, drug delivery routes and various antibiotics that are used in the management of periodontal diseases. The pros and cons of systemic and local antibiotic therapy are described together with practical guidelines for their delivery. The available data indicate, in general, that mechanical periodontal treatment alone is adequate to ameliorate or resolve the clinical condition in most cases, but adjunctive antimicrobial agents, delivered either locally or systemically, can enhance the effect of therapy in specific situations. This is particularly true for aggressive (early onset) periodontitis, in patients with generalised systemic disease that may affect host resistance and in case of poor response to conventional mechanical therapy. Locally delivered antibiotics together with mechanical debridement are indicated for non-responding sites of focal infection or in localised recurrent disease. After resolution of the periodontal infection, the patient should be placed on an individually tailored maintenance care programme. Optimal plaque control by the patient is of paramount importance for a favourable clinical and microbiological response to any form of periodontal therapy.

Periodontitis as an infectious disease: specific features and their implications

Periodontitis may be viewed as an infectious disease with a number of specific characteristics. Pathogens of the subgingival microbiota can interact with host tissues even without direct tissue penetration. Hence, antimicrobial agents must be available at a sufficiently high concentration not only within the periodontal tissues, but also outside, in the environment of the periodontal pocket. The subgingival microbiota accumulate on the root surface to form an adherent layer of plaque with the characteristics of a biofilm. Several mechanisms, such as diffusion barriers, and selective inactivation of agents lead to an increased resistance of bacteria in biofilms. Mechanical supragingival plaque control is indispensable to prevent the re-emergence of periodontal pathogens and the re-establishment of a biofilm in treated sites. Since specific features have important implications for the use of antimicrobial agents in periodontal therapy, extrapolations from experiences made in the therapy of other infections are only partially valid. The ultimate evidence for the efficacy of systemic or local chemotherapy must be obtained from treatment studies in humans with adequate follow-up.

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.

Local antibiotic therapy guided by microbiological diagnosis

BACKGROUND

The aim of this study was to determine the distribution patterns of Porphyromonas gingivalis and Actinobacillus actinomycetemcomitans in periodontitis patients after standard mechanical periodontal therapy, and to evaluate the effect of additional local antibiotic therapy, given to all teeth with cultural evidence of these bacteria.

METHODS

17 patients were included. 852 separate subgingival microbial samples were taken from the mesial and distal aspect of every tooth in 17 subjects at baseline. 46 of these samples, from 10 positive subjects, showed cultural evidence for P. gingivalis. 82 samples, from 5 subjects, were A. actinomycetemcomitans-positive. Three subjects showed no evidence for persistence of A. actinomycetemcomitans or P. gingivalis. In the other 14 subjects, all A. actinomycetemcomitans- or P. gingivalis-positive teeth were treated with tetracycline fibers (ACTISITE(R)). Sub-gingival microbial samples were again taken from two sites of every tooth, 1 month after fiber removal. 89% of the initially P. gingivalis-positive sites were now negative, but 16 previously negative sites now tested positive. 77% of the initially A. actinomycetemcomitans-positive sites were now negative, but 5 previously negative sites now tested positive. The teeth with persisting P. gingivalis or A. actinomycetemcomitans were again treated with fibers. Two sites of every tooth were once more sampled after 1 month. At this time, 5 subjects still showed cultural evidence of P. gingivalis at a total of 19 sites, and 4 subjects were positive for A. actinomycetemcomitans in a total of 27 sites. These 9 patients were finally submitted to systemic antibiotic therapy (3 x 250 mg metronidazole plus 3 x 375 mg amoxicillin/d for 7 days). Despite of all efforts, P. gingivalis was again detected 3 months later in isolated sites in 3 subjects, and A. actinomycetemcomitans could be cultivated from one single site.

CONCLUSIONS

Therapy with tetracycline fibers guided by microbiological diagnosis effectively reduced P. gingivalis and A. actinomycetemcomitans locally, but was unable to completely eradicate the target organisms. Additional systemic antibiotic therapy further reduced P. gingivalis and A. actinomycetemcomitans. The observed persistence patterns suggest that reemergence of A. actinomycetemcomitans was due to recolonization, whereas the strikingly reproducible local reemergence of P. gingivalis in some sites indicated failed eradication.

Amoxicillin plus metronidazole in the treatment of adult periodontitis patients. A double-blind placebo-controlled study

BACKGROUND, AIMS

The aim of this double-blind, parallel study was to evaluate the adjunctive effects of systemically administered amoxicillin and metronidazole in a group of adult periodontitis patients who also received supra- and subgingival debridement.

METHODS

49 patients with a diagnosis of generalised severe periodontitis participated in the study. Random assignment resulted in 26 patients in the placebo (P) group with a mean age of 40 years and 23 patients in the test (T) group which had a mean age of 45 years. Clinical measurements and microbiological assessments were taken at baseline and 3 months after completion of initial periodontal therapy with additional placebo or antibiotic treatment. Patients received coded study medication of either 375 mg amoxicillin in combination with 250 mg metronidazole or identical placebo tablets, every 8 hours for the following 7 days.

RESULTS

At baseline, no statistically significant differences between groups were found for any of the clinical parameters. Except for the plaque, there was a significantly larger change in the bleeding, probing pocket depth (PPD) and clinical attachment level (CAL) in the T-group as compared to the P-group after therapy. The greatest reduction in PPD was found at sites with initial PPD of > or = 7 mm, 2.5 mm in the P-group and 3.2 mm in the T-group. The improvement in CAL was most pronounced in the PPD category > or = 7 mm and amounted to 1.5 mm and 2.0 mm in the P- and T-groups, respectively. No significant decrease was found in the number of patients positive for any of the test species in the P-group. The number of patients positive for Porphyromonas gingivalis, Bacteroides forsythus and Prevotella intermedia in the T-group showed a significant decrease. After therapy there was a significant difference between the P- and the T- group in the remaining number of patients positive for P. gingivalis, B. forsythus and Peptostreptococcus micros. 4 subgroups were created on the basis of the initial microbiological status for P. gingivalis positive (Pg-pos) and negative patients (Pg-neg) in the P- and the T-groups. The difference in reduction of PPD between Pg-pos and Pg-neg patients was particularly evident with respect to the changes in % of sites with a probing pocket depth > or = 5 mm. This % decreased from 45% at baseline to 23% after treatment in the Pg-pos placebo subgroup and decreased from 46% to 11% in the Pg-pos test subgroup (p < or = 0.005). In contrast, the changes in the proportions of sites with a probing pocket depth > or = 5 mm in the Pg-neg placebo and Pg-neg test subgroup were similar, from 43% at baseline to 18% after treatment versus 40% to 12% respectively.

CONCLUSIONS

This study has shown that systemic usage of metronidazole and amoxicillin, when used in conjunction with initial periodontal treatment in adult periodontitis patients, achieves significantly better clinical and microbiological results than initial periodontal treatment alone. Moreover, this research suggests that especially patients diagnosed with P. gingivalis benefit from antibiotic treatment.

Additional clinical and microbiological effects of amoxicillin and metronidazole after initial periodontal therapy

The aims of this study were to evaluate the clinical and microbiological effects of initial periodontal therapy (IT) and to determine the additional effects of systemic amoxicillin (Flemoxin Solutab) 375 mg TID plus metronidazole 250 mg TID therapy, in patients with adult Actinobacillus actinomycetemcomitans (Aa)-associated periodontitis in conjunction with either Porphyromonas gingivalis (Pg), Bacteroides forsythus (Bf) and/or Prevotella intermedia (Pi). In addition the adverse effects of the antimicrobial therapy were also documented. A total of 22 patients were enrolled. The deepest, bleeding pocket in each quadrant was selected and at these 4 experimental sites clinical measurements and microbiological testing was carried out at baseline, after (IT), i.e., 21 weeks after baseline, and after antimicrobial therapy (AM), i.e., 35 weeks after baseline. At baseline, the mean plaque index (PI) amounted 0.5, 0.1 after IT and 0.3 after systemic AM. The mean bleeding index decreased from 1.6 to 1.2 after IT and a further decrease to 0.7 after AM was noted. Suppuration was completely eliminated after AM. The mean change of probing pocket depth (PPD) after IT amounted 1.4 mm and was further reduced with an additional mean change of 1.1 mm after medication. Clinical attachment gain was 1.1 mm after IT and an additional 0.9 mm was observed after AM. One of the 22 Aa positive patients and 4 of 17 Pg positive patients became negative for these species after IT. The number of patients with detectable Pi decreased from 16 to 10 after IT. After AM, in comparison to baseline, suppression below detection level for Aa was achieved in 19 out of 22, for Pg in 9 out of 17, for Bf in 13 out of 14, and for Pi in 11 out of 16 patients. By contrast, higher frequencies of Peptostreptococcus micros and Fusobacterium nucleatum were found after AM. On the basis of the microbiological results the study group was separated into 2 subgroups: group A consisted of subjects who had no detectable levels of Aa, Pg, Bf and <5% of Pi after AM. Group B consisted of those who still showed presence of one of these 3 species and/or > or =5% levels of Pi. After AM, group B had significantly higher PI, BI, PPD and CAL scores then group A. It is concluded that group A showed low plaque scores and no detectable periodontal pathogens. This microbiological condition has been associated with a long-term stable periodontium.

Evaluation of tetracycline fiber therapy with digital image analysis

The aims of the present study were to assess radiographically the effects of scaling/root planing combined with antibiotic therapy using tetracycline fibers (TCF): (I) on alveolar bone density and linear descriptors and (II) on supracrestal soft tissue density. 19 subjects with generalized adult periodontitis (with at least 20 teeth present, at least 4 teeth with pockets >4 mm and bleeding upon controlled force probing) and high cultural counts of Porphyromonas gingivalis were recruited from a pool of 57 patients. The full mouth treatment group (FT) consisted of 10 patients, who underwent a full mouth supra-gingival scaling and prophylaxis treatment and were instructed to rinse 2x daily with a 0.1% chlorhexidine solution. 1 week later, tetracycline-hydrochloride-containing fibers (Actisite periodontal fiber) were applied around all teeth. After 7-12 days, the fibers were removed and all teeth were scaled and root planed under local anaesthesia. The chlorhexidine rinsing continued for another 2 months. In 9 subjects (local treatment group LT), 2 teeth with periodontal lesions with pocket probing pepth (PPD) > or =5 mm were treated by placement of tetracycline fibers, which remained in place for 7 to 12 days. Upon removal of the fibers, scaling and root planing was performed on these 2 teeth, while the rest of the dentition remained untreated, and no chlorhexidine rinse was applied. 2 of the untreated teeth revealing similar periodontal lesions were chosen to represent sites affected by untreated periodontitis (NT). In this group, a limited local treatment was performed (2 teeth) with the inherent potential for recolonization from the untreated pocket sites. Standardized periapical radiographs were obtained from the 4 monitored sites within each patient at baseline (before treatment) and 2 and 6 months thereafter. One radiograph was exposed in a standard way for bone assessment. The second radiograph was underexposed, at about a 1/5 of the original exposure time to allow the evaluation of soft tissue. Mean changes in the linear parameters and changes in density (CADIA) observed at multiple sites within each patient and treatment group were used as the best estimate of treatment outcome. Over the observation period of 6 months, a significant difference in bone height changes was found between the untreated sites (median loss -0.29 mm) and the sites from full-mouth treated patients (median gain 0.24 mm, p=0.008). When comparing the baseline to the 6 months radiographs, a loss in bone density was observed for the untreated group (median=-2.13 CADIA). Both treatment groups revealed a gain in density (median=1.58 and 2.43 CADIA for the locally and the full-mouth treated groups, respectively). Differences in density were significant, both between the nontreated and locally treated sites (p=0.026) and between the nontreated sites and the sites from the full mouth treated patients (p=0.002). The analysis of the soft tissues showed a similar pattern of changes in density to those seen in the bone defect. At 2 months, there was a tendency for loss in density for the nontreated group (median=-0.17 CADIA) that continued over the 6 month period (median=-0.31 CADIA). A significant increase in density was observed for the full-mouth treated sites (median=1.57 and 0.64 CADIA for the 2 and 6 months radiographs, respectively). A significant increase was also observed for the locally treated group when compared to the untreated sites (median=0.13 and 0.10 CADIA for the 2 and 6 months radiographs, respectively). Comparing untreated sites with full-mouth treated sites, a significant difference was observed for CADIA measurements (p<0.001). No significant difference was observed comparing locally treated and untreated sites (p=0.24). It was concluded that scaling and root planing combined with TCF therapy can result in increased bone density and alveolar bone height. Full-mouth treatment seemed to result in more pronounced gains compared to local tre

Identification of bacterial markers by culture technique in evaluation of periodontal therapy

The aim of the present study was to evaluate whether the presence of A. actinomycetemcomitans, P. gingivalis and P. intermedia, as revealed by culture technique, could discriminate between three distinct adult patient groups, those: with recurrent periodontal disease, with cured periodontal disease or who were periodontally healthy. Forty one patients previously treated for advanced periodontitis were divided into recurrent or cured groups, with a third periodontally healthy reference group. All subjects were sampled for the three bacterial strains under scrutiny. Although all three micro-organisms were found significantly more often in diseased sites, it was concluded that a sample positive for all three may indicate a false record of disease activity. However, a sample negative for the three bacteria strongly indicates an absence of disease activity.

Rapid chair-side DNA probe assay of Bacteroides forsythus and Porphyromonas gingivalis

This study compared a rapid, colorimetric DNA probe assay designed to be performed in a dental office within 40 min, with anaerobic culture and indirect immunofluorescence microscopy (IFM) for detection of Bacteroides forsythus and Porphyromonas gingivalis in subgingival plaque samples. The DNA probe assay used the Periodontal Microbial Identification Test (Saigene Corporation, Bothell, Washington, USA). B. forsythus was detected in 46 (52%), 49 (55%) and 39 (44%) of the samples by DNA probe, culture (at levels > or = 10(5)) and IFM, respectively. P. gingivalis was detected in 24 (27%), 18 (20%) and 29 (33%) of the samples by DNA probe, culture (at levels > or = 10(5)) and IFM, respectively. Results from the DNA probe assay were compared to culture. Culture negative, probe positive samples were re-evaluated by IFM, and IFM positive samples were considered positive in "resolved" data. Using resolved data. DNA probe detection sensitivity and specificity values for B. forsythus were 81% and 91% and for P. gingivalis were 80% and 95%, respectively. DNA probe test results were further compared with culture and IFM. For samples negative by both culture and IFM, probe specificity was 92% in 25 B. forsythus samples and 95% in 57 P. gingivalis samples. For samples positive by both reference methods, probe sensitivity was 82% in 27 B. forsythus samples and 73% in 15 P. gingivalis samples. B. forsythus was detected more frequently by culture compared with IFM; the reverse was observed for P. gingivalis. The rapid DNA probe assay for B. forsythus and P. gingivalis was comparable to cultivable and IF analyses.

Effects of metronidazole in patients with "refractory" periodontitis associated with Bacteroides forsythus

The aim of the present study was to monitor the microbiological and clinical effects of renewed supra- and subgingival debridement in conjunction with systemic metronidazole therapy (500 mg TID for 7 days) in 27 "refractory" periodontitis patients, culture positive for Bacteroides forsythus and negative for Actinobacillus actinomycetemcomitans. Clinical evaluation included assessment of plaque, bleeding upon probing, probing pocket depth and clinical attachment loss at the deepest, bleeding site in each quadrant. Microbiological evaluation was carried out by anaerobic cultivation of subgingival plaque samples from the same sites. 6 months after renewed debridement and systemic metronidazole (RD+M), a statistically significant improvement of all clinical parameters was observed, except for the plaque index. After RD+M, B. forsythus was suppressed below detection level in 17 of the 27 patients, P. gingivalis in 9 out of 15 patients and P. intermedia in 14 of the 21 patients. Before RD+M, 12 patients harboured simultaneously B. forsythus, P. gingivalis as well as P. intermedia. Out of these, 6 patients were culture negative for the 3 species after therapy and showed the greatest reduction in pocket depth (3.1 mm) and gain of clinical attachment level (2.5 mm). In the treatment of refractory periodontitis, associated with patients culture positive for B. forsythus and negative for A. actinomycetemcomitans, metronidazole can significantly improve the clinical and microbiological parameters.